Philosophical roots

Functional Contextualism

ACT is rooted in the pragmatic philosophy of functional contextualism, a specific variety of contextualism that has as its goal the prediction and influence of events, with precision, scope and depth. Contextualism views psychological events as ongoing actions of the whole organism interacting in and with historically and situationally defined contexts. These actions are whole events that can only be broken up for pragmatic purposes, not ontologically.

Because goals specify how to apply the pragmatic truth criterion of contextualism, functional contextualism differs from other varieties of contextualism that have other goals. ACT thus shares common philosophical roots with constructivism, narrative psychology, dramaturgy, social constructionism, feminist psychology, Marxist psychology, and other contextualistic approaches, but its unique goals leads to different qualities and different empirical results than these more descriptive forms of contextualism, seeking as they do a personal appreciation of the complexity of the whole rather than prediction and influence per se.

ACT itself reflects its philosophical roots in several ways. ACT emphasizes workability as a truth criterion, and chosen values as the necessary precursor to the assessment of workability because values specify the criteria for the application of workability. Its causal analyses are limited to events that are directly manipulable, and thus it has a consciously contextualistic focus. From such a perspective, thoughts and feelings do not cause other actions, except as regulated by context.

Therefore, it is possible to go beyond attempting to change thoughts or feelings so as to change overt behavior, to changing the context that causally links these psychological domains.

Further information on functional contextualism is available here

Theoretical roots

RFT: A Theory of Language and Cognition

ACT is based on Relational Frame Theory (RFT), which is a comprehensive basic experimental research program into human language and cognition. RFT has become one of the most actively researched basic behavior analytic theories of human behavior, with over 70 empirical studies focused on it tenets. In ACT, virtually every component of the technology is connected conceptually to RFT, and several of these connections have been studied empirically.

According to RFT, the core of human language and cognition is the learned and contextually controlled ability to arbitrarily relate events mutually and in combination, and to change the functions of specific events based on their relations to others. For example, very young children will know that a nickel is larger than a dime by physical size, but not until later will the child understand that a nickel is smaller than a dime by social attribution. In addition to being arbitrarily applicable (a nickel is “smaller” than a dime merely by social convention), this more psychologically complex relation is mutual (e.g., if a nickel is smaller than a dime, a dime is bigger than a nickel), combinatorial (e.g., if a penny is smaller than a nickel and a nickel is smaller than a dime then a penny is smaller than a dime), and alters the function of related events (if a nickel has been used to buy candy a dime will now be preferred even if it has never actually been used before).

The applied implications of RFT derived from the following key features:

1. Human language and higher cognition is a specific kind of learned behavior. RFT researchers have shown that arbitrarily applicable comparative relations (the nickel and dime situation just mentioned) can be trained as an overarching operant in young children; similar evidence has emerged with frames of opposition and coordination.
2. Relational frames alters the effects of other behavioral processes. For example, a person who has been shocked in the presence of B and who learns that B is smaller than C, may show a greater emotional response to C than to B, even though only B was directly paired with shock
3. Cognitive relations and cognitive functions are regulated by different contextual features of a situation.

The primary implications of RFT in the area of psychopathology and psychotherapy extend from the three features just described. RFT argues that:

1. verbal problem solving and reasoning is based on some of the same cognitive processes that can lead to psychopathology, and thus it is not practically viable to eliminate these processes,
2. much as extinction inhibits but does not eliminate learned responding, the common sense idea that cognitive networks can be logically restricted or eliminated is generally not psychologically sound because these networks are the reflection of historical learning processes;
3. direct change attempts focused on key nodes in cognitive networks creates a context that tends to elaborate the network in that area and increase the functional importance of these nodes, and
4. since the content and the impact of cognitive networks are controlled by distinct contextual features, it is possible to reduce the impact of negative cognitions whether or not they continue to occur in a particular form. Taken together, these four implications mean that it is often neither wise nor necessary to focus primarily on the content of cognitive networks in clinical intervention. Fortunately, the theory suggests that it is quite possible instead to focus on their functions.

RFT has proven itself successful so far in modeling higher cognition in a number of areas, and the neurobiological data collected so far comport with the theory. RFT is meant to be a comprehensive contextualistic account of human language and cognition and thus its goals extend far beyond ACT or even the behavioral and cognitive therapies in general. Because all of the key features of the theory are cast in terms of manipulable contextual variables, it has readily lead to applied interventions in such areas as education.

Theory of Psychopathology

Core Problem Processes

From an ACT / RFT point of view, while psychological problems can emerge from the general absence of relational abilities (e.g., in the case of mental retardation), a primary source of psychopathology (as well as a process exacerbating the impact of other sources of psychopathology) is the way that language and cognition interact with direct contingencies to produce an inability to persist or change behavior in the service of long term valued ends. This kind of psychological inflexibility is argued in ACT and RFT to emerge from weak or unhelpful contextual control over language processes themselves, and the model of psychopathology is thus linked point to point to the basic analysis provided by RFT. This yields an accessible and clinically useful middle level theory bound tightly to more abstract basic principles.

A core process that can lead to pathology is cognitive fusion, which refers to the domination of behavior regulatory functions by relational networks, based in particular on the failure to distinguish the process and products of relational responding. In contexts that foster such fusion, human behavior is guided more by relatively inflexible verbal networks than by contacted environmental contingencies. This is fine in some circumstances, but in others it increases psychological inflexibility in an unhealthy way. As a result, people may act in a way that is inconsistent with what the environment affords relevant to chosen values and goals. From an ACT / RFT point of view, the form or content of cognition is not directly troublesome, unless contextual features lead this cognitive content to regulate human action in unhelpful ways.

The functional contexts that tend to have such deleterious effects are largely sustained by the social / verbal community. There are several. A context of literality treats symbols (e.g., the thought, “life is hopeless”) as one would referents (i.e., a truly hopeless life). A context of reason-giving bases action or inaction excessively on the constructed “causes” of one's own behavior, especially when these processes point to non-manipulable “causes” such as conditioned private events. A context of experiential control focuses on the manipulation of emotional and cognitive states as a primary goal and metric of successful living.

Cognitive fusion supports experiential avoidance -- the attempt to alter the form, frequency, or situational sensitivity of private events even when doing so causes behavioral harm. Due to the temporal and comparative relations present in human language, so-called “negative” emotions are verbally predicted, evaluated, and avoided. Experiential avoidance is based on this natural language process – a pattern that is then amplified by the culture into a general focus on “feeling good” and avoiding pain. Unfortunately, attempts to avoid uncomfortable private events tend to increase their functional importance – both because they become more salient and because these control efforts are themselves verbal linked to conceptualized negative outcomes – and thus tend to narrow the range of behaviors that are possible since many behaviors might evoke these feared private events.

The social demand for reason giving and the practical utility of human symbolic behavior draws the person into attempts to understand and explain psychological events even when this is unnecessary. Contact with the present moment decreases as people begin to live “in their heads.” The conceptualized past and future, and the conceptualized self, gain more regulatory power over behavior, further contributing to inflexibility. For example, it can become more important to be right about who is responsible for personal pain, than it is to live more effectively with the history one has; it can be more important to defend a verbal view of oneself (e.g., being a victim; never being angry; being broken; etc) than to engage in more workable forms of behavior that do not fit that that verbalization. Furthermore, since emotions and thoughts are commonly used as reasons for other actions, reason-giving tends to draw the person into even more focus on the world within as the proper source of behavioral regulation, further exacerbating experiential avoidance patterns. Again psychological inflexibility is the result.

In the world of overt behavior, this means that long term desired qualities of life -- values -- take a backseat to more immediate goals of being right, looking good, feeling good, defending a conceptualized self, and so on. People lose contact with what they want in life, beyond relief from psychological pain. Patterns of action emerge and gradually dominate in the person’s repertoire that are detached from long term desired qualities of living. Behavioral repertoires narrow and become less sensitive to the current context as it affords valued actions. Persistence and change in the service of effectiveness is less likely.

Quick & Dirty ACT Analysis of Psychological Problems

• Most psychological difficulties have to do with the avoidance and manipulation of private events.

• All psychological avoidance has to do with cognitive fusion and its various effects.

• Conscious control belongs primarily in the area of overt, purposive behavior.

• All verbal persons have the “self” needed as an ally, but some have run from that too.

• Clients are not broken, and in the areas of acceptance and defusion they have the psychological resources they need if they can be harnessed.

• To take a new direction, we must let go of an old one. If a problem is chronic, the client's solutions are probably part of them.

• When you see strange loops, inappropriate verbal rules are involved.

• The value of any action is its workability measured against the client's true values (those he/she would have if it were a free choice). The bottom line issue is living well, not having small sets of “good” feelings.

• Two things are needed to transform the situation: accept and move.

The Six Core Processes of ACT

The general goal of ACT is to increase psychological flexibility – the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends. Psychological flexibility is established through six core ACT processes. Each of these areas are conceptualized as a positive psychological skill, not merely a method of avoiding psychopathology.

Acceptance

Acceptance is taught as an alternative to experiential avoidance. Acceptance involves the active and aware embrace of those private events occasioned by one’s history without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm. For example, anxiety patients are taught to feel anxiety, as a feeling, fully and without defense; pain patients are given methods that encourage them to let go of a struggle with pain, and so on. Acceptance (and defusion) in ACT is not an end in itself. Rather acceptance is fostered as a method of increasing values-based action.

Cognitive Fusion

Cognitive defusion techniques attempt to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency or situational sensitivity. Said another way, ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished. There are scores of such techniques that have been developed for a wide variety of clinical presentations. For example, a negative thought could be watched dispassionately, repeated out loud until only its sound remains, or treated as an externally observed event by giving it a shape, size, color, speed, or form. A person could thank their mind for such an interesting thought, label the process of thinking (“I am having the thought that I am no good”), or examine the historical thoughts, feelings, and memories that occur while they experience that thought. Such procedures attempt to reduce the literal quality of the thought, weakening the tendency to treat the thought as what it refers to (“I am no good”) rather than what it is directly experienced to be (e.g., the thought “I am no good”). The result of defusion is usually a decrease in believability of, or attachment to, private events rather than an immediate change in their frequency.

Being Present

ACT promotes ongoing non-judgmental contact with psychological and environmental events as they occur. The goal is to have clients experience the world more directly so that their behavior is more flexible and thus their actions more consistent with the values that they hold. This is accomplished by allowing workability to exert more control over behavior; and by using language more as a tool to note and describe events, not simply to predict and judge them. A sense of self called “self as process” is actively encouraged: the defused, non-judgmental ongoing description of thoughts, feelings, and other private events.

Self as Context

As a result of relational frames such as I versus You, Now versus Then, and Here versus There, human language leads to a sense of self as a locus or perspective, and provides a transcendent, spiritual side to normal verbal humans. This idea was one of the seeds from which both ACT and RFT grew and there is now growing evidence of its importance to language functions such as empathy, theory of mind, sense of self, and the like. In brief the idea is that “I” emerges over large sets of exemplars of perspective-taking relations (what are termed in RFT “deictic relations”), but since this sense of self is a context for verbal knowing, not the content of that knowing, it’s limits cannot be consciously known. Self as context is important in part because from this standpoint, one can be aware of one’s own flow of experiences without attachment to them or an investment in which particular experiences occur: thus defusion and acceptance is fostered. Self as context is fostered in ACT by mindfulness exercises, metaphors, and experiential processes.

Values

Values are chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment. ACT uses a variety of exercises to help a client choose life directions in various domains (e.g. family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance, social compliance, or fusion (e.g. “I should value X” or “A good person would value Y” or “My mother wants me to value Z”). In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather they clear the path for a more vital, values consistent life.

Committed Action

Finally, ACT encourages the development of larger and larger patterns of effective action linked to chosen values. In this regard, ACT looks very much like traditional behavior therapy, and almost any behaviorally coherent behavior change method can be fitted into an ACT protocol, including exposure, skills acquisition, shaping methods, goal setting, and the like. Unlike values, which are constantly instantiated but never achieved as an object, concrete goals that are values consistent can be achieved and ACT protocols almost always involve therapy work and homework linked to short, medium, and long-term behavior change goals. Behavior change efforts in turn lead to contact with psychological barriers that are addressed through other ACT processes (acceptance, defusion, and so on).

Taken as a whole, each of these processes supports the other and all target psychological flexibility: the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values. The six processes can be chunked into two groupings. Mindfulness and acceptance processes involve acceptance, defusion, contact with the present moment, and self as context. Indeed, these four processes provide a workable behavioral definition of mindfulness (see the Fletcher & Hayes, in press in the publications section). Commitment and behavior change processes involve contact with the present moment, self as context, values, and committed action. Contact with the present moment and self as context occur in both groupings because all psychological activity of conscious human beings involves the now as known.

A Definition of ACT

ACT is an approach to psychological intervention defined in terms of certain theoretical processes, not a specific technology. In theoretical and process terms we can define ACT as a psychological intervention based on modern behavioral psychology, including Relational Frame Theory, that applies mindfulness and acceptance processes, and commitment and behavior change processes, to the creation of psychological flexibility.

ACT Therapeutic Posture

• Whatever a client is experiencing is not the enemy. It is the fight against experiencing experiences that is harmful and traumatic.

• You can't rescue clients from the difficulty and challenge of growth.

• Compassionately accept no reasons—the issue is workability not reasonableness.

• If the client is trapped, frustrated, confused, afraid, angry or anxious be glad—this is exactly what needs to be worked on and it is here now. Turn the barrier into the opportunity.

• If you yourself feel trapped, frustrated, confused, afraid, angry or anxious be glad: you are now in the same boat as the client and your work will be humanized by that.

• In the area of acceptance, defusion, self, and values it is more important as a therapist to do as you say than to say what to do

• Don't argue. Don't persuade. The issue is the client's life and the client's experience, not your opinions and beliefs. Belief is not your friend.

• You are in the same boat. Never protect yourself by moving one up.

• The issue is always function, not form or frequency. When in doubt ask yourself or the client “what is this in the service of.”

Readings on this topic
Follette, V. M., & Batten, S. V. (2000). The role of emotion in psychotherapy supervision: A contextual behavioral analysis. Cognitive and Behavioral Practice, 7(3), 306-312.

Pierson, H. & Hayes, S. C. (2007). Using Acceptance and Commitment Therapy to empower the therapeutic relationship. Chapter in P. Gilbert & R. Leahy (Eds.), The Therapeutic Relationship in Cognitive Behavior Therapy (pp. 205-228). London: Routledge.

Wilson, K. G., & Sandoz, E. K. (2008). Mindfulness, values, and the therapeutic relationship in Acceptance and Commitment Therapy. In S. F. Hick & T. Bein (Eds.), Mindfulness and the therapeutic relationship. New York: Guilford Press.

ACT Therapeutic Steps

• Compassionately confront the unworkable agenda, appealing always to the client's experience as the ultimate arbiter

• Support the client in feeling and thinking what they directly feel and think already—as it is not as what it says it is—and to find a place from which that is possible.

• In the service of that goal, teach acceptance and defusion skills.

• Help the client make a richer and less defended contact with the present moment, and with their own on-going thoughts, feelings, and sensations.

• Help the client contact a transcendent sense of self.

• Help the client become more consistently mindful.

• Help the client move in a value direction, with all of their history and automatic reactions.

• Help the client detect traps, fusions, and strange loops.

• Repeat, expand the scope of the work, and repeat again, until the clients generalizes.

• (and don't believe a word you are saying).

Common Misunderstandings About ACT / RFT

Here are a number of common misunderstandings about ACT and RFT.

I've listed only ones that I think are demonstrably false. Ones that could be true I have not listed since this page is about misunderstandings, not legitimate weaknesses. Comments follow each. If you know of others, let me know

- Steven Hayes

• ACT is just _____ (fill in your favorite: Buddhism, CT, BT, CBT, Logotherapy, a psychology of the will, Gestalt, existential, est, Morita, constructive living, solution focused therapy, Kelly role therapy, and so on and so on)
  
  Resemblance is a fun game to play but I have yet to have anyone say these things in strong form (it is just _____) when they have really delved into the philosophy, theory, data, and technology. It is actually a positive sign when you see that others are pointing to somewhat similar issues. If multiple paths lead in a direction perhaps that is a direction worth exploring. If folks want to draw the connections above, it would be good to do them seriously and in print so people can understand the connections. The only ones I could see myself fully agreeing to is "ACT is just behavior analysis" ... or, properly understood, "ACT is just behavior therapy," but I'd quickly want to add "but that area itself has to be understood in a different way to say that." As far as roots, some of these are indeed influences on ACT. You could find some historical connections with CT, BT, CBT, Logotherapy, Gestalt, existential, and est for example. Probably a few more and as it expands lots of new things come in. ACT is a vast community now.

• ACT is a cult
  
  James Herbert has a great powerpoint on this site walking through why that comparison is unfair and inaccurate.

• ACT is just the latest fad
  
  ACT will ultimately die, as will we all, and it may do so soon, but if you mean that it is frivolous or insubstantial, that is just factually incorrect. When you last over 25 years, do over 100 basic and applied studies, and train over 10,000 people, "fad" is just not an applicable term. We do suspect that the theory underlying ACT is wrong but that is because so far in science all theories have ultimately been shown to be incorrect.

• ACT is new on the scene
  
  It is over 25 years old.

• ACT is old on the scene and thus its outcome studies should be __ times more
  
  ACT followed a different development path linked to philosophy, basic research, and process measurement. The 14 years in between outcome studies from 1986 to 2000 that it took to do that should not be held against it ... especially since the detour taken by ACT /RFT in essence was linked to even higher standards and goals. ACT is willing to be held to RCT-linked standards and we have quite a number now. But if you are saying that is all that is important, we will say your sights are set far too low because RCTs alone are not enough to create a progressive field. You need a theory and development strategy that works. If you look at the outcome studies since 2000 it would be a hard case to make that ACT does not care about outcome data.

• ACT seeks ridiculously high goals and thus is making grandiose predictions or claims
  Aspirations are not predictions or claims. Seeking a comprehensive account of behavior that would apply to all human action has always been the goal of behavior analysis as is shown in things such as Walden II. Why is a grand aspiration grandiose?

• ACT is just for smart people
  
  It works for the psychotic and there is some limited evidence that it works for the retarded. It works for the poor and the illiterate.

• ACT works only for white middle class Americans
  
  There are ACT studies from 10 countries includinging countries in Asia and Africa. Successful studies have been done with poor urban black populations; unemployed poor Asian American populations; institutionalized South African blacks, etc. The outcomes are equally good.

• ACT is not committed to science
  
  Download the studies. And don't say that within arm's reach of me or you'd better be able to duck fast.

• ACT is just a technology
  
  It is a far more ... do your reading. It is a model linked to a philosophy, basic science, and a strategy of development.

• ACT is just a philosophy
  
  Ditto.

• ACT is just acceptance
  
  Ditto.

• ACT is just commitment
  
  Ditto.

• ACT is just acceptance and commitment
  
  Aw, come on. This comes from folks reading the titles of books instead of books.

• Acceptance is important because it is a way to change the content of emotion (so ACT is really about that)
  
  The data suggest otherwise. Emotion do sometimes change, but it predicts behavioral outcomes more poorly that changes in the functions of emotions -- and sometimes good outcomes come without a change in emotion within the extant ACT literature.

• Defusion is important because it is a way to change the content of thought (so ACT is really about that)
  
  Double ditto. Same point. Also decent data supporting it.

• The ACT model of cognition is no different than any CBT model -- it is just different in its terminology
  
  If you believe that, have the courage to do your homework in detail and write it up in article form. Then be prepared to have others go after your ideas. We have so far responded to every single serious criticism in print in ACT or RFT, so anyone can read the criticisms and the response and judge the arguments. So far no one, I mean no one, has made the claim above in a careful scholarly article. But it is not the ACT world's obligation to prevent the claim from being made in the hallways of convention hotels or on listserves. Even here we do what we can, however. You are reading exhibit A in that area.

• Defusion is just distancing as that concept is used in CT
  
  They are indeed related. That is one of the real historical sources of ACT. But in ACT there are scores of such techniques, the are emphasized a great deal, and they are put to a quite different purpose than in traditional CT.

• ACT is just mindfulness as that concept is used by Buddhists or ______ (fill in the blank)
  
  ACT is clearly broader at the level of theory and technology. Mindfulness is itself a vague and broad term that it is hard to be precise if it is left at that level. That is why we have written 4-5 articles walking through the concept of mindfulness and trying to come up with a tighter analysis of it. When defined in the right way, ACT is a mindfulness-based approach but it is more than that as well.

• Defusion is just exposure in a traditional sense
  
  Research shows that defusion supports exposure. If you say it is exposure then you have expanded exposure to conver most contact of human beings with events and that is troublesome. Besides exposure itself is not well understood, and ACT folks have a flexibility and pattern-based account of exposure that comports with the ACT model.

• Acceptance is just exposure in a traditional sense
  
  Research shows that it too supports exposure but for the same reasons as the above that does not mean it is just itself exposure. ACT is an exposure-based technology. We said that in 1987. But its goal is teaching more flexible contact with private events and more flexible patterns of responding. We do not do exposure to reduce emotions (thought they usually are reduced).

• ACT does not care about the relationship
  
  We have a model of it; we teach it; we emphasize it. We have data showing that ACT gets high aliance scores; they predict outcome; but they are themselves explained in part by changes in acceptance/defusion/valued action.

• ACT eschews meditation and contemplative practice
  
  It is often in our protocols; ACT targets mindfulness at the level of process in multiple ways however.

• You should not mix behavioral procedures with ACT
  
  The model says you should. ACT is part of behavior therapy. You don't get to peel it away from the model.

• If you do mix behavioral procedures with ACT you now have a combined treatment
  
  ACT is a model. Since the model says you should do this, it does not become a combo treatment to follow the model.

• The other aspects of ACT add nothing to the behavioral elements
  
  We know that they other elements are helpful and that they can support the behavioral elements. If you mean have the other elements that are helpful been shown to make the behavioral elements overall more impactful in outcomes the answer is "not yet in large trials." We shall see.

• The data on traditional CBT is far stronger
  
  Duh. ACT is part of the CBT / BT / BA family but its specific research program is inherently slower since we focused so much on basic science, processes of change, micro-studies and so on. But dig deeper. The vast majority of what is specifically supported in traditional CBT is stuff that ACT folks agree with anyway. If you insist on drag race studies --OK. Be patient. But you can't start outcomes studies in 2000 and expect less than 10 years later to have the same amount of data as the biggest dog on the block.

• It is surely safe to mix ACT techniques with other techniques I'm more comfortable with while I wait passively to understand the model
  
  Ah, no. Down that path lies chaos. It is such a poor model of scientific development. Understand first. Get the data. Then change if you must for good theoretical and practical reasons, not just because you feel like it.

• When I do that I should be able to rename it and get famous tomorrow because what I added (here you can pick any of the other misunderstandings -- relationship, emotion, mindfulness, etc etc) is obviously missing from the model
  
  You can rename it and still come and talk at our conventions etc but branding helps people find the work so at least rename it for a good reason. What is more important? Real progress or a deck on your house and your name in lights?

• You can mix ACT with the cognitive elements of CT / CBT easily
  
  With some, but it is easy to pervert ACT into the same agenda and ACT has a different one. Be careful. Incoherence is not usually helpful and patients will detect the incoherence if it is there.

• It is safe to do research on ACT without doing any training in ACT
  
  Is it safe to do surgery that way? You cannot read a book and do this well. Get some training. It is cheap and available and non-proprietary. ACT folks will collaborate and consult. Reach out.

• It is safe to criticize ACT based on what you've heard about it from others who are not expert in it
  
  What is it about reading carefully that is so aversive?

• ACT contains nothing new
  
  If you've studied it thoroughly, just say it in print and say why you say that and let us all look at it dispassionately. If you've not done your homework yet, see above.

• ACT is behavioral in an S-R sense
  
  ACT is actively hostile to S-R psychology.

• ACT is behavioral in a traditional behavior analytic sense
  
  ACT / RFT is part of behavior analysis, but RFT changes everything. ACT is part of post-Skinnerian behavior analysis -- which is a new form. We call it "contextual behavioral science." Read the RFT book for why we say that.

• For these reasons ACT is not oriented toward cognition
  
  70-80 studies on cognition later, how can folks still say that?! Come to a training at least.

• For these reasons ACT is not oriented toward emotion
  
  Come to a training!

• Because ACT is broadly applicable it is based on non-specific clinical process
  
  The theory says why it is broadly applicable and the process data so far say it is successful due to specific process changes. We now have nearly 15 mediational analyses out or in press.

• Anything that works for such a broad range of problems must be bulls**t
  
  The theory says why it is broadly applicable. Who are you to say a priori what nature is like?

• There are not many outcome studies on ACT
  
  About 30 RCTs and several more controlled time series designs and counting. We just really started in the year 2000.

• ACT / RFT is a small minority
  
  Maybe. But there are about 1800 folks on the ACT / RFT listserves and nearly 1200 in the association. Besides, minority or not, we are speaking of ideas and data, not politics.

• ACT proponents make excessive claims that go beyond the data
  
  A quote would be nice.

• ACT is hierarchical and you have to pledge allegiance to a leader to be involved with it
  
  It's an open list serve; an open website; no certification of therapists; no cut goes to originators from members/trainers/etc; you can get our protocols for free; anyone can become a trainer. Ther are more ACT books by others than by the originators, by far. This is just so unfair.

• ACT processes have not been studied
  
  Download the list of studies and read them. We think our process data re getting pretty strong.

• RFT can't explain anything other models of cognition cannot explain
  
  RFT researchers have explained phenomena that other approaches have had hard times with. For example, we are learning how to establish a sense of self, we know a lot about how metaphor works, we know a core process in human cognition. I'll send you some studies if you agree to read them.

• RFT is just jargon
  
  How much have you carefully read so far? Until you read carefully you cannot distinguish jargon and a technical language. We think it is a techical language. If you disagree, pick a technical term and show how it is the same as another more popular one. Maybe there was a slip.

• ACT is just jargon
  
  Same reaction as above.

• No one can understand RFT
  
  Do the [[RFT tutorial]] on this website. Yes the basic studies are damn hard to understand ... but it is not beyond anyone reading this website. Physics is hard too -- so?

• No one can understand ACT
  
  You can. And "understanding" in a purely intellectual sense is not the point for clients anyway. Usually what therapists mean when they say this is that they are afraid that if they don't understand it thoroughl they can't do it effectively. Folks like Raimo Lappalainen have shown that ACT works even when delivered by beginning therapists who don't really understand it. In fact most of the outcome data on ACT was not done with experienced ACT therapists. It's a miracle these studies work at all -- but they do.

• RFT has little to do with ACT
  
  Many links are there. Others are being developed. ACT and RFT are co-evolving. That is how applied and basic science should relate, we believe.

• ACT folks don't want CT people to be involved and they look down on them
  
  Ask some CT people who got involved in ACT work what they think about how they were treated. Just ask.

• We don't know which components work because there are no dismantling studies
  
  ACT comes from an inductive tradition. Rather than wait decades for dismantling studies we've done nearly 20 technique building and micro-analytic studies. Almost every aspect of the model has some targetted research data.

• I hate the enthusiasm of students who do these workshops -- it scares me
  
  Enthusiasm is not the same as substance ... but must enthusiasm be hostile to substance? Besides I thought you were a scientist. Why let emotion substitute for data just because it is now your emotions (I hate it) at issue? Be consistent. If enthusism creeps you out try to make room for being creeped out, hand on to your legitimate skepticism, and follow the data.

• I just don't like ACT
  
  See above.

• Talk of spirituality in ACT is creepy
  
  It is treated as a naturalistic concept. ACT is not a religion.

• I don't want to be told my values
  
  ACT folks will never do that ... your values are your choice.

• There is no data on ACT in groups
  
  There are 10 RCTs on ACT in groups right now.

• ACT works through the same process as ____ (fill in your favorite)
  
  Show me the actual research please.

• ACT is not self-critical
  
  Lurk on the list serve and see.

• Steve Hayes is a jerk -- I saw him do a mean joke or a mean comment at ABCT
  
  ACT is not Steve Hayes -- there are scores of leaders in ACT / RFT. Besides, distinguish the message from the messenger. Some of us are confrontational about intellectual issues, but we don't go after people or traditions: just ideas. We are just playing hard. Why not? It is fun and can be helpful. No everyone plays hard though. if you hate folks who do, go to ACT talks (etc) by softer folks. As for mean humor, sometimes roast human slips a bit, but we tease those we respect. In the ACT community we use humor to remind us all that this work is not about the muckity mucks ... it is a shared enterprise and everyone is part who wants to be part and is willing to bring science b=values and caring to the table. If you come to an ACT conference you will see that the ACT / RFT leadership is outright ridiculed in the "follies" and it is just great fun. Anyone has access to the stage. Even cognitive therapists! :)

• ACT is crazy (or my personal favorite variant since I'm writing this, Steve is crazy)
  
  Ah, finally you are getting somewhere. But as that Time guy said in the last line of the story -- we may just be crazy enough to pull it off. If you are nutty enough to want to help us, come help us succeed.

Criticisms of ACT

Given the values of ACBS, there has been efforts from the beginning of the ACBS community to encourage responsible criticism, to give thoughtful critics a stage to speak to the group, of trying to respond thoughtfully in writing to knowledgeable critics, and of trying to resolve issues empirically where possible. Criticisms of ACT have appeared in published forms. The written criticisms of RFT (and to a lesser degree, functional contextualism) are extensive and in writing, as are the defenses. They can be found in the other sections of the website.

Self-Criticism

Part of the core of the ACT / RFT tradition is the openness to criticism, including self-criticism. At the LaSalle ACT Summer Institute (Philadelphia, 2005) James Herbert gave a really solid paper walking through many of the criticisms he knew about, under the title "Is ACT a fad?" He considers not just whether the criticisms are correct, but what those in the ACT / RFT community should do about them. You can look at that talk by clicking on the link below.

• Criticisms of ACT, ACT Summer Institute II (July 2005, PowerPoint file)

Published Criticisms and Responses: An Ongoing Conversation Below is a list of papers that have been published criticizing ACT as well as replies that have been published when available. If you know of other criticisms or replies please email us or add a child page to this page.

• Corrigan, P. (2001). Getting ahead of the data: A threat to some behavior therapies. The Behavior Therapist, 24(9), 189-193.

This was the first strong criticism of ACT published. Corrigan argued that the ratio of non-empirical to empirical articles could be used to argue that third-wave CBT was ahead of its data.

A reply: Hayes, S. C. (2002). On being visited by the vita police: A reply to Corrigan. The Behavior Therapist, 25, 134-137.

The reply argued that the ratio of non-empirical to empirical articles could not be meaningfully used as a measure of getting ahead of data since there were many good reasons to write theoretical discussion pieces. Instead, actual claims that got ahead of the data had to be identified and none have been. Pat has been helpful to ACT researchers in various capacities over the years since that article.

• Corrigan, P. (2002). The data is still the thing: A reply to Gaynor and Hayes. The Behavior Therapist, 25, 140.

• Asmundson, G. J. G., & Hadjistavropolous, H.D. (2006). Acceptance and Commitment Therapy in the Rehabilitation of a Girl With Chronic Idiopathic Pain: Are We Breaking New Ground? Cognitive and Behavioral Practice, 13, 178–181.

• Hofmann, S. G., & Asmundson, G. J. G. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28, 1-16.

• Hofmann, S. G. (2008). Acceptance and Commitment Therapy: New Wave or Morita Therapy? Clinical Psychology, Science and Practice, 5, 280-285.

The theme of these two articles is that ACT and other mindfulness-based treatments is the same as CBT, and that ACT is the same as Morita Therapy. After these articles were written Stefan Hofmann was invited and funded to speak to the ACBS community in Chicago (2007). We had a great time in respectful dialogue. Read more about this criticism in non-peer-reviewed settings and the ensuing dialogue, click on the child page"ACT is Outright Taken from Morita Therapy" below.

• Öst, L. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), 296-321.

This article is in part based on proactive efforts by the ACBS community to encourage knowledgeable criticism. Lars-Goran Öst has been invited and funded to come to several ACT conferences beginning even before he was knowledgeable of ACT work, given that he was asked to play the role of an outside critic at the first World Conference in Linkoping, Sweden (2003). He was later also invited to London (2006), and Enschede, The Netherlands (2009), that last invitation coming after the article itself was available.

The theme of Lar-Goran's criticisms have been that ACT research has methodological weaknesses, and that it is not as well done as mainstream CBT research. The latter was based on a comparison of ACT studies with a matched set of traditional CBT studies. His conclusion is that ACT is not an evidence-based treatment.

Gaudiano reply: Gaudiano, B. A. (2009). Öst's (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching apples with oranges? Behaviour Research and Therapy, 47, 1066-1070.

Öst reply: Öst, L. -G. (2009). Inventing the wheel once more or learning from the history of psychotherapy research methodology: Reply to Gaudiano's comments on Öst's (2008) review. Behaviour Research and Therapy, 47, 1071-1073.

Gaudiano rejoinder: Gaudiano, B. (2009b) Reinventing the Wheel Versus Avoiding Past Mistakes when Evaluating Psychotherapy Outcome Research: Rejoinder to Öst (2009). Brandon has replied again in a piece self-published online (in an attempt to keep the conversation flowing without the confines of the lengthy peer-review process).

The theme of the replies was that errors were made in Lar-Goran's matching and coding process, resulting in a distorted comparison, and that ACT studies are not weaker when resulting differences in population and funding are weeded out. Further, it is noted that ACT is already listed by APA as an evidence-based treatment. Lars-Goran admits that the two sets of studies are not matched in areas such as funding, and that APA lists ACT as evidence-based, but holds to his original views.

• Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science & Practice, 5, 263-279.

A reply: Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of ACT and traditional CBT. Clinical Psychology: Science and Practice, 5, 286-295.

The theme of the response was that ACT is part of the CBT tradition, but it is not possible to compare intellectual similarities until CBT says what it is. Efforts of the authors to do so were argued to change long standing mainstream views, which explain some of why the two could be argued to be very similar. Both the critical article and response agreed that there were good empirical issues to be explored.

Reflective of the tone of this dialogue, several ACT researchers (Georg Eifert, John Forsyth, Steve Hayes, Mike Twohig) are doing work with Michelle Craske and her colleagues trying to study the issues raised. Michelle has been invited to speak at an ACBS World Conference. She was not able to come in 2009 but we hope to hear her in the future.

• Powers, M.B., Vörding, M.B., & Emmelkamp, P. (2009). Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 8, 73-80.

A reply: Levin, M., & Hayes, S.C. (2009). Is Acceptance and commitment therapy superior to established treatment comparisons? Psychotherapy & Psychosomatics, 78, 380.

Author response: Powers, M. B., & Emmelkamp, P. M. G. (2009). Response to ‘Is acceptance and commitment therapy superior to established treatment comparisons?’ Psychotherapy & Psychosomatics, 78, 380–381.

ACT researchers have critically examined the method of the meta-analysis and have published a response to the study, with a revised analysis. A counter response by Powers and colleagues is also available. We invited Paul Emmelkamp to come to Enschede but he could not ... we hope to get him to an ACBS conference in the future.

Replies to Critiques in General: Articles Describing the CBS Strategy Extensive reviews of the issued raised in this article are out or in press, but they are too extensive to simply call them "replies." The theme of the articles (which you can read by clicking the link above) has been to describe the ACT approach, its knowledge development strategy and to show its distinctive features.

Getting Beyond the Way of the Guru and Other Scientific Deadends

ACT is drawing a great deal of attention and many of the folks now connecting with the work are not behavior analysts. In addition, behavior analysis itself is not necessarily evolving fast enough for visitors to see through to its core and to its potential without a bit of a roadmap. Many of the folks who visit this site would recoil from ACT's intellectual home base if dropped into an Association for Behavior Analysis convention, say, without a friend. Much of what is there will seem foreign or even hostile to an ACT / RFT perspective. But do the same with someone knowledgeable -- especially someone to help deal with the confusion because both mechanists and contextualists co-exist inside this tradition and to help find the right resources -- and the vast majority of those who connect with the ACT work will see the relevance of behavior analysis.

If the ACT / RFT agenda is successful this problem will eventually resolve itself because RFT (especially) and perhaps to a lesser degree ACT will move the home base itself. But we are not there yet.

The grand strategy here is this (this is not so much sequential and linear as it is an interconnected web):

build the contextualistic wing of BA, build the RFT research program, build the ACT program, build the links between ACT and RFT, build the other applied extensions of RFT, use ACT to draw mainstream clinical to the work, expose mainstream CBT to the value of RFT, expose mainstream cognitive psychology to the value of RFT and use RFT to do hard work in that area, expose other areas of psychology (prevention, education, etc etc etc) to the value of ACT / RFT and use ACT/RFT to do substantial work in those areas, use the support for ACT and RFT to build support in academic departments for basic behavior analysis, bump behavior analysis itself along, end up with a revitalized form of behavior analysis inside the mainstream of psychology.

Whew

This is not politics, though it may look like it in some of its features. It makes sense only if you believe that for the good of humanity functional contextual psychology should play far more of a role in the future of psychology than it otherwise seems destined to, and that to do that it needs not just to be understood but to develop itself.

But if you look at the list above you will see a problem. This agenda cannot work if the work begins and ends with ACT. The explosion of popularity of ACT is both a blessing and a danger. Folks come to the work and think it is just a neat technology. Some immediately start to modify it based not on theory or development of needed processes but on comfort (I like doing X, X is not in there, I will do ACT + X). Some folks are doing ACT studies without ever having been to an ACT / RFT conference, or even an extended ACT training, etc. So just when we have a chance to leverage attention for even more dramatic change, we risk crumbling into incoherence.

Once ACT is a technology only, it is done. Because then, how doe sit develop?

If you just let the technology stay as it is you have:

Option A. The Way of the Empirically Supported Treatment Manual. The technology is it. Sell the manuals. Validate them. Sell them some more. Then let them gather dust.

If you are going to let it develop then you have other options:

Option B: The Way of the Guru. A charismatic leader declares new things to be in or out. Yuck.

Option C: The Way of Politics. Anything goes provided enough folks support it, thus create subgroups to support innovations/styles/techniques etc. Eventually this option becomes Option B, or ACT just splinters into nothingness
and you are left just with a name and canonical texts.

Option D: The Way of Scientific Battleships. Anything goes provided you have some data. The kitchen sink is useful, too, so don't forget to throw that in. And, way the way, where did those ideas you threw in come from in the first place? Ahhh. Hmmm. Brute force science linked to commonsense cannot see through to the essence of things. Precision, but no scope. Eventually this becomes a sequential version of Option A.

There is another option. It is the way bieng followed in the ACT / RFT approach. ACT is a model, based on processes and techniques that modify those processes. The processes are linked to basic principles and a basic research program on those principles. All of that stands on a philosophy of science and on an intellectual and methodological tradition.

This is Option E: The Way of an Evolving Science.

But to do this, we have to take responsibility for it. Folks drawn into ACT, for example, need to take seriously the possibility that overtime they will need to learn more about RFT, and then about behavior analysis itself (even if they are, say, psychoanalysts, or existentialists, or cognitive therapists). If you force that too early or too rudely and it is a barrier. But ignore it altogether, and it is a recipe for ultimate irrelevance. Thus ACBS. Thus, the World Conferences. Thus this website.

We cannot expect someone else to do it. Together, as a community, we have to work together to create a progressive science more adequate to the challenge of the human condition.

- Steve Hayes

ACT Study Group for Beginners

How This Came About

In February 2004 several beginners, interested but little experienced with ACT, found themselves on the ACT listserve. The idea arose for launching an on-line study group for beginners. Very soon 30 or more folks signed in, and the “ACT study group for beginners” was born.

We began reading the book chapter by chapter, and discussing it on the listserve. The first, theoretical part was tough. Kate Partridge raised the idea of starting each discussion with a summary of a section of the book. The summarizing began on 04/13/04, when we reached the clinical part of the book.

What you find below is a uncensured, uncorrected collection of the summaries. They’re meant for discussion, not for teaching purposes per se, but we are allowing them to become part of this website simply because we hope they might be useful to other beginners. People from 7 countries did parts of it: Australia, Belgium, Canada, Netherlands, Spain, United Kingdom, and the USA. (More countries participated in the discussion: Germany, Israel, Sweden, …) It was fun to participate, and very inspiring, … but sometimes hard too: we chose a fixed schedule of weekly reading, discussing, and sometimes summarizing … but we were willing and committed.

Part of the value in doing this probably cannot be achieved just by reading these products. This way we structured it beginners, hesitatant to take part in discussions between more experienced ACT-ors, had unique learning opportunities by taking part in the beginners’ discussion. The “masters” could watch us and interfered when helpful, which also was stimulating. I can recommend the formula to other beginners and hesitating “lurkers”. It might be worth while to start a second round. But that’s up to others. Meanwhile, here are our written products.

Thanks to all beginners who participated, and to the listserve for the opportunity!

ACT/RFT Reader's Update (December, 2009)

Science and Practice: ACT/RFT Reader’s Update December, 2009

___________________
Acceptance and Values-Based Action in Chronic Pain: A Study of Treatment Effectiveness and Process

Cognitive-behavioral approaches to pain management have an established record of empirical support. However, as true with other behavioral problems, the mechanism by which improvement occurred is inconsistent with the theoretical underpinnings of CBT. In a recent paper, Vowles and McCracken add to their ongoing line of research in acceptance-based approaches to the treatment of chronic pain. In their paper, they present their findings of an inter-disciplinary treatment program based in Acceptance and Commitment Therapy, with a focus on acceptance and values-based action. One-hundred seventy-one participants completed the program which consisted of 3 to 4 weeks of inpatient treatment for about 30 hours per week. Participants improved across almost all domains, including pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance, and effect sizes for these improvements were medium to large. Analysis of reliable change revealed that 75.4% of participants improved in at least one key domain assessed. In contrast with CBT-based approaches to pain management, improvements across these domains were associated with ACT's proposed mechanisms of action, namely, acceptance of pain and values-based action. The authors conclude that these findings provide support for the ACT model of treatment for chronic pain, and the processes associated with improvement – acceptance and values-based action.

Vowles, K., & McCracken, L. (2008). Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process. Journal of consulting and clinical psychology, 76(3), 397-407.

___________________
Rule-Governed Behavior and Psychological Problems

Humans, uniquely among animals, can come to understand and respond to linguistic rules, both effective ones and not so effective ones. The effective ones help us to learn and adapt to our environment. The ineffective ones can cause maladaptive behavior and diminish our lives considerably. This paper presents a functional analysis of patterns of rule-governed behavior (RGB) and shows how rules can contribute to psychopathology.

Rules have been described as antecedent stimuli that alter the functions of stimuli in our environment. They allow us to respond to that environment in complex and efficacious ways. But what are rules? Relational Frame theory suggests that we humans learn to respond in accordance with abstract relational patterns based on cues (e.g., SAME). Rules are essentially combinations of cues that specify particular relations between environmental stimuli and between environment and behavior and thus allow us to respond in new ways (‘transformation of function’).

The paper describes three functional patterns of RGB. These are pliance, tracking and augmental rule following. Pliance is RGB under the control of a history of socially mediated reinforcement for coordination between behavior and antecedent verbal stimuli (rules). A typical example might be a child obeying the rule ‘Don’t touch my laptop’ because their parent has given them this rule and because their parent has previously provided consequences for following or not following rules.

Tracking is RGB under the control of a history of coordination between the rule and the way the environment is arranged independently of the rule. An example might be a child obeying the parental rule ‘Eat your breakfast because it will give you more energy’ because in the past the child has experienced the effect of other rules that have been accurate in their description of the environment. If this rule also shows coordination (i.e., the child finds an increase in energy when they eat breakfast), then this will further strengthen tracking behavior.

Augmenting is RGB due to relational networks that alter the degree to which events function as consequences. The example given is ‘Eat your vegetables to be a big strong boy’. If this rule makes vegetable eating more reinforcing then it might be described as augmenting.

Each of these patterns has its advantages and its disadvantages, including maladaptive behavior. It’s useful for children to learn pliance since this allows them to acquire useful adaptive habits, but doing things just because one is told to can make one insensitive to one’s environment. Tracking allows independence from social whim, but tracking can also lead to ineffective behavior; for example, tracking short term reinforcement can mean one misses longer term reinforcement. Augmenting is the most advanced form of rule governed behavior and as such it can interact with and reinforce either of the other two functional patterns resulting in strongly adaptive or maladaptive patterns. Experiential avoidance can be a product of the latter while valuing, an important part of the antidote to EA, is an example of the former.

Törneke, Luciano and Valdivia (2008) have provided an excellent description of RGB and its relationship to psychopathology.

Törneke, N. Luciano, C. & Valdivia Salas, S. (2008). Rule-Governed Behavior and Psychological Problems. International Journal of Psychology and Psychological Therapy, 8 (2), 141-156.

___________________
Brief Review: A Parametric Study of Cognitive Defusion and Believability

The effects of the “Milk, milk, milk” exercise are dependent upon the length of the intervention: Reducing distress in respect to private events has been a major emphasis of traditional behavioral and cognitive behavioral therapies. The inclusion of mindfulness interventions in some contemporary therapies like ACT has shifted this focus from distress reduction to changing the behavior regulatory functions of distressing private events. One means of examining this change is by asking clients about the believability of their thoughts. Defusion interventions represent efforts to disrupt this behavior regulation, and the “milk, milk, milk” exercise is the intervention examined in this article. Two studies examined the effect of this exercise on the emotional discomfort and believability of a negative, self-relevant word identified by the participant as sufficiently problematic. Each study varied the amount of time spent repeating the word – 0, 3, or 20 seconds in study 1 and 1, 10, or 30 seconds in study 2. A rationale for the procedure and training with the word “milk” was provided before each intervention. Results showed that emotional distress reduced significantly within 3-10 seconds, while believability reduced significantly only after 20-30 seconds. The difference in timing for these reductions suggests that discomfort and believability are functionally distinct behaviors. The authors suggest extending defusion exercises until the believability of thoughts, rather than just emotional distress, diminishes.

Masuda, A., Hayes, S. C., Twohig, M. P., Drossel, C., Lillis, J., & Washio, Y. (2009). A parametric study of cognitive defusion and the believability and discomfort of negative self-relevant thoughts. Behavior Modification, 33, 250-262.

___________________
Brief Review: Relational Frame Theory and Social Categorization

The Matching-to-Sample procedure can transform the functions of arbitrary stimuli in the Implicit Associations Test: This study examined the acquisition of obesity stigma to arbitrary stimuli. More specifically, the matching-to-sample (MTS) procedure was used to provide relational conditioning sufficient to generate a transformation of stimulus functions for stigma to images of either horizontal or vertical lines. The Implicit Associations Test (IAT) was used to detect this transformation of functions. Fifty undergraduate psychology students engaged in a series of five computerized tasks: (1) an IAT containing evaluative words and images of horizontal and vertical lines, to confirm a lack of pre-existing bias, (2) an established IAT for detecting implicit evaluative bias toward obesity, to confirm the presence of pre-existing bias, (3) two MTS tasks providing relational conditioning sufficient to generate the transfer of positive and negative evaluative functions to images of horizontal and vertical lines, (4) the same IAT used in step 1, to assess for the acquisition of bias, and (5) the same IAT used in step 2. Results confirmed no pre-existing bias at time 1, a large and significant predicted bias at time 2, and a small and significant predicted bias at time 4. The results of this study are discussed in respect to an RFT account of the development of stigma and social categorization and contrasted with a more mainstream, cognitive account known as the Social Knowledge Structure.

Weinstein, J. H., Wilson, K. G., Drake, C. E., & Kellum, K. K. (2008). A relational frame theory contribution to social categorization. Behavior and Social Issues, 17, 39-64.

Revised/Reviewed by: Walser, R., Chartier, M., Sears, K., Drake, C., Valverde, M., Stewart, I., Ulmer, C., & Westrup, D. Read the ACT RFT Reader's Update: References & Abstracts, 2008 in an interactive PDF, attached below.

ACT/RFT Reader's Update (Fall, 2008)

Science and Practice: ACT /RFT Reader's Update Fall, 2008

Welcome to ACT/RFT Reader's Update:

In our second issue we summarize 5 articles recently published in peer-reviewed journals. The references to full citations and whether they are available for download on the ACBS website is also included. Citations for the latest books, book chapters, and unpublished dissertations are listed at the end of the update. If you don't see your recently published article….hang on, we continue to work on future issues and have a fair number of articles that are being reviewed and summarized for our coming issues. However, if you are publishing or have recently published please make us aware by either sending us the reference or pdf. Thanks.

We hope you will find our e-mail updates of interest and value. If you have questions, please contact Robyn Walser, Robyn.Walser@va.gov or robyn.walser@sbcglobal.net, or Maggie Chartier at maggie_chartier@yahoo.com.

Enjoy your read!

Our editors and reviewers/writers:

Editors:
Robyn D. Walser, Ph.D.
Maggie Chartier, MPH, MS

Reviewers/Writers:
Chad Drake, MA
Miguel Rodríguez Valverde, PhD
Ian Stewart, PhD
Christi Ulmer, PhD

This issue of Science and Practice: ACT/RFT Readers Update contains 5 summaries:

ACT ARTICLES AND RELATED TOPICS

Acceptance and commitment training reduces prejudice and promotes diversity-oriented behaviors in college students

Despite increased efforts at promoting diversity in recent years, prejudice continues to result in diminished quality of life for ethnic, racial and religious minorities across numerous life domains. Interventions designed to reduce prejudice have been moderately successful with short-term improvements, but do not seem to promote sustained equitable attitudes and behavior. In fact, in some instances, the interventions actually result in an increased bias. ACT may be particularly applicable to prejudice due to its focus on intransigent and difficult cognitions. Luoma and Hayes compared a brief ACT Training protocol to an education-based prejudice awareness training intervention for reducing racial and ethnic prejudice in college students. Material was presented to students using a counterbalanced within-group design such that the impact of each approach could be evaluated independently. The outcome measure, developed for this study, consisted of items assessing the following: awareness of bias; acceptance and flexibility; thought control and defusion; and positive actions. Student responses suggest that the ACT training produced greater reductions in prejudice across most dimensions, and that only ACT training promoted greater intention to engage in diversity-oriented behaviors. Changes in these positive intentions were partially mediated by acceptance and flexibility, and defusion processes explained more variance in positive intention outcomes than acknowledgement of bias. The authors suggest that the combined findings of this study and a previous ACT-based study on prejudice lend preliminary support to an ACT-RFT based model of understanding and reducing prejudice. The findings are also consistent with the theory underlying acceptance-based approaches stating that it is the relationship with thought rather than the content of thought that matters. Limitations of the study include the use of an unvalidated outcome measure, the potential self-selection bias of students who choose to enroll in a class on the psychology of racial differences, the potential for bias of the interventionist in favor of ACT, and a short follow-up interval. Future studies are proposed using a more intensive intervention and assessing longer-term outcomes. Given the need for empirically supported approaches to address prejudice, the findings of the current study are promising. In terms of clinical application, the authors propose that similar processes are likely in play with regard to mental health stigma, and that cognitive processes that promote prejudice are themselves psychologically damaging.

Read the Article:

Lillis, J., & Hayes, S. C. (2007). Applying acceptance, mindfulness, and values to the reduction of prejudice: A pilot study. Behavior Modification, 31(4), 389-411.

________________

ACT and CT for anxiety and depression, a randomized controlled effectiveness trial

For some period of time there has been discussion and even argumentation between those who hold true to cognitive models of intervention (e.g. Beckian) and acceptance models of intervention (e.g. Hayesian). Forman and colleagues take a closer look. They explain that Cognitive Therapy (CT) has a mixed record of success in producing theoretically-consistent mediation of treatment outcomes while Acceptance and Commitment Therapy (ACT) has a relatively impressive, though preliminary record, of the same. Given that only a handful of studies have directly compared these treatments and that all contained methodological shortcomings the authors undertook that task of comparing each therapy's ability to produce mediation and positive outcomes among an outpatient sample of college students in a well-controlled trial. Services were provided by clinical psychology doctoral candidates working at a student counseling center. Outcome measures included self-reports of symptoms (BDI-II, BAI, OQ-45) and self-reports of quality of life (QOLI, SLS). Two mediational measures were administered (KIMS, AAQ). The study also included measures of treatment fidelity, therapist allegiance, and participant expectancies of treatment. Results showed that all measures were comparable between treatments, and that each treatment generated large effect sizes. Mediational analyses showed that the observing subscale of the KIMS more strongly (though nonsignificantly) predicted outcomes for CT, while the AAQ and the acting with awareness and acceptance subscales of the KIMS more strongly (and significantly) predicted outcomes for ACT. The authors reported that "changes in "observing" and "describing" one's experiences were more strongly associated with outcomes for those in the CT group relative to those in the ACT group, whereas experiential avoidance, acting with awareness, and acceptance were more strongly associated with outcomes for those in the ACT group" (p. 792). Although, the authors concluded that "these findings support the notion that CT and ACT are functionally distinct from one another" (p. 792), it was never explained why the capacity to observe and describe one's private experiences is a fundamental component of CT but not ACT.

Read the Article:

Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behavior Modification, 31, 772-799.

RFT ARTICLES

How does multiple-exemplar training and naming establish derived equivalence in an infant?

Stimulus equivalence at its simplest can be described as follows. Imagine I train someone in the following two relations between physically different arbitrary stimuli: Pick stimulus B when you see stimulus A, and pick stimulus C when you see stimulus B. If given the opportunity, a verbally able human might subsequently go on to demonstrate further relations, without being trained to do so, including picking A when he sees B, and picking B when he sees C (i.e., reversing the trained relations, referred to as symmetry), picking C when he sees A (i.e., combining the trained relations, referred to as transitivity) and picking A when he sees C (a combination of symmetry and transitivity). This pattern of derived responses has been called stimulus equivalence, because it appears that, suddenly and unexpectedly and without being trained to do so, the person is treating a number of physically different stimuli as mutually substitutable for or equivalent to each other. There is growing interest in stimulus equivalence research as only verbally able subjects seem to be able to show this pattern readily, suggesting a link between equivalence and language. But what is the nature of this link? How are the two connected? The present paper discusses two theoretical approaches that claim to account for this link - Relational Frame Theory (e.g., Hayes et al., 2001) and Naming Theory (Horne & Lowe, 1996). More importantly, however, the paper reports a series of experiments involving training an infant in relational responding that provide important additional evidence pertaining to the debate between these approaches. More specifically, the results add to evidence in favour of the RFT account, while demonstrating a phenomenon that directly contradicts Naming Theory. This study is a significant empirical contribution for a number of reasons (i) It demonstrates the use of multiple exemplar training to establish generalized contextually controlled receptive mutual entailed relational responding; (ii) it provides the youngest empirical example of coordinate (sameness) combinatorial entailed relational responding (equivalence) ever recorded; and (iii) it provides extremely important evidence vis-a-vis the Naming Theory / RFT debate by providing empirical evidence that directly contradicts a core tenet of Naming Theory while being consistent with RFT.

Read the Article:

Luciano, C., Becerra, I. G., & Valverde, M. R. (2007). The role of multiple-exemplar training and naming in establishing derived equivalence in an infant. Journal of the Experimental Analysis of Behavior, 87(3), 349-365.

________________

Can the Implicit Relational Assessment Procedure be faked? First evidence says no.

The Implicit Relational Assessment Procedure (IRAP) is a computer-based task for the assessment of implicit cognitions recently devised within the theoretical framework of RFT. It is a latency-based response measure that intends to assess the participants' existing verbal-relational networks (i.e. beliefs). It works by requiring participants to respond as quickly and accurately as possible across trials when presented with particular relations (among sample and target stimuli) that may be consistent or inconsistent with their beliefs (i.e. relational networks). The idea is that participants will be faster when required to respond to stimulus relations that are consistent (e.g. categorizing words like love or peace as pleasant, and words like vomit or death as unpleasant) than to stimulus relations that are inconsistent with their verbal histories (e.g. categorizing vomit or death as pleasant, and love or peace as unpleasant). This idea is supported by empirical evidence from several recent studies. As with other implicit measures, like the Implicit Association Test (IAT), one of the strengths of the IRAP is that it may be less sensitive than questionnaires and other explicit measures to assess deliberate attempts to conceal information about one's own socially sensitive attitudes. This study attempted to see to which extent this is the case (i.e. whether the IRAP can be faked). Three groups of participants underwent two consecutive exposures of the IRAP task with the same stimuli (the words pleasant and unpleasant as samples, the words similar and opposite as response options, one set of six pleasant target words, and one set of six unpleasant target words). Between both exposures, one group was informed about how the IRAP works. Another group received the same information and was told to fake the IRAP, without a specific strategy to do so. The third group received the same information and were also provided with a strategy, namely slowing down on consistent trials and going fast on inconsistent trials. Results showed no evidence of faking in any condition. All groups showed an IRAP effect in the second exposure regardless of the instructions or strategies received. According to a post-task questionnaire, only two participants in the third group reported using the specific strategy they had received. All in all, participants found it difficult to fake the IRAP, even if provided with specific strategies. This contrasts with previous findings with the IAT, which can be successfully faked when explicitly told how to do so. This observed resistance to deliberate attempts to fake performance renders the IRAP a solid procedure for the assessment of implicit cognitions.

Read the Article:

McKenna, I., Barnes-Holmes, D., Barnes-Holmes, Y., & Stewart, I. (2007). Testing the Fake-ability of the Implicit Relational Assessment Procedure (IRAP): The First Study. International Journal of Psychology and Psychological Therapy, 7, 253-268. (in English)

______________________

What can RFT add to the study of pain?

The current study focuses on an RFT interpretation of the way that pain takes part in complex behavioural episodes for humans. It is a theoretical/conceptual study that reviews functional-contextual approaches to the study of private events specifically related to pain and with a special emphasis in recent research in verbal behaviour, behaviour-behaviour relations, and transformation of psychological functions. The review is divided into four parts. The first summarizes the philosophical assumptions of functional-contextualism and its implications for the study of pain (e.g. the extent to which explanations of pain allow for effective action as the criterion against which these explanations should be tested). The second focuses on the classical behaviour-analytic point of view, where pain experiences have been conceptualized as private events that exert discriminative control over subsequent behaviours (e.g. abuse of pain-killers, inactivity, social isolation, etc.). This discriminative function (behaviour-behaviour relation) is the product of specific histories of reinforcement along the individual's development, in direct-contingency terms. This view is illustrated with the presentation of the contributions of Schoenfeld and, more specifically, of Fordyce. RFT is proposed as a more comprehensive framework for the behaviour ral study of pain, a framework where verbal (derived) histories can be included as part of the explanation. In line with this, pain-related clinical problems are conceptualized as a form of experiential avoidance disorder, where it is the verbal functions of pain, rather than pain itself, that limit the individual's life (i.e. the consideration of pain as a literal barrier for engaging in valued actions). This is described in the third part of the article. Finally, the last part of the article presents a general overview of ACT and describes its implications for the treatment of pain-related problems.

For more information, read the original article in Spanish:

Gutiérrez Martínez, O., & Luciano Soriano, C. (2006). Un studio del dolor en el marco de la conducta verbal. International Journal of Clinical and Health Psychology, 6, 169-188. [A study of pain in the framework of verbal behavior: from the contributions of W. E. Fordyce to Relational Frame Theory (RFT)]

(for correspondence and reprints): olgaguti@ugr.es

BOOKS

Ciarrochi, J. V., & Bailey, A. (2008). A CBT practitioner's guide to ACT. Oakland, CA: New Harbinger.

BOOK CHAPTERS

DISSERTATIONS

Barthold, C., & Hoffner, C. (2007). Factors affecting the generalization of 'wh-' question answering by children with autism. Dissertation Abstracts International Section A: Humanities and Social Sciences, Vol 68(4-A): 1403.

EDITORIALS AND COMMENTARIES

Hayes, S. (2007). Hello Darkness. Psychotherapy Networker, Sept/Oct. 46-52.

Hummelen, J. W., & Rokx, T. A. J. J. (2007). Individual-context interaction as a guide in the treatment of personality disorders. Bulletin of the Menninger Clinic, 71(1): 42-55.

Muran, J. C. (2007) Commentary: Language, Self, and Diversity. In S. C. Hayes (Ed.), Dialogues on difference: Studies of diversity in the therapeutic relationship ) pp. 275-279. Washington, DC, US: American Psychological Association.

A reminder:

** If you are a graduate student working on an ACT/RFT study and would like to have us include your dissertation or thesis citation in this update, please send us an email backchannel.

**If you have published an editorial you would like us to include that citation, please send us an email back channel.

ACT/RFT Reader's Update (Winter, 2007)

Welcome....
to the first issue of the ACT /RFT Reader's Update, an electronic newsletter provided for your information and perusal. This online newsletter provides summaries of recent, ACT and RFT articles (or related articles) published in peer-reviewed journals. In addition, citations for the latest books, book chapters, and unpublished dissertations will be listed. This will be an ongoing project, and new article summaries will be distributed via email every 4 months. You can identify these email summaries by the subject title "ACT/RFT Readers Update".

Our main aim with this update is to keep the ACT/RFT community informed. We hope to include information that is relevant, scientifically sound, and of interest in the ACT/RFT community. Our purpose is not to recreate the abstract of these articles, but to provide a broader summary of the article. However, are goal is to keep the "busy" reader in mind, and therefore, we will work to keep the summaries brief. Additionally, we had to start somewhere, so we are only including summaries of some of the most recent articles.....and our next issue will include more from 2007 (such as ACT and diabetes and social anxiety disorder). We will conduct regular searches, however, if we missed your publication (from mid-2007 until now), please let us know.

** If you are a graduate student working on an ACT/RFT study and would like to have us include your dissertation or thesis citation in this update, please send us an email backchannel.

**If you have published an editorial and you would like us to include that citation, please send us an email back channel.

We hope you will find our e-mail updates of interest and value. If you have questions, please contact Robyn Walser, Robyn.Walser@va.gov or Maggie Chartier, maggie_chartier@yahoo.com

Our reviewers include:

Robyn Walser, PhD
Christi Ulmer, PhD
Maggie Chartier, MPH, MS
Ian Stewart, PhD
Miguel Rodríguez Valverde, PhD

This issue contains 8 summaries. Please find references at end of summary and references listing at end of document:

ACT ARTICLES AND RELATED TOPICS

Acceptance and pain in children....

The literature supporting the use of cognitive-behavioral interventions for chronic pain in adults is fairly extensive. Nevertheless, considerably less empirical support is available for psychological approaches to pain in children. Even more limited is the literature on psychological approaches to idiopathic (of unknown cause) chronic pain in youths. Acceptance-based approaches have been implemented into behavioral pain treatments in adults, and have been found to be associated with better outcomes. The authors of a recent study investigated the impact of an ACT intervention with an exposure component for increased functioning and school attendance in 14 adolescents experiencing idiopathic chronic pain. The intervention was administered in individual therapy sessions tailored to the individual patient, but generally followed a format that included education, ACT, and exposure. Parents were also seen in separate sessions to provide guidance on an intervention-consistent parental coaching role versus a caretaking role. The number of sessions varied across patients. Post-intervention data revealed large effect sizes for improvements in the primary outcomes (functioning and school attendance) in addition to the secondary outcomes (pain intensity, pain interference, and catastrophizing). Interestingly, pain intensity and interference decreased following this intervention despite the absence of intervention components targeting pain reduction. Limitations of the study included lack of a control group, variability in session number and therapeutic skills, and absence of a measure of the proposed mechanism of action (psychological flexibility). Despite the limitations, this pilot study contributes to a nascent area of research on the treatment of chronic pain in youths, and suggests a potential role for ACT-based interventions in this population.

Read the Article:

Wicksell, R. K., Melin, L., & Olsson, G. L. (2007). Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - A pilot study. European Journal of Pain, 11(3), 267-274.
__________

Hair pulling and experiential avoidance...

Trichotillomania (TTM) is estimated to be present in up to 3.4% of the population and is associated with significant psychosocial difficulties. Previous research has identified several specific cognitions and affective states that are associated with the tendency to engage in hair pulling. A recent internet-based study investigated the potential relevance of the stance of the TTM sufferer towards aversive thoughts and emotions in hair pulling severity. More than 700 individuals reporting a diagnosis of TTM completed an anonymous online survey assessing: DSM-IV TTM criteria; hair pulling severity, urge, behavior and consequences; shame; self-perceived appearance; and fear of negative evaluation; and experiential avoidance. In spite of the waning criticism of internet-based research, the sample characteristics suggest that is was similar to those of studies completed in clinical settings, and the reported internal consistencies of the employed measures suggested that participants provided meaningful responses. As found in previous research, hair pulling behavior was associated with greater negative cognitions. However, in the current study, these associations were either significantly reduced or eliminated when experiential avoidance was introduced as a mediator. Under the premise that aversive cognitions are functionally related to hair pulling behavior, clinicians commonly target thought content using a cognitive restructuring approach to TTM. However, the findings of the current study suggest that targeting avoidance may result in a greater degree of behavior change. Replication of this study is needed in a clinical sample and should include longitudinal data to explore causal pathways plus a larger battery of private events should be investigated. Despite the need for additional study, the findings of the current study implicate experiential avoidance as a potentially critical factor in the understanding and treatment of TTM.

Read the Article:

Norberg, M. M., Wtterneck, C. T., Woods, D. W., & Conelea, C. A. (2007). Experiential avoidance as a mediator of relationships between cognitions and hair-pulling severity. Behavior Modification, 31, 367-381.
__________

Preliminary findings suggest that ACT is useful for coping with psychological distress related to breast cancer.

A recent article in the Spanish journal of psychooncology (Psicooncología) suggests that psychological problems resulting from diagnosis, treatment, and possible sequels of breast cancer, can be analysed as a form of an experiential avoidance disorder. The authors explored the application of an acceptance-based psychological intervention to these problems in a Spanish sample, comparing it with a more traditional intervention based on cognitive-control. Twelve women (ages 42 to 50) that had been diagnosed and treated for breast cancer took part. Half of them were randomly assigned to treatment with a brief adaptation of Acceptance and Commitment Therapy. This acceptance-based protocol focused on the clarification of personal values, the detection and acceptance of psychological barriers to acting towards those values, and on the continued practice of cognitive defusion through experiential exercises and metaphors. The other six women were treated with a brief adaptation of the official cognitive-behavioral program of the Spanish Association Against Cancer. This protocol focused on analysing the relationships among disease-related thoughts, feelings, and actions, and in the modification of those cognitions and emotions through several strategies (e.g. identification and management of automatic dysfunctional emotional reactions, emotional ventilation techniques, breathing and relaxation techniques for anxiety control, etc.). The general aim was to promote a sense of personal control over problematic private events, and to encourage a positive coping style. Overt behavioral components (exposure and activity planning) were explicitly excluded from this protocol. Both interventions were administered in eight sessions (two initial individual sessions, five group sessions, and a final individual session), with pre- and post -treatment assessment, and up to 12-month follow-ups. Post-treatment effects were similar for both conditions, but after one year, ACT was significantly more effective, with improvements in anxiety and depression scores, quality of life scores, and affected valued life areas. Despite the key limitation in terms of generalizability due to the small sample size, the results are promising and these findings point to ACT as a potentially effective treatment for disease-related psychological distress in long-term medical conditions.

Read the Original Article in Spanish:

Páez, M. B., Luciano, C., & Gutiérrez, O. (2007). Tratamiento psicológico para el afrontamiento del cáncer de mama. Estudio comparativo entre estrategias de aceptación y de control cognitivo. Psicooncología, 4, 75-95. [Psychological treatment for coping with breast cancer. A comparative study of acceptance and cognitive-control strategies].
__________

Can brief training for new therapists in ACT and CBT be effective?

Many psychotherapy effectiveness trials use experts in the therapies they are testing. In this Finnish study, the authors wanted to first reduce this professional bias common in many head-to-head trials, by using graduate-level therapists. They explored level of training, regardless of therapeutic intervention, required to achieve significant psychological effects in treated individuals. Therapists were taught both CBT and ACT, through a combination of lectures, reading, and case supervision. Each therapist delivered a CBT treatment and an ACT treatment. The only criteria for entry into the study was a desire for individual therapy, thus a range of diagnoses were represented in the study population of 28. The techniques used within each model were based on a functional analysis case formulation model, and as such there was some overlap in techniques. For example, both interventions set treatment goals, used behavioral activation and exposure; and the treatments were problem, not syndrome focused. Overall, ACT showed significantly larger effect sizes at post and follow-up for symptom improvement. Both groups showed improvements on symptom reduction, but the ACT group was "virtually indistinguishable" from community norms. CBT showed more rapid improvement in self-confidence than ACT, and ACT improved acceptance of private experience more than CBT. When controlling for self-confidence, acceptance remained a significant predictor of improved outcome on the SCL-90 at both post and follow-up assessment. There were no differences between the two on client satisfaction or client willingness to recommend the therapy. There were also no differences post treatment in the therapist comfort with therapy or how much they felt they had helped their clients, although therapists reported more discomfort and confusion about learning and delivering ACT. So the answer is, yes. Brief training in either ACT or CBT with novice therapists produced moderately good psychological effects. The authors emphasize in their discussion of the limitations that this was not an effectiveness trail comparing the two therapies, but rather an effectiveness trial focusing on the issues of brief training and competency.

Read the Article:

Lappalainen, R., Lehtonen, T., & Skarp, E. (2007). The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification, 31(4), 488-511.
__________

Do we need to challenge thoughts in CBT?

The title says it all. In this review of CBT component analyses, the authors investigate the 'three anomalies of CBT' put forth by Steve Hayes in a previous paper. These are that component analyses do not show added value of cognitive interventions; that there is often early rapid improvement in CBT prior to cognitive intervention; and that changes in cognitive mediators (thoughts/beliefs) don't seem to precede symptom changes. The authors found 13 component analysis for Cognitive Therapy (CT) in the treatment of depression and anxiety, published since 1980 in English. There were no significant differences between conditions that targeted cognitive process only or primarily and comparison groups that often included behavioral activation (BA). In many cases, BA was found to be as effective as CT and/or Automatic Thought (AT) interventions. To quote the authors, "the case at issue is not that CT performed poorly, but that BA performed so well." They discussed preliminary findings from a long-term large-scale project that has been presented at conferences (but not yet published) in which BA performed as well as antidepressant medication, and that both were superior to CT. For anxiety disorders, cognitive interventions have not been found to be more effective than disorder-specific exposure techniques. In addressing the second anomaly the authors concluded that that early responding has insufficient evidence to support CT. And as for the third, it appears that there is insufficient evidence to support cognitive mediation as a mechanism of change in therapy. The authors conclude that, almost without exception, among component analysis studies, there was no difference in effectiveness between the behavioral and cognitive components of CBT. The cognitive interventions appeared to add no additional value to behavioral interventions. The authors called CT theorists and researchers to task, requesting further investigation of the fundamental tenets of CT therapy.

Read the Article:

Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27(2),173-187.

RFT ARTICLES

Training more-than/less-than relations can facilitate derived comparative relations in young children ...

One critical assumption in RFT is that relating events is operant behavior. This is a challenge to demonstrate empirically, since relating is theorized to develop early in life. Examining relatively complex relations among older, more manageable subjects is one means of avoiding certain difficulties in this analysis. This study was conducted with four normally functioning females between four and five years old. The design of the study involved a multiple baseline across participants in groups of two. Stimuli were paper slips displaying arbitrary pictures. Sessions were conducted between 1 and 3 times weekly, each lasting between 40 and 60 minutes. Participants required between 2 and 6 months to complete the study. All participants displayed deficiencies in more-than/less-than relating before training and demonstrated derived performances after sufficient training. Two of the four participants required non-arbitrary training among differing stacks of pennies before demonstrating criterion responding in training with arbitrary stimuli. In summary, these results provide evidence supporting the contention that relating events is an operant class, and that a repertoire of relating among non-arbitrary events may be a prerequisite for arbitrarily applicable derived relational responding.

Read the Article (available for download on the ACBS website):

Berens, N. M., & Hayes, S. C. (2007). Arbitrarily applicable comparative relations: Experimental evidence for a relational operant. Journal of Applied Behavior Analysis, 40, 45-71.

__________

Combinatorial entailment in young children is facilitated by multiple
exemplar training...

RFT is built on the basic tenet that relating events is a generalized operant. In other words, the ability to derive relations among arbitrary stimuli develops from explicit training with multiple exemplars in early life. Consistent with this assumption, a former study found that derived symmetrical relations among the majority of a sample of 4-5 year old children were contingent upon explicit training with multiple exemplars. The current work contains two studies, each incorporating a multiple baseline design. Participants were two female and two male children between the ages of 4:6 and 4:10 years/months. The first study examined the repertoire for symmetrical relations using the procedures of the former study. Participants received conditional discrimination training for an action (e.g., clapping, waving) given an object (e.g., doll, truck). Subsequently they were tested for symmetrical relations between the action and the object. All children successfully derived symmetrical relations without encountering exemplar training. The second study examined for equivalence relations, building upon the training provided in the first study. A new set of actions (e.g., touching forehead, touching shoulder) were trained in respect to the objects. Subsequently the children were tested for equivalence relations between the actions trained in the first study and the new actions. Three of the four children required exemplar training for equivalence before demonstrating derived equivalence. These results support the developmental trajectory hypothesized in RFT, and suggest a means of remediation for delayed or absent relational abilities.

Read the Article:

Gomez, S., Lopez, F., Martin, C. B., Barnes-Holmes, Y., & Barnes-Holmes, D. (2007). Exemplar training and a derived transformation of functions in accordance with symmetry and equivalence. Psychological Record, 57, 273-294.
__________

RFT and Perspective-taking in children with high-functioning autistic
spectrum disorder .

The current research involves using a test of perspective taking based on the Relational Frame Theory to (i) compare normally developing children and autistic children and (ii) demonstrate how perspective taking skills may be trained when they are deficient. According to RFT, language essentially involves relating things in accordance with particular learned patterns referred to as relational frames. Perspective taking is one specific pattern of relating or 'relational framing' in which the relating depends on the perspective of the person who is doing the relating. According to RFT, there are three core relational patterns or frames involved in perspective taking: I-YOU, HERE-THERE and NOW-THEN. This article reports on two experiments focusing on perspective taking in normal and autistic subjects. In the first experiment they use an RFT-based test of perspective taking to compare two groups of 9 children each. One of these groups is composed of normally developing children while the other is composed of high functioning autistic children. Results from this first experiment were that (i) there was a significant difference between the means scores for the normal and autistic groups of children on both the clinical tests; (ii) across both groups, most errors in the perspective taking test were made on reversed relations and there was a significant difference between performance on the simple and reversed level tasks; (iii) the two groups - normally developing and autistic - differed significantly as regards to performance on the reversed relations tasks but not as regards to performance on either of other two task types; (iv) there was a correlation across all subjects between performance on the NOW-THEN reversed relations task and Daily Living Skills scores. The researchers suggest that despite a small sample size, the results provide support for the RFT account of perspective taking as deictic relational responding in that autistic children did perform more poorly than the normally developing children in the relational perspective-taking tasks provided. They performed significantly more poorly in the reversed relational tasks than in the simple tasks. They did not perform significantly more poorly in the double reversed relational tasks than in the simple tasks. However, as the researchers point out, this may be because these tasks may be answered correctly without necessarily responding appropriately in accordance with deictic relations. In the second experiment, the researchers used the RFT tasks employed in Experiment 1 combined with appropriate feedback (cartoon animations for correct responses) to train up perspective taking ability in two of the children from the normally developing group from the first experiment. The results showed that the relational pattern involved in perspective taking could indeed be trained up as RFT would predict. They suggest that this implies that the RFT account of perspective taking is a useful one, and that RFT-based perspective taking tasks such as those used in the current experiments may be used in future work to train up perspective taking in autistic children.

Read the Article:

Rehfeldt, R.A., Dillen, J.E., & Ziomek, M.M.(2007) Assessing Relational Learning Deficits in Perspective-Taking in Children with High-Functioning Autism Spectrum Disorder. Psychological Record, 57(10), 23-47.

BOOKS

Gregg, J. A., Callaghan, G. M., & Hayes, S. C. (2007). Diabetes lifestyle book. Oakland, CA: New Harbinger Press.

Follette, V. M., & Pistorello, J. (2007). Finding life beyond trauma. Oakland, CA: New Harbinger Press.

Hayes, S. C., Bond, F. W., Barnes-Holmes, D., & Austin, J. (2007). Acceptance and Mindfulness at Work: Applying Acceptance and Commitment Therapy And Relational Frame Theory to Organizational Behavior Management. Binghamton, NY: Haworth Press.

Lejeune, C. (2007). The Worry Trap: How to Free Yourself from Worry & Anxiety using Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Press.

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. Oakland, CA: New Harbinger Press.

Walser, R., & Westrup, D. (2007). Acceptance & Commitment Therapy for the Treatment of Post-Traumatic Stress Disorder: A Practitioner's Guide to Using Mindfulness & Acceptance Strategies. Oakland, CA: New Harbinger Press.

Zettle, R. D. (2007). ACT for depression: A clinician's guide to using acceptance and commitment therapy in treating depression. Oakland, CA: New Harbinger Press.

Also: Check out the ACT in ACTion DVD set. Available at newharbinger.com

BOOK CHAPTERS

Pierson, H., & Hayes, S. C. (2007). Using acceptance and commitment therapy to empower the therapeutic relationship. In P. Gilbert & R. L. Leahy (Eds.), The therapeutic relationship in the cognitive behavioral psychotherapies (pp. 205-228). New York, NY: Routledge/Taylor & Francis Group.

Twohig, M. P., Pierson, H. M., & Hayes, S. C. (2007). Acceptance and Commitment Therapy. In N. Kazantzis & L. L'Abate (Eds.), Handbook of homework assignments in psychotherapy: Research, practice, prevention (pp. 113-132).New York, NY: Springer Science + Business Media.

DISSERTATIONS

Pellowe, M. E. (2007). Acceptance and commitment therapy as a treatment for dysphoria. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 67(9-B), 5418.

Braekkan, K. C. (2007). An acceptance and commitment therapy intervention for combat veterans with posttraumatic stress disorder: Preliminary outcomes of a controlled group comparison. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 67(12-B), 7365.

EDITORIALS

Curran, J., & Houghton, S. (2007). Moving beyond mechanism. Mental Health Practice, 10(8), 20-23.

Blackledge, J. T. (2007). Disrupting verbal processes: Cognitive defusion in Acceptance and Commitment Therapy and other Mindfulness-based Psychotherapies. The Psychological Record, 57(4).

ACT/RFT Reader's Update: Final 2009 Review (July, 2010)

Science and Practice: ACT /RFT Reader’s Update:  Final 2009 Review

Welcome to the ACT/RFT Reader’s update. This is the last issue reviewing the literature on ACT and RFT from 2009. We will be publishing updates for 2010 in late summer, fall and winter.

To kick off the issue, we want to extend a thank you to Dr. Chad Drake who has been with the Update since its inception. We thank Chad as he closes the “Update chapter of his life” and wish him much success in his new and fun endeavors. Thanks Chad!

In this issue, we summarize articles on assessment, ACT and diagnostic populations, experiential avoidance, behavioral health, RFT, mindfulness and “The Great Debate”.

The attached PDF includes a Table of Contents that allows you to “click” directly to the summary of multiple articles covering a topic and/or references and abstracts that you may be interested in. In addition, citations for the latest books, book chapters, editorials, and unpublished dissertations are listed.

Our aim with this update is to provide information that is clinically relevant, scientifically sound, and of interest in the ACT/RFT community. We have worked to keep the “busy” reader in mind and hope that you find the Update useful.

** If you are a graduate student working on an ACT/RFT study and would like to have us include your dissertation or thesis citation in this update,please send us an email backchannel.

**If you have published an editorial you would like us to include that citation, please send us an email back channel.

We hope you will find our e-mail updates of interest and value.  If you have questions, please contact Robyn Walser, Robyn.Walser@va.gov or Maggie Chartier, maggie_chartier@yahoo.com

Our editors and reviewers include:
       Robyn Walser, PhD
       Maggie Chartier, PhD, MPH
       Katie Sears, PhD
       Thuy Tran, BS
       Chad Drake, PhD
       Elizabeth Gifford, PhD
       Ian Stewart, PhD
       Christi Ulmer, PhD
       Miguel Rodríguez Valverde, PhD
       Darrah Westrup, PhD

How does ACT differ from traditional CBT interventions?

ACT is part of the behavior therapy / behavior analysis / and cognitive behavior therapy tradition writ large so it would be silly to compare ACT to CBT as a whole which ACT is part of and which ACT has been influencing. “Traditional CBT-interventions” presumably means interventions organized around the idea that thoughts cause emotions and behavior. Even that subsection encompasses a broad range of things – theoretically and procedurally, so only generalizations are possible given such a question. What is different is the philosophy, basic science, applied theory, targeted processes of change, and many of the techniques of change. That is a pretty long list and it would take volumes to fully explain them. In outline form:

1. Philosophy

ACT is rooted in the pragmatic philosophy of functional contextualism, a specific variety of contextualism that has as its goal the prediction and influence of events, with precision, scope and depth. Contextualism views psychological events as ongoing actions of the whole organism interacting in and with historically and situationally defined contexts. These actions are whole events that can only be broken up for pragmatic purposes, not ontologically. Because goals specify how to apply the pragmatic truth criterion of contextualism, functional contextualism differs from other varieties of contextualism that have other goals, such as hermeneutics, narrative psychology, dramaturgy, social constructionism, feminist psychology, Marxist psychology, and the like which are forms of ”descriptive contextualism” because their goal seems to be to appreciate the participants in the whole event. There are contextualistic varieties of CBT (the constructivists, for example) but they look more like descriptive contextualists than functional contextualists.

The mainstream of CBT is elementalistic and integrative (it is looking for an overall model of parts, relations and forces). The word for this kind of philosophy can create problems because it has negative connotations: mechanistic. Remember though that philosophy is not a metter of good and bad, or right and wrong. Philosophy is a matter of owning ones assumptions and assumptions are nothing to thump one’s chest over. Mechanism is a very powerful set of assumptions and it has done well in many areas of science. But it is different than the assumptions underlying ACT. If you think people think sort of like computers calculate, you will probably not like ACT. It will feel strange.

Take things like the importance of values in ACT or the importance of cognitive defusion. The former is needed in order to specify the criteria for the application of workability, which is what a pragmatist takes to be ”true.” The later is what language looks like if you hold to that pragmatic assumption. If a person states an irrational thought, a traditional CBT person may want to know how it biases the facts – exactly what is demanded by the ontological assumption of mechanism – while an ACT person wants to know what saying that is in the service of and what functional role it plays due to history and context -- exactly what is demanded by the pragmatic assumptions of contextualism.

2. Basic Theory

Nearly a decade and a half passed between the earliest randomized trials on ACT and those in the modern era. In that interval, the basic theory of human language and cognition underlying ACT, Relational Frame Theory was developed into a comprehensive basic experimental research program. RFT is not a basic theory of ACT. It is a basic theory of cognition. But if RFT is workable and if ACT makes sense, you have to be able to do a basic analysis of ACT using RFT – just as you would have to be able to do an analysis of any cognitive procedure using RFT. That is the aspiration – and if you know behavior analysis you will recognize that it is an entirely traditional aspiration for people who do work on behavioral principles – the difference is that now we now think we have an angle on human cognition that is empirically and conceptually workable. We are not fully there yet, of course, but we are now seeing the RFT studies of defusion, acceptance, values, and so on and the early data are tremendously exciting.

According to RFT, the core of human language and cognition is the learned ability to arbitrarily relate events, mutually and in combination, and to change the functions of events based on these relations. For example, very young children will know that a nickel is larger than a dime by physical size, but not until later will the child understand that a nickel is smaller than a dime by social attribution. RFT researchers have shown that such relations as knowing that one event is “larger” than another arbitrarily can be trained as an operant and will alter the impact of other behavioral processes. We even have some new data seemingly showing that the symmetry of names and objects are trained as an operant in infants. There are neurobiological data showing that the brain lights up when performing RFT tasks much as it does when doing natural language tasks modeled by the theory.

Virtually every component of ACT is connected conceptually to RFT, and several of these connections have been studied empirically. Among other applied implications of RFT, its primary implications in the area of psychopathology and psychotherapy can be summarized as follows 1. normal cognitive processes necessary for verbal problem solving and reasoning underlie psychopathology, thus these processes cannot be eliminated; 2. the content and impact of cognitive networks are controlled by distinct contextual features; 3. cognitive networks are historical and thus are elaborated over time. Much as extinction inhibits but does not eliminate learned responding, the logical idea that cognitive networks can be logically restricted or even eliminated is generally not psychologically sound; and, 4. direct change attempts focused on key nodes in cognitive networks, tend to elaborate the network in that area and increase its functional importance. ACT is based on these ideas. Most of traditional CBT is not.

3. Applied Theory

From an ACT / RFT point of view, while psychological problems can emerge from the general absence of relational abilities (e.g., in the case of mental retardation), the primary source of psychopathology in most adults and language able children is the way that language and cognition interacts with direct contingencies to produce an inability to persist or change in the service of long term valued ends. This kind of psychological inflexibility is argued in ACT and RFT to emerge from weak or unhelpful contextual control over language processes themselves. The now vast literature on experiential avoidance is but one example of how this manifests itself. Other processes are cognitive fusion; the domination of temporal and evaluative relations over contact with the now; the effect of all of this on weak self-knowledge; attachment to a conceptualized self; unclear values or values based in looking good in the eyes of others or avoiding pain rather than self-congruent choices; and impulsivity or avoidant persistence.

The contextual theory behind ACT situates all of these processes in context – it does not leave them “in the head.” These contexts can be directly changed and that is exactly what ACT tries to do. The functional contexts that tend to have such deleterious effects include excessive or poorly regulated contexts of literality, reason-giving, and emotional control, among others. In essence, the contexts that support verbal / cognitive functions are too widespread and are over applied. Acceptance and mindfulness are a prophylactic for that excess.

4. Clinical Methods

ACT targets each of these core problems with the general goal of increasing psychological flexibility – the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends. The six targeted processes are acceptance, defusion, being present, a transcendent sense of self, values, and committed action.

These core ACT processes are both overlapping and interrelated. Taken as a whole, each seems to support the other and all target psychological flexibility. They can be chunked into two groupings. Mindfulness and acceptance processes involve acceptance, defusion, contact with the present moment, and self as context. Indeed, these four processes provide a workable behavioral definition of mindfulness. Commitment and behavior change processes involve contact with the present moment, self as context, values, and committed action. Contact with the present moment and self as context occur in both groupings because all psychological activity of conscious human beings involves being in the now as known.

You can draw lots of parallels to new developments in CBT, and even some in traditional CBT, but it is pretty obvious that these packages are not the same thing. I have trained several thousand therapists in ACT workshops of one day or more. I have literally never had a single CBT person do extensive training and come out saying “this is the same as traditional CBT.”

If you want to pick one of the most salient differences, pick defusion (also known as deliteralization). In ACT, a troublesome thought might be watched dispassionately, repeated out loud until only its sound remains, or treated as an external observation by giving it a shape, size, color, speed, or form. A person could thank their mind for such an interesting thought, say it very slowly, or label the process of thinking (“I am having the thought that I am no good”). They might note how the back and forth of a mental argument is like a volley ball game and then literally play that out while watching from the sidelines. There are perhaps 100 defusion techniques that have been written about somewhere in the ACT literature. Not a one of them involves evaluating or disputing these thoughts.

ACT is an approach to psychological intervention defined in terms of it philosophy, basic principles, and targeted theoretical processes. You can easily create and test protocols to test ACT with various disorders but it is not a specific technology anymore than, say, using candy contingently is “reinforcement.” In theoretical and process terms we can define ACT as a psychological intervention based on modern behavioral psychology, including Relational Frame Theory, which applies mindfulness and acceptance processes, and commitment and behavior change processes, to the creation of psychological flexibility.

Are there advantages of ACT as compared to traditional CBT?

Ultimately this is an empirical question. After considering that we can look at the possible advantages in a theoretical sense.

Right now there are a handful of studies that have looked directly and they tend to be medium to small. Only a few are published, and one of these barely mentions outcome because it was a piece on process of change. So we have a long way to go before this question will be answered empirically.

Here are the studies done so far:

Rob Zettle, who trained with Beck, did two very small randomized trials on ACT versus CT for depression – one using individual ACT and CT and the other using ACT and CT group therapy. A larger multi-site randomized trial is underway right now. In his two studies (see the ACT Handout) he found Cohen’s d’s at post between ACT and CT of 1.23 (individually delivered) and .53 (group) and at follow-up of .92 and .75. The N was very small though. The ACT group was only an N of 6 in the individual study and about 10 or so in the group study.

The 4 other studies are brand new and are not published yet. Ann Branstetter did a randomized trial with end stage cancer distress. Ann was trained in traditional CBT and she applied CBT procedures she thought would help (such as cognitive restructuring). There was not follow up because the patients were in end stage cancer but at week 12 ACT had a Cohen’s d of .9 compared to traditional CBT on distress over dying. You can email her for details – she is at Southwest Missouri State University.

Jennifer Block’s dissertation at Albany (she was just hired as a faculty member at LaSalle) compared ACT and CBGT in social phobia and found a Cohen’s d of .45 at post in favor of ACT compared to traditional CBT on the behavioral measure (standing up and speaking).

Carmen Luciano’s team at the University of Almeria just did a smoking trial comparing ACT and a CBT package used by a Spanish cancer society and found a Cohen’s d of .42 at a one year follow up on smoking cessation.

Raimo Lappalainen and his group at the University of Tampere has data in an effectiveness trial comparing ACT and traditional CBT (using CBT methods linked to functional analysis, such as skills training, or exposure) in a training clinic. Beginning student therapists were randomly assigned one ACT and one traditional CBT client (N = 14 each condition). Problems ranged across the usual outpatient spectrum but they were mostly anxiety and depression. On the SCL 90 the post Cohen’s d between ACT and CBT was .62. At follow up the effect was larger. Here is the reference: Lappalainen, R., Lehtonen, T., Skarp, E., Taubert, E., Ojanen, M., & Hayes, S. C. (2007). The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification, 31, 488-511. By thw ay at the process level there was greater acceptance for ACT patients; great self-confidence for CBT patients. Both correlated with outcomes, but when partial correlations are calculated, only acceptance still relates to outcome. The effect was accidentally not included in the publication but at follow up ACT was now significantly better than CBT in self-confidence.

Evan Foreman and James Herbert reported similar data from their clinic at Drexel University: Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D. & Geller, P. A. (2007). A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behavior Modification, 31(6), 772-799. In this study 101 heterogeneous outpatients reporting moderate to severe levels of anxiety or depression were randomly assigned either to traditional CT or to ACT. 23 junior therapists were used. Participants receiving CT and ACT evidenced large and equivalent improvements in depression, anxiety, functioning difficulties, quality of life, life satisfaction and clinician-rated functioning. “Observing” and “describing” one’s experiences mediated outcomes for those in the CT group relative to those in the ACT group, whereas “experiential avoidance,” “acting with awareness” and “acceptance” mediated outcomes for those in the ACT group.

It is also known that ACT methods can empower behavioral methods (which are also part of the ACT model by the way ... so this finding is in essences a confirmation of the model itself). For example, consider this study: Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747-766. In it acceptance methods (drawn directly from the ACT book) did a better job than control strategies in promoting successful exposure to CO2 gas in panic disordered patients.

A similar finding was reported in:

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44, 1251-1263. As with the study above, brief acceptance methods led to lower heart rate during exposure to an aversive film and less negative affect during the post-film recovery period that did control strategies in individuals with anxiety and mood disorders.

So far it looks as though there might be a small advantage for ACT over traditional CBT methods in outcomes; there is a different set of change processes involved, and ACT methods may empower traditional behavioral methods.

Theoretically, the strengths of the ACT model as compared to CBT are these.

1. The model is easily scalable and broadly applicable. If you look at the whole outcome literature done so far (RCTs, controlled time series designs, and case studies) the problems targeted form a pretty broad list: PTSD, panic, depression, racist prejudice, burnout, epilepsy, smoking, OCD, pain, psychosis, cancer, diabetes, multiple sclerosis, sports psychology, attitudes against pharmacotherapy, skin picking, learning new procedures at work, heroin abuse, worksite stress, work innovation, marijuana abuse, and several others.

2. The putative processes of change are well specified with at least marginally adequate measures available in most areas. These change processes are a small set and they do not wildly vary from disorder to disorder.

3. The mediational analyses seem to be working. There are by our count already 16 successful formal mediational analyses published, or completed and coming. So far the data are very supportive. The processes successfully examined so far include acceptance, defusion, values, committed action, and psychological flexibility so most of the key ACT have some data in mediational trials.

4. Specific components seem to be working when inductively tested. There are at least 18 such studies. In every case ACT methods are impactful and work in a way that is theoretically coherent. These include all 6 points of the hexagon model.

5. The basic theory is intricately linked with the technology and itself seems to be working. For example, we are approaching 10 RFT studies linked to the three senses of self in ACT; RFT work on values is coming; and so on.

For those who believe only in RCTs of manuals, much of this answer will be dismissed. But the history of science shows that you cannot create a progressive science using only outcome studies. I (SCH) explained why in The Scientist-Practitioner (Hayes, Barlow, & Nelson-Gray, 1999). In a nutshell, though, it is this: without good theory, the technological development problem is based on common sense categories and it becomes empirically and practically overwhelming.

This should not be heard as “ACT adherents say RCTs are not important.” ACT folks have published nearly 30 RCTs of ACT methods. But they are not enough! Development in the areas of philosophy of science, basic principles, applied theory, specification of processes of change and effectiveness are just as important (and in the long run more important) than efficacy tests of technology.

The scientific game the ACT / RFT / Contextual psychology group is playing is this: to try to create a truly progressive science of psychology that can address the human condition in a more adequate way. Sure that is bold, but why not have bold goals? Is the ACT group willing to stand or fall on RCTs as a measure of success? Ultimately yes. But we want and demand another, even more difficult criteria: seeing a more truly useful psychology emerge as a result. That means concepts, theories, components, basic principles, effectiveness, training, dissemination and so on.

We think it is only fair to insist that ACT be measured against its own very difficult criteria when considering the progress of this effort. For example, examining ACT without examining RFT is like examining a cancer drug without looking at physiology.

Like the hare and the tortoise, ACT is following the slow and steady path. We think traditional CBT hopped ahead into a lay theory of cognition -- which produced quick progress but long term problems. We'd rather take the slow, one step at a time approach of contextual behavioral science. Which one will go farthest? Let's see. Let's be patient and see.

If there is an advantage of the ACT wing of CBT as compared to traditional CBT, this is where you are most likely to see it.

Are there any potential advantages of traditional CBT compared to ACT?

It is an empirical question, as was the previous one.

As for data so far, right now we have two studies showing a smaller effect size for ACT than for a traditional CBT procedure done outside of an ACT model. Zettle, 2003 found a smaller effect for ACT than for systematic desensitization with trait anxiety when treating a relatively minor problem (math anxiety). The effect was the same in the area of math anxiety per se.

The second study is Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Bradsma, L. L., & Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45(10), 2372-2386. They compared ACT to a traditional CBT program for those who were impacted at different levels by food. 98 participants with chocolate cravings were exposed to a well known CBT-based protocol (Kelly Brownell’s LEARN program) and an ACT-based protocol or no instructions and required to carry chocolate with them of for two days. Those highly impacted by food related cues ate less and had fewer cravings in the ACT condition. But those not impacted by food, did worse in the ACT condition than in the CBT condition (and both did worse than doing nothing at all).

It may not make that much sense to use a procedure like ACT with minor problems because the issues it raises are so fundamental. This could be proven wrong with data. But note that in the Zettle study, ACT worked better with highly experientially avoidant subjects than with low avoidant subjects; desensitization did not show that relationship; in the Forman study those with high food impact were helped by ACT but not those with low food impact. It is not a comparison to CBT but another study [Masuda, A., Hayes, S. C., Fletcher, L. B., Seignourel, P. J., Bunting, K., Herbst, S. A., Twohig, M. P., & Lillis, J. (2007). The impact of Acceptance and Commitment Therapy versus education on stigma toward people with psychological disorders. Behaviour Research and Therapy, 45(11), 2764-2772 found that ACT was not better than education in reducing mental health stigma significantly among participants who were relatively flexible and non-avoidant to begin with. For experientially avoidant and inflexible participants, however, ACT was much better.

It seems possible based on this line of reasoning that CBT might actually work better than ACT in more confined and minor areas; in more severe or chronic areas ACT, might work a bit better ... and perhaps all of that because more avoidant and inflexible folks will be more dominant in severe areas. That is not a conclusion -- it is too early to say -- but it is a guess based on a few studies so far. And remember that ACT is part of CBT -- when we say "CBT" here we mean CBT methods placed into the context of a traditional CBT model that basically focuses on the idea that thoughts cause emotions and behavior.

It helps to keep in mind that ACT is a model not just a package. All of the behavioral methods and some of the cognitive ones can easily be put into ACT protocols. They are still ACT when that happens if they fit the model. That is especially true with behavioral methods -- which are a node on that hexagon model of ACT.

But ultimately we will have to show that, for example, exposure from an ACT perspective is better than (or at least works through a different process than) exposure from a traditional CBT perspective. We have a couple of small studies that indicate that might be true (e.g., see Jill Levitt’s dissertation in Behavior Therapy, 2004) but not large RCTs on the question. Some of these are underway right now (such as in Michelle Craske’s lab) so in a few years we will know.

Is there much in traditional CBT that is helpful? Yes, of course, and virtually all of what is known to work at the level of components fits with the ACT model so these procedures can be used from an ACT perspective. The things that contradict an ACT model are not known to work as components, such a cognitive restructuring. But even there you can modify it to be more a matter of cognitive flexiblity.

Is the ACT model a better place to put all of these procedures? Let’s see. The answer will probably not be “yes, always.” Presumably it is more likely to be “sometimes yes, sometimes no.” But both the yes and no answers will move us forward, and that is the whole point, not silly name brand struggles.

Why to skeptics argue that there is a quite limited support for ACT while advocates seem to say otherwise?

Some skeptics have not really read the whole literature and considered it carefully. Let's put these aside -- they are easy to detect and there is little to say about such criticism. What you then have left behind are honest critics. These are very valuable and helpful people because they can light the way for additional research and development. The differences with honest critics so far seem to be in these areas.

Breadth of the criteria. The ACT / RFT community gives more weight to a model that is working than to RCTs alone. Mediational analyses, RFT progress, AAQ studies, component studies, experimental psychopathology, the like all weigh in very heavily. It is absolutely fair to let RCTs be the ultimate arbiter but if they are the only criterion, right now critics will see less support than people within the ACT / RFT community might believe is there. Over time, however, if the ACT / RFT community does its job, even that problem will be self-correcting because the development path being following includes randomized controlled trials as a centrally important area -- just not the only area.

The temporal measure of progress. Given the larger purpose of ACT / RFT, this harder set of criteria needs to be considered in terms of how hard the actual task is. The ACT / RFT community wants to be held to a high (amazingly high) standard, but this also means that judgments about accomplishment of such goals have to be made in the context of that stated purpose. This does mean that there is a certain prolonged sense of ambiguity. ACT / RFT research is more than 20 years old and critics can still doubt whether we are actually producing a more progressive psychology. That is fair, but then by the time the ACT / RFT community meets its goals to everyone's satisfaction, most folks in psychology and the behavioral sciences will know it, because these goals are so darned lofty.

Breadth of application. The ACT / RFT community think that the breadth of the model really matters, because the model itself claims to be about a deeper understanding of human cognition. In traditional syndromal treatment studies, the models are often quite narrow and breadth of application is not a fair test so when these folks look at ACT / RFT they don't quite know what to say. Right now, only pain and smoking have more than two ACT RCTs … and in both cases only one is yet published. So we are not over the bar in any one area yet, but across the board the progress is more notable and the breadth of application is already pretty amazing. This problem will be self-correcting, however, because if the program succeeds there will be multiple studies of ACT / RFT applications within specific areas.

RCTs versus controlled time series designs. ACT comes from behavior analysis. If you eliminate time series designs in favor of only RCTs, the outcome data weaken.

Quality of controls. Many of these early ACT studies are put together by students and young faculty. Only a few are funded. That is now changing. But these early studies are often amazingly underpowered and the methodological bells and whistles are sometimes not there. This is getting better, and we are starting to see replications with better controls. When you compare ACT to established CBT research from the best labs in the world, you are comparing research programs at two very different stages of development. We shall see what happens over time as funded ACT research becomes more common.

Published versus coming. This is the biggest one. ACT / RFT advocates often know about the data that are coming. We may know the researchers involved and feel that we can make some judgments. If you just look at publications (which an outside critic simply must do in order to be responsible) the picture looks different from the outside than it does from the inside. ACT / RFT research has been going on for 20 years, but it has only been visible for a few years, with the publication of the 1999 book on ACT and the 2001 book on RFT. If the program is truly progressive, these differences will narrow over time however. Those who want to look at the state of the ACT literature as of the beginning of 2006 may want to download the meta-analysis by Hayes, Luoma, Bond, Masuda, and Lillis, 2006. It is in the publications section (and if you are an ACBS member you can get it there ... and if you are not, then click here to join!

Where is ACT and RFT going?

Everywhere that cognizing humans go. We want a theory of human behavior that allows us truly to make a difference in our homes, schools, workplace, and clinics. The ACT / RFT community wants it all: a technology that works, a theory that works, basic principles, AND a powerful linkage to our deepest human desires. But we can distinguish aspirations from data – and we have created a culture of openness and self-criticism that seems scientifically healthy.

It is often that culture which seems most powerful when people first contact the ACT and RFT community. We are using ACT / RFT to create an ACT / RFT community that is open, non-hierarchical, diverse, committed, sharing, caring, and just plain fun. The vitality the young professionals and students as seen on this very website beg for the question: “what would happen if we worked together to create a community dedicated to the production of a psychology worthy of the human needs we are meant to address?” By appealing to the better nature of out clients (e.g., self-acceptance, mindfulness, values, commitment) we seem to be creating change in the clinic. Similarly, by raising our sites as professionals and creating a supportive, open, generous culture the same might happen in our training programs, clinics, and research teams.

For those of us in the ACT / RFT / Contextual Psychology community we do not think that basic and applied science can safely stand apart. We seek the creation of a new empirical contextual psychology that carries forward and deepens our intellectual tradition, revitalizing basic psychology and linking our work to principles that help us address problems of human suffering and human growth. We want to see us create a psychology more adequate to the challenges of the human condition.

This was part of the original vision of behavioral psychology and behavior therapy. Behavioral psychology lost its way over the issue of human cognition, and traditional CBT resulted, but perhaps we have found a way forward that will go beyond the excessively narrow goal of empirically evaluated technologies, to include also the two other aspects of our original tradition that were left behind: a firm link of application to basic principles, and an expansive vision of a form of psychology that can help create a better world in every area of human life. If we can do that, psychology itself may become more robust and useful. That is the vision.

Does ACT work for minorities or the poor?

The ACT literature is just now getting large enough to consider whether its impact is differential based on SES, ethnicity, gender, nationality, and the like.

So far the news is good.

There are now several randomized trials with minority populations. Some examples are Gregg, Callaghan, Hayes, & Glenn-Lawson (2007), Lundgren and Dahl (2006), and Gaudiano and Herbert (2006)

Gregg, Callaghan, Hayes, and Glenn-Lawson is an RCT showing that a six hour ACT workshop with patient education works significantly better than a six hour patient education workshop alone in producing changes in diabetes self-management and blood glucose (at 3 month follow-up). The study was done at a public health clinic in a poor and largely Latino and Asian section of East Palo Alto. The percentage of minority participants was 76.5%.

Lundgren and Dahl is an RCT done in South Africa showing that a 9 hour ACT protocol reduced seizures in epileptics 96% (90& were seizure free at a one yar follow up), while an attention placebo had no effect. The participants were all poor South African blacks living in a residential center.

Guadiano and Herbert replicates the Bach and Hayes study on psychosis with better measures and a better control condition that controlled for experimental contact and attention. It had good results especially on measures of overt psychotic behavior (the Brief Psychiatric Rating Scale) and mediational analyses fit the ACT model. 80% of the population in this was African-American, mostly very poor since this was done in a public mental hospital.

Other such studies are coming, both international studies in countries like Japan, India, Brazil, and elsewhere -- in addition to the many studies in Europe -- and studies in the United States and elsewhere done with poor and minority populations.

The overall effect size (Cohen's d) for these three studies are 1.26 at post and .74 as follow up (average length of follow up 22.3 weeks). Both of these values are above the average values overall in the ACT literature, which you can examine in the Hayes, Luoma, Bond, Masuda, & Lillis, 2006 meta-analysis. You can download this from the publication section too (if you are an ACBS member ... and if not you should join by clickinghere!).

As for gender, in all of the studies so far ACT works as well for women as men, except for one analogue pain study in which it worked better for women.

Byt the way, there is some indication that ACT helps with racial prejudice directly. In Lillis & Hayes (2007) undergraduates enrolled in two separate classes on racial differences were exposed Acceptance and Commitment Therapy and an educational lecture drawn from a textbook on the psychology of racial differences in a counterbalanced order. Results indicate that only the ACT intervention was effective in increasing positive behavioral intentions at post and a 1-week follow-up. These changes were associated with other self-reported changes that fit with the ACT model.

Overall, so far as we can tell so far, ACT works well in different ethnical, cultural, national, and socio-economic groups; and works for both men and women. We shall learn more as the data come in, but it is pretty cool that ACT researchers are already refusing to limit their work for middle class majority populations. A similar thing can be said for cognitively disabled populations, as the psychosis data are showing.

Here are the references for the studies mentioned:

Gaudiano, B.A., & Herbert, J.D. (2006). Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy. Behaviour Research and Therapy, 44,Behavioural and Cognitive Psychotherapy, 34, 497-502.

Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336-343.

Lillis, J. & Hayes, S. C. (2007). Applying acceptance, mindfulness, and values to the reduction of prejudice: A pilot study. Behavior Modification, 31, 389-411.

Lundgren, A. T., Dahl, J., Melin, L. & Kees, B. (2006). Evaluation of Acceptance and Commitment Therapy for drug refractory epilepsy: A randomized controlled trial in South Africa. Epilepsia, 47, 2173-2179.
Mediational analyses for this study are reported in Lundgren, T., Dahl, J., & Hayes, S. C. (in press). Evaluation of mediators of change in the treatment of epilepsy with Acceptance and Commitment Therapy. Journal of Behavioral Medicine.

Is ACT based on behavior analysis?

In a word: yes.

Long ago, behavior analysis was relied on by behavior therapists to provide a model of case conceptualization and intervention (e.g., Kanfer & Grimm, 1977; Kanfer & Saslow, 1969) but that idea fell away when clinicians came to believe that behavior analysis could not deal with the issue of cognition. ACT folks were behavior analysts but they agreed that behavior analysis needed to be developed before it could work in this area.

ACT, RFT, functional contextualism, and a contextual behavioral science approach was the result of years of work to change that picture. It emerged from behavior analysis, but carries that tradition forward into the experimental analysis of cognitive processes, which extends the armamentarium of behavioral principles and alters many of the key concepts in traditional behavior analysis (e.g., see Barnes-Holmes, Hayes, & Roche, 2003).

What has been created in the ACT/RFT/CBS tradition is a different stream of thought within behavior analysis and a different stream of thought within the CBT family of approaches. But it retains all of traditional behavior analysis as well. We are proud to see that as ACT/RFT/CBS has impacted clinical areas it is rekindling an interest in behavior analysis. That in itself is progressive we believe. In the modern era few clinical students are even exposed to a well-crafted course in behavioral principles, taught by a basic scientist knowledgeable in that tradition, which is a sad state of affairs given how robust these principles are. They are even more so when augmented with RFT, greater philosophical clarity, and a renewed development strategy (which is what contextual behavioral science refers to).

Is the linkage between ACT and RFT post hoc?

It has sometimes been said that the link between ACT and RFT is post hoc, but that is not the case. The basic, applied, and philosophical work co-evolved from the very beginning.

In some areas of behavior analysis, applied work is based on animal work that is well worked out. Unfortunately, in the area of language and cognition the animal work never got there, so there was a more iterative process.

RFT began from a clinical lab that was trying to fill a need for a better basic analysis. The work went back and forth from basic to applied constantly.

Many of the publications come out years later, so understanding the sequence of events requires a closer look at the record. For example Steele and Hayes, 1991 if the first undeniably RFT experimental study, but it was designed and conducted in 1985-86 and was the cap of a six or seven year long process of both basic and applied development.

Rob Zettle has written about this history. He was not just there but also created some of the key conceptual advances that lead to both ACT and RFT. The history is available in the publications area (search for Zettle, 2005).

By the late 1970s we were getting frustrated with cognitive therapy / cognitive behavior therapy. We wrote a critical chapter on RET in 1979; we were doing conceptual work on rule-governance even that early. In 1981 a chapter interpreting CT from the point of view of rule-governed behavior was written -- it appeared in 1982. It too is on in the publications section (search for Zettle & Hayes, 1982). That chapter is concerned about rule-based insensitivity and undermining pliance; it breaks with Skinner on the definition of rules and do so in a way that demands RFT or something like it.

In that same year we were already doing the basic studies on rule-based insensitivity that would publish in the mid-80s. So we were already testing how rule produce psychological inflexibility. Studies were being planned to try to learn how to undermine that effect. The earliest ACT (nee “Comprehensive Distancing”) manual was drafted in that same year and the earliest applied tests were begun

Probably the easiest way to document this is to look at papers presented orally in 1981-1982, since oral presentations overcome most of the distortions due to publication lags.

Here is part of that list:

Hayes, S. C., Korn, Z., Zettle, R. D., Rosenfarb, I., & Cooper, L. (November 1982). Rule governed behavior and cognitive behavior therapy: The effects of comprehensive cognitive distancing on pain tolerance. AABT, Los Angeles.

Hayes, S. C., Zettle, R. D., & Rosenfarb, I. (May 1982). An empirical taxonomy of rule governed behavior. ABA, Milwaukee.

Hayes, S. C. (May 1982). Rule governed behavior and psychopathology. ABA, Milwaukee.

Hayes, S. C., Rosenfarb, I., & Zettle, R. D. (May 1982). Rule governed behavior and sensitivity to changing contingencies. ABA, Milwaukee.

Hayes, S. C. (May 1981). Rule governed behavior: Functional units of listener activity. ABA, Milwaukee.

Rosenfarb, I., Hayes, S. C., & Zettle, R. (May 1981). Self reinforcement: A social commitment analysis. ABA, Milwaukee.

Hayes, S. C. (November 1981). Running on empty: The ascendance of technical research. AABT, Toronto.

Thus, you can see that the experimental rule-governed studies on insensitivity; studies on commitment; conceptual work on rules; conceptual work linking rules to sychopathology; criticisms of CBT; philosophical work on the need for theory; and the earliest studies on ACT all emerged iteratively at the same time.

By 1984 the paper on Making Sense of Spirituality (Hayes, 1984 … you can find this in the publication list) makes it all clear what will come later. Self, deictic frames, defusion, flexibility and more are in there in one way or another. Shortly after that, the first RFT studies and the first ACT randomized trials began to appear.

RFT is far broader than ACT ... but it has been an ACT-RFT effort from the very beginning. This does not mean that ACT processes are in a point to point correspondence with RFT processes. Over time this is happening more and more, but linkages in each direction were created on the fly.

The bottom line is this: the record shows that ACT, RFT, and contextualism are all part of one research and conceptual program that emerged at the same time and that have co-evolved for 25 years.

- S

Steven C. Hayes

What is the role of ...?

This is a place to put thought about the role of certain exercises or issues

What is the role of intensive, experiential training in learning ACT?

ACT has a tradition of doing intensive, experiential training in addition to training in the core skills and competencies needed to do ACT. Why are these part of the ACT tradition?

These trainings are not training in doing ACT per se -- they are more oriented toward learning what it feels like and how it works to adopt a defused, accepting, present-focused, mindful, values-based posture with regard to your own issues. These experiences are not meant to be therapy. Unlike other traditions, there is no belief that you have to somehow get fully analyzed (etc) and thus no longer be reactive in therapy in order to do good work. The point is not to be the world's most mindful or accepting human. The point is to learn to discriminate these states of mind to a degree that allows you to track what is happening during ACT intervention, and to have some skills in sitting with the painful space of sitting with another human being in pain. We hope that doing some experiential work with yourself will humanize and level ACT work because you learn how hard it is to do the things you are going to try to establish in others through ACT.

There are curently no data showing that these kinds of trainings are needed to learn ACT, and even if you do them, they will not remove the need to learn ACT as a technical matter. This means you should not feel pushed to do them, especially if you are still just learning about ACT and your gut sense is that you might not respond well to such an approach. In that case, do more didactic training first and talk to others about their experiences and then decide.

If you do such trainings remember this: you should never go beyond what you are willing to do. I always tell people to say and do only what they are willing to say and do, and to try to do the work of acceptance, defusion, mindfulness and so on with their own issues within themselves first, and to express that (if they choose) to others as an outward expression of that work, not as a substitute for it. The ACT model itself suggests that blurting out past pains (for example) can itself be traumatizing if it is not associated with acceptance, defusion, and mindfulness.

Having said that, thousands of people have done more experiential training and the very subtitle of the ACT book says that it is an experiential approach. There seems to be something worthwhile in this type of training. Just don't allow yourself to feel forced into anything and don't mistake these experiences as a substitute for training in the technical skills involved in doing this work.

ACT Articles in Veja Magazine (in Portugese)

Several articles on ACT have appeared in Brazil, following a long piece in "Veja" -- the Brazilian equivalent of Time Magazine -- in March 2006. A few are linked as attachments to this page

An Overview of ACT; Psychotherapy Australia Magazine; Aug 2006

This a simplified overview of ACT, written deliberately in a non-technical manner, so that therapists and counsellors of all backgrounds can appreciate it.

Audio: Herbert & Hayes on WHYY (March, 2006)

James Herbert and Steven Hayes discussing ACT on "Voices in The Family," March 6, 2006. The shows are stored on the WHYY website and will be available here.  

Audio: Interview with Steven Hayes by Dr. Alvin Jones

The interview follows a brief intro/ad for the radio show.

Australia's SBS TV Insight on Anxiety, May, 2010

Australia's SBS TV Insight on Anxiety includes a segment on ACT.

BigThink.com Interview with Steve Hayes (December, 2009)

The BigThink.com interview with Steve Hayes on December 15, 2009 can be found at http://bigthink.com/stevenhayes.

Topics discussed in the interview:

• What Keeps Steven Hayes Up at Night?

• The Tolerating Cure

• How to Deal With a Panic Attack

• Happiness Is an Empty Promise

• The Catch-All Nature of Acceptance and Commitment Therapy

• Finding a Career by Way of a Panic Attack

Full Interview Transcript:

Question: What led you to explore this field of psychology?

Steven Hayes: Well, I'm in psychology probably the way a lot of people get into psychology: you're interested in why there's so much pain and suffering around you. And I certainly saw that at home, just growing up, and decided early on that it was a place to put my science interests and also just my humanitarian interests, and you could put those two together in one field. After I was a psychologist I developed a panic disorder, and that changed a lot of -- what kind of work I do, because I was trained as a behavior therapist and as a cognitive behavior therapist. And when I applied the methods that I would apply with others when they had panic disorder, it didn't really fully hit what I thought was needed for me.

And I turned back towards several things that were sort of in my experience from more eastern traditions, human potential traditions, and then tried to marry that up -- I'm a child of the '60s and grew up in California, so was exposed to the kind of garden variety eastern thinking that most folks in my generation were exposed to, and I actually found more in mindfulness and acceptance methods that were directly of benefit to me than in the traditions I was nominally part of.

So that really changed my thinking, and it caused me to set out on about a 30-year journey as to how dig down to the essence of what's inside some of our deepest clinical traditions, but also our spiritual and religious traditions, particularly these eastern traditions. But not just that; all of the mystical wings of the major spiritual and religious traditions have methods that are designed to change how you interact with your logical, analytical, linear thinking. And I didn't want to leave that just intact; I didn't want to simply be a meditation teacher or something. I wanted to understand it, and we spend a lot of time kind of pulling at its joints and trying to understand why these things might be helpful to people, I think particularly helpful to people in the modern world who are exposed through the media and the kind of chattering world that we've created to a lot of horror, a lot of pain, a lot of judgment, a lot of words, and need to find a place to go that is more peaceful and more empowering, being able to lives their lives in an intimate, committed, effective way. So that's kind of how I came there, or I ended up where I ended up.

Question: What is ACT and how does it differ from traditional forms of cognitive therapy?

Steven Hayes: Sure. Well, the empirical clinical traditions, especially in the cognitive behavioral tradition, early on they were trying to apply behavioral principles mostly developed with animal models directly to people. And there's a lot of benefit that happened there; it's still relevant today. You can do a lot of good things for people who suffer with anxiety, depression and so on using those methods. I'm old enough to have seen all three of these steps, and somewhere in the late '70s and mid-'80s people realized that you had to have a better way of dealing with cognition, and they couldn't find it in the animal models. So they went to more commonsense clinical models where they would sort of divide thinking styles up into rational and irrational processes, making cognitive errors and so forth. And they thought if we could just get people to think more rationally and focus on the evidence and take some of those over-expansive thoughts that are creating difficulty for them and change them, then they'd do better. And some of it was -- the techniques were helpful, but the theory didn't work very well.

Increasingly over time we learned that the components that theory tells you to put in and the processes that should change didn't really explain the outcomes and add to the outcomes. And it had this potential for a downside: people can get even more self-focused, even more caught up in their own thinking. And we're part of a newer sort of third generation of tradition that is using acceptance and mindfulness practices and values, commitment, behavior change practices and marrying them up. So the difference between traditional CBT and the acceptance and commitment therapy, or ACT -- but not just ACT; also mindfulness-based cognitive therapy, dialectical behavior therapy, a number of the other more kind of modern acceptance and mindfulness approaches -- instead of teaching people to detect, to challenge, to dispute and change their thinking, we teach people to notice what they're thinking and to notice what they're feeling, what their body is doing, learn from it, but then focus also on their values and getting their feet moving towards the kinds of lives that they want to produce to have a life worth living.

And it turns out that that's, we think, a quicker and more direct way, a more certain way, to moving ahead in your life than first trying to get the cognitive ecology inside this skull of ours all lined up with an ability to detect our logical errors and correct them and so forth. Meanwhile, the clock is ticking. There's relationships to have, children to be raised, work to be done, contributions to be made, and you're waiting to get the world within all lined up. We think it's more effective to find a way to back up from that a little bit; notice it, see what's there, learn from it, and move ahead directly towards the kind of lives that you want to produce. And it turns out those processes are not just in therapy, but in this office, in your home, in the schools and organizations. And so the ACT work has very quickly expanded out from psychotherapy into behavioral medicine, and from that even into organizational work and now into prevention work and into communities and schools. So it's kind of exciting to see psychology touching people where they are, in the streets, in a way that is empowering and sort of simplifies what it is that people need to learn to be more effective and happy, successful, vital in their lives.

Question: How can a therapist help someone realize their values?

Steven Hayes: You know, a couple of things: if someone watching this were to focus on what pains them the most, and then would take the time to look inside -- what do I care about such that that's particularly painful? -- they're probably going to find a significant area that they value. I'll give an example: most people are hurt deeply by betrayals in relationships. And what your mind tells you to do is, don't be so vulnerable; don’t be so silly; don't open yourself up; don't be so trusting; you can be betrayed. In fact, the reason why you hurt so much is that you want relationships that are loving, committed, intimate; you want trust. And what your mind's telling you to do in a way is, don't care about that so much so that you won't be hurt so much. It might be better to really get up against and sort of contact that caring, and maybe take a more loving stance even with your own pain, and keep your feet moving towards what you really want, because the cost in terms of intimacy and connection and caring that comes when you try not to be vulnerable, when you're constantly looking out for betrayals of trust, is too great. It makes it very hard to have relationships of the kind that you really want. So there's an example. One, look where the pain is. Flip it over; you'll find that's where the values are.

Another one is just to think of the times that you've felt most with yourself, most connected, most vital, most energized, most flowing, natural. And if you take some of these specific memories and you walk inside them, you're going to find that there's things in there that you care about. There's things in there that, when it's really working well, are kind of a lighthouse, like a beacon in the distance, that you can move towards. You never fully reach these things. I mean, I'll give you an example. There are times when you felt especially important to another person, or cared about or loved or accepted. Well, loving relationships aren't something you can have like a precious little jewel you put in a box and then put on your shelf. It's something you walk towards. And there's always difficulties; there's always pain in relationships. But you can keep walking towards that beacon in the distance. That process, that journey, is called life. And if you're moving towards the things that you value, life is more vital, flowing; it's more empowering. And so that's another way: go inside the sweetness of life, catch the places where you genuinely were moved by or connected with life, and you'll find in there kind of a light that can direct you when the cacophony gets very noisy and you get confused and lost, that can direct you towards what you care about.

Question: How does the role of an ACT therapist differ from the role of traditional psychologists?

Steven Hayes: It might be a little bit, because this psychology is a psychology of the normal. A lot of the psychologies that are out there are built on the psychology of the abnormal. We have all these syndromal boxes that we can put people in and so forth. The actual evidence on syndromes is not very good. I mean, there's no specific biological marker, for example, for any of the things that you see talked about in the media. Even things like schizophrenia -- there's no specific and sensitive biological markers for these things. So yeah, there may be some abnormal processes involved in some of them, but vastly more of human suffering comes from normal processes that run away from us. Like normal processes of problem-solving work great on the world without; when it's applied within, you too easily get into a mode of mind where you can start living when the problem of your history is solved.

But your history's not going to go away; it isn't the same thing as dirt on the floor or paint peeling off the walls; it's not going to be solved in that way. It's more like learning how to carry it, to contact it, to see it. Because it's based on the psychology of the normal, the therapist is part of that too. And so when the therapist gets in there and is working on acceptance and mindfulness and values, they too are working with those very same processes. And so it requires a therapist not to be a master at it -- you don't even have to be good at it -- but just to see the value of it and to be willing to look at their own difficult emotions and thoughts and find a way to carry them gently in the service of the clients that they're serving.

So for example, if a therapist is feeling insecure in therapy, a lot of therapists will try to sort of push that aside to try to do the therapy. Instead, we would ask people to get with that feeling of insecurity, because after all, the client is being asked to do the same thing. So it tends to be relatively intense, interactive, horizontal. It's not one up; the therapist is in the same soup. And it has a kind of a quality of two human beings in the same situation, really, working through these psychological processes. And yeah, I'm working for you; you hired me; I'm working for you as a therapist. But I'm not up here and you're down there. And what you're struggling with, at other times and with other areas I'm struggling with.

Question: Why can ACT treat everything from schizophrenia to prejudice?

Steven Hayes: Well, and even more than that. I mean, I've mentioned even in this office the same processes are there. We've done research showing that ACT and the processes that underlie it can help things like can secretaries learn new software? Can therapists learn new methods? What about stigma and prejudice between people? So it isn't just in the psychotherapy areas. And why that would be, as an empirical fact there's a pretty enormous breadth to these methods. And why that would be -- because everywhere that a human mind goes, these processes of avoiding the world within in order to try to regulate your behavior, or becoming entangled in your thoughts interfering with your ability to take advantage of what's around you, or losing contact with your values for fear that you'll know more about the places where you hurt -- those kinds of processes are just normal psychological processes that are built into language and cognition itself. They're built into problem-solving. And so if you take the mode of mind that works great in 95 percent of your life and apply it within, it then implodes. It starts creating barriers, and that's true at work, it's true in organizations, it's true in our culture, true in our politics. And yeah, it's true in our consulting rooms.

So we're going -- the reason why it spreads out -- we have pretty good evidence for this; I know it sounds a little grandiose -- but the mental cognitive processes that we're targeting are ones that narrow human beings' repertoire and make it harder for them to learn to be more flexible, to take advantage of the opportunities in front of them. And we think that's something we can have something to say about, something to help with in all of these different areas, maybe even in areas like child development or organizations and schools, or maybe even things like prevention or how peoples interact with each other, one to the other. So we've taken the work, for example, into things like prejudice and stigma, because in the modern world, if we can't solve that we have planes flying into buildings. And then we have planes flying over countries. The amount of hate and objectification and dehumanization that's on the planet isn't something we can tolerate any more in a world that's coming of suitcase bombs and the ability to amplify that hate out into harm towards each other. So it applies broadly because anywhere that a human mind goes these processes go.

Question: What is happiness?

Steven Hayes: You know, there's many different definitions of it. I think one dangerous definition of it is to think of happiness as kind of a warm, joyful, **** feeling in your heart that you have to pursue and grab and hold onto for fear that it'll go away. I mean, it's fun when you have those feelings, but we know, and the evidence shows, them more intent you are on having those feelings and chasing those feelings, that's a butterfly that flies away the more you chase it. A better way to think about happiness that actually is something that I think you can reach towards is, it's living in accord with your values and in a way that is more open and accepting of your history as it echoes into the present, that's more self-affirming, self-validating and values-based. The Greeks had a word for it; they called it eudaimonia, and it's not a bad definition. And I think that definition of happiness is something that will empower human lives.

The definition that we have that gets very hedonistic and emotion-oriented -- the problem is that there's too many quick and dirty ways to chase that in ways that end up being unhelpful to people. If you avoid the feelings of betrayal and the sense of insecurity that comes in relationships that aren't working by running into detuned relationships, by sexuality that isn't connected to intimacy, et cetera. Yeah, you might feel good, but it doesn't live well. If you just have another martini or even more severe forms of substance use, yeah, it might feel good, but it doesn't live well. And if you escape into kind of a materialism -- the right car, the right woman, the right house, the right trip, the right place, the right job, the right praise -- you know, these things -- all of the folks who are wise in our culture, over the history of our culture, have written about the dangers of trying to define a meaningful life that way. But commercial culture and our media is constantly encouraging us to think that if we feel good we live well. And then we're only too happy, thank you very much, to sell you goods and services from the dancing oivoids and the pill you can take, or the trips or the cars or the clothes or the women that you can get with -- whatever that is that will give you the quick route to that.

And it's an empty promise. I think young people know it's empty, but they're not quite sure what to do. And I kind of look at what's on the T-shirts and I see another solution, which also worries me. I see "Just do it." "No fear." -- this kind of suppressive response to the treacle that the culture tries to define for us as a meaningful life also blows up on you. "No fear" is not something that you should put on your shirt. How about "I can hold my fear and still connect with you"? Put that on your shirt. "It’s okay to be me, with all of my history." Put that on your shirt. So there's a middle path. There was a guy who sat under a tree a long time ago who is important to a pretty big chunk of the human population that called it The Middle Path. There is a middle path between indulgence and suppression, but the culture has overwhelmed that in the cacophony that has been created in the modern world and the commercial encouragement of avoidance and indulgence on the one hand, or suppression and "just do it," treating yourself as an object on the other. We've got to find a way that's more compassionate, softer, that allows us to move forward towards the kind of lives that we really want to live.

Question: Are Americans striving too much for happiness?

Steven Hayes: I think the commercial culture, and also science and technology after all, which gives us greater ease but also makes it harder for us to sit with the small amounts of distress that come just by living itself, is probably -- the combination of the commercial culture and the media culture and the science and technology has probably made it more difficult in American culture. But I think it's built into language and cognition. It was only given some counterweights -- the major institutions that are there are our spiritual and religious traditions, which emerged very early on, at the point at which human language grew and written language created kind of the problem that we can have now with language kind of running away from us. And those traditions have weakened too in our culture, and they've changed. So we probably do -- it isn't that we're chasing happiness; I think we have the wrong model of happiness. I mean, defined as eudaimonia, defined as a values-based life of integrity and fidelity to yourself and what you most deeply want to stand for, that definition of happiness -- man, that's the kind of life I want to live and I think that will support people and sustain people.

But this cheap-thrill version, this sort of ease definition, the feel-good definition of happiness is an empty promise. And the culture in the West I think has done a particularly bad job of indulgence in that vision of what happiness is and encouraging people to chase it. And I think we can see in the growing amount of problems that we have in the developed world that it's an empty promise. And I'll give you an example, not from the U.S., but in Scandinavia probably the most worker-supportive part of the planet, they have the highest rate of chronic pain and the greatest rate of worker-related disability. So right inside this idea that any kind of pain and difficulty is so much unwelcome that if you say that you're in pain, we're going to come in guns a-blazing and even pay you full salary to quit work because you're burned out, or to -- inside that what you're going to create is gigantic amounts of chronic pain syndrome. Scandinavians spend 15 percent of their gross national product on disability. Fifty percent of the public health nurses are on disability. I mean, and that's where we're headed in the U.S. too, because unless we get wiser as to how to carry the difficulties of life in a way that's self-compassionate and empowering, we can create this kind of world in which we'd rather sort of plug into the matrix with whatever pills or escapist tendencies we can think of instead of walking through a process of living that's going to include loss. It's going to include limitations on function. It's going to include some significant difficulties. We need to learn and teach our children how to do that. And the West is just doing a terrible job of that right now.

Question: Do you believe in medicating depression and other forms of mental illness?

Steven Hayes: Medication -- I want good science, and big pharma is only too happy to give us bad science, because the way the FDA is set up and what the requirements are -- I mean, these are geek topics, and the normal person wouldn't really know how to evaluate it. But you only require a certain number of randomized trials. You don't have to have the proper control groups. You can have the blind be penetrated; people can know that they're on the medication, which we know there's a big placebo effect inside medications. So the science is often inadequate. The best science that's out there, then I want to -- then that's fine; let's go there. And there's decent science.

Let's take something like antidepressant medications. There's decent science saying it has an effect, but it's shockingly small after you control for penetration of the blind, people knowing that they're getting the active pills versus sugar pills, if you use an active control. It's probably only a few points. Like in depression, on the 56-point scale, the estimate is it probably accounts for about two points difference. But it's a multi, multibillion-dollar industry. And by the way, has huge side effects. And some of these medications, 40 percent of the people taking them have significant sexual side effects, for example. And that's just one. The level -- a single antidepressant medication can be worth a billion dollars to a company.

So I want good science, and I want it to be realistically marketed. I wouldn't like -- I think all these commercials that we have -- only two countries on the planet that allow pharmaceutical companies to market directly to people, New Zealand and the United States -- it's a bad idea, in my opinion. I think it ought to be better regulated. And when it's presented to people, it ought to be presented in a way that's realistic. For example, often people will prescribe these medications, and we'll say, you have a brain disease; you'll have to be on these medications permanently. It's because you have a brain disease. Well, brain disease -- there would be a specific biological marker for the so-called disease. There is no biological marker for depression. It's not true that we know that it's a brain disease. Is the brain involved in depression? Yes, the brain is involved with what you and I are doing right now. If neither one of us had a brain, we wouldn't be having a conversation. But that doesn't mean it's a brain disease.

And so the prescribers very often overstate, oversell, and the detail people are only too happy to tell them to do that. This idea that there's something wrong with your brain, and because of that you're permanently -- by the way, almost never are these medications evaluated with what will happen if you're on them for three, four, five, 10, 15 years. Sometimes some of the side effects that come up come up only later, and sometimes they're very severe, even irreversible side effects. So I would like it to be more like yes, these medications might be helpful to a degree, but what they do in areas like depression or antipsychotics is, they give you a little more distance between the things that cause you to get entangled with thoughts and feelings. And so they might be of some help, open up a little window. Now can we go in there and learn some of these methods directly to do that?

For example, antidepressant medications, you still have some depressive thoughts. Antipsychotic medications, you still have some psychotic symptoms for the vast majority of the people taking them. But it gives them a little separation, and it doesn't control his behavior as much when you have a sad feeling, difficult thought, an odd perceptual experience. We can teach people those exact skills in therapy, and so evidence is pretty good if you use it as just a window to get in there and teach these skills, you get longer-term benefits and without the side effects. So don't be sold just because a commercial interest wants to sell you things. The government ought to help out, because the average citizen can't go out and be doing reviews of the scientific literature. And focus on the processes that have low side effects and good long-term outcomes. Right now you're going to find those in the psychosocial area, in the therapy area, in the empirically supported treatments such as ACT or cognitive behavior therapy, behavior therapy. And go there first rather than going to the pill bottle as if it's going to be the end of your journey, that it's going to solve the problem. Very often it's only going to help, and even only to a minor degree, and more is going to be needed.

Question: What’s your advice to someone dealing with a panic attack?

Steven Hayes: Well, the advice I'd give if you were my patient would be a little different because we'd have a little more time. But if I can distill it down to the essence of what we do in a course of therapy, the person with panic -- I can say this from the inside out since you're looking at a panic-disordered person in recovery -- has adopted a posture with regard to the world within in which their own anxiety is their enemy. And they think that if they can just get the anxiety to go down, go away, not occur as much or not occur with such intensity, or at least not occur here, or there, in that situation, that then things would be better. In fact, all of that is not the solution to the problem; it is the problem. Holding anxiety as your own enemy, and that it has to go down, diminish it, go away and not happen here is a kind of self-invalidating, interiorly focused process that would get you even more entangled with these processes. Instead, what we're going to need to learn to do is to allow your history to bring into the present thoughts and feelings and memories, and to sort of hold them mindfully and self-compassionately, and then focus on what you do and bring them along for that journey.

So -- feelings are only your history being occasioned by the present moment. If that's your enemy, then your history is your enemy. If sensations are your enemy, your body is your enemy. And if memory is your enemy, you'd better have a way of controlling your mind in such a way that you never are reminded of things that are painful from the past. Well, there is no such thing like that that's healthy. And most of the things that people do that are called psychopathology are the unhealthy things people do when they try to accomplish that agenda. If you avoid people, avoid having your buttons pushed, avoid going to places that might occasion anxiety; if you're hammering down drugs and alcohol; these are all methods of trying to mount that unhealthy agenda.

So I would say, could we instead take this anxiety to be something that may be of importance, may even be meaningful? And it says something about your history, and could we learn to sort of hold it in a way that's more compassionate, to sort of bring the frightened part of you close and treat it with some dignity, and keep focused -- instead of making that go away -- focused instead on what kind of life you want to live connected to what kind of meaning and purpose. That's going to be a quicker, more self-compassionate and more certain journey forward than this kind of "out with the anxiety, in with the relaxation," "out with the self-doubt, in with the confidence" kind of -- "let's just snap out of it" kind of harsh and non-compassionate place that we stand with ourselves inside things like panic disorder.

Question: Why don’t some psychologists believe in the effectiveness of ACT?

Steven Hayes: It's an argument about theory and processes, but the processes, and the ones we've been talking about, inform what we think of ourselves and what we should encourage in our children and what we should try to put into the culture. And I think really we've been through a time when we thought we could think our way out of this, and kind of think clearly and that would solve the problem, and detect logical errors and that would solve the problem. We thought of suffering as a problem of sort of dysfunctional cognitions. I think we're coming into a time instead where it has to do with how you stand in relationship to your own world within and in relationship to those around you in the world without. And I believe these are the things that we need to put into our schools, education, into our psychotherapy and into our culture more, finding a way to not be so harsh and judgmental, so objectifying and dehumanizing, constantly focused within and trying to get these difficult thoughts and feelings to go away; or focused without and objectifying and dehumanizing others. So the core of the controversy is, is it more powerful to take an acceptance and mindfulness-based approach compared to a cognitive and emotional change approach when we're dealing with these problems? I think the evidence is more in our favor, especially the process evidence.

And I think if you look at where the culture is going, there's a reason why Eckhart Tolle is on Oprah. There's a reason why The Purpose-Driven Life is a best seller, quite apart from appealing to evangelicals and the Christianity that's in it. It's also -- there's a yearning for meaning, for values and for mindfulness and acceptance, because we've created a modern world where our children are exposed to 10, 20, 30 times the number of words that our great-grandfathers were exposed to. And we're exposed in a single day or two to more horror on our Internet Web pages than our great-grandfathers were exposed to in decades of living. And we have not created modern minds for that modern world. Science and technology has just dumped it on us. And I think people yearn for it. I think you see it in what's popular. And why are people wanting to learn about meditation, and why are they going on mindfulness retreats? And why are they talking about a purpose-driven life? It's because they know more is needed in the modern world.

And that's the core of the controversy. I think it's pretty clear in how things are moving in empirically supported treatments that we're going to be speaking to the culture in a different voice. It's not going to be the loosey-goosey voice of the '60s, but it's going to have some echoes of some of the deeper clinical and spiritual and religious traditions that had wisdom in it. If we're not going to get there through religious means and things of that kind, which greatly has weakened in the West, we're going to have to find a way to put it in the culture in a different way, because we need something right now other than yet another cable shoutcast or yet another Internet Web page showing us the cellulite on the actress's rear end. I mean, the amount of sort of judgment and harshness that's in our culture -- we need something that's prophylactic for that, and I think that's what's inside these new methods.

Question: What keeps you up at night?

Steven Hayes: What keeps me up at night in a positive way is the possibility that we might contribute to the development of human culture in a way that, years from now, people who will never know our names may be able to live more empowered lives. And if you ask like what is the name of your great-great-great-grandfather, you probably don't even know if you get three or four greats out. So it's not that we're immortal; we're going to die very, very soon. It's not that what we produce is going to live on; it will not. But the changes that we can make in the culture can be there for people that we will never meet, that will never know us, and that's what keeps me up at night. It's what excites me about science, that we can learn ways of being with each other. And the behavioral sciences have not been enough of a part of cultural development. The physical sciences have; the behavioral sciences have not. And I would like to see if we can bring some things into human culture that would humanize and soften and empower people.

What keeps me up at night in a negative way is, if we don’t solve these problems of the human heart and of the human head, of human psychology, there is no technological solution so great that it can prevent the world that is coming, and a world of suitcase bombs or of the ability to pollute the planet in a way that it cannot recover, of global warming and the rest. We've created through science and technology a different world that has frightening sides to it, and psychology and behavioral science has to be part of this, because if you take something like the so-called war on terrorism, if we go out another 20 years and it isn't just planes into buildings, but it's a suitcase bomb in the middle of New York, there's not enough soldiers and there's not enough bullets to kill enough people to make us safe. I think we're going to have to find a way to humanize the culture itself.

And it isn't just them; it's us. When we fly planes over countries, dropping bombs on the evil ones, I think we're doing something very similar to what's being done when the infidels are getting their comeuppance with planes going into buildings. So it's gotten to the point where if we are not healthy psychologically as a human society, we will not have a planet to live on. And that's what keeps me up at night, when I see so little focus on the behavioral side of these problems, and the idea that just politics, or just physical science, is going to solve this. Or just the military; it's not true. We have to solve this, and we've got to solve it in our own heads and in our own hearts, one at a time. And I think psychotherapy actually tells us a little bit about what we might need to do to soften the culture and make it more possible for us to live together as human beings on this planet.

Martha Beck column in O magazine, 2001: Get a New Leash on Life

Martha beck Column "Beck on Call" in "O" - The Oprah Magazine

From: www.oprah.com/omagazine/200208/omag_200208_beck.jhtml.

An innovative therapy argues that acceptance is the route to happiness. Martha Beck brings you a new leash on life!

I'm trying an exercise designed by psychologists to help me gain my sanity by gently losing my mind. This process is utterly different from typical attempts to pursue happiness, most of which depend on controlling events and feelings.

Think of a problem that has plagued you for a long time—your weight, a loved one's bad habits, fear of terrorism, whatever. No doubt you've tried valiantly to control this issue, but are your efforts working? The answer has to be no; otherwise you would have solved the problem long ago. What if your real trouble isn't the issue you brood about so compulsively, but the brooding itself?

Psychologists who subscribe to acceptance and commitment therapy (ACT) call "clean" pain what we feel when something hurtful happens to us. "Dirty" pain is the result of our thoughts about how wrong this is, how it proves we—and life—are bad. The two kinds of suffering occupy different sections of the brain: One part simply registers events, while another creates a continuous stream of thoughts about those events. The vast majority of our unhappiness comes from this secondary response—not from painful reality but from painful thoughts about reality. Western psychology is just accepting something saints and mystics have taught for centuries: that this suffering ends only when we learn to detach from the thinking mind.

Judge not...

Learning to detach starts with simply noticing our own judgmental thoughts. When we find ourselves using words like should or ought, we're courting dirty pain. Obsessing about what should be rather than accepting what is, we may try to control other people in useless, dysfunctional ways. We may impotently rage against nature itself, even—perhaps especially—when that nature is our own.

This amounts to mental suicide. Resisting what we can't control removes us from reality, rendering our emotions, circumstances and loved ones inaccessible. The result is a terrible emptiness, which we usually blame on our failure to get what we want. Actually, it comes from refusing to accept what we have.

Victory by Surrender

Surrendering allows the truth to set us free. And how do we surrender?

I recently watched television interviews with two actresses, both in their late fifties. Each was asked if she'd found anything good about aging. Both snapped, "No. Nothing. It's horrible." A few days later, I saw Maya Angelou on TV. She said that aging was "great fun" and gleefully described watching her breasts in their "incredible race to see which one will touch my waist first."

"Sure, the body is going," she said. "But so what?"

Ms. Angelou has said many wise things, but I thought "So what?" was one of her wisest. It expressed the sweet detachment of someone who has learned how to rest in her real being and knows that it is made not of flesh or thought, but of love.

The Fruits of Acceptance

There is enormous relief in detaching from our mental stories, but in my experience, the results go well beyond mere feeling. Surrendering leads directly to our right lives, our hearts' desires. Whenever I've managed to release my scary stories and accept the truth of my life, I've stumbled into more happiness than I ever dreamed possible.

When I stop trying to control my mind—that verbose, paranoiac old storyteller—my thoughts become clearer and more intelligent. It's a delicious paradox: By not trying to control the uncontrollable, we get what we thought we'd get if we were in control. This thought pleases me greatly.

Still not happy? Your mind might be your biggest obstacle.

Martha Beck's story in the February 2006 issue of "O" Magazine

This is Martha Beck's column in "O":

MELANIE'S LIFE WAS SHRINKING LIKE A CHEAP BLOUSE in an overheated dryer. At 30 she'd developed a fear of flying that ended her dream of world travel. Within a year, her phobia had grown to include—or rather, exclude— driving. After the World Trade Center attacks, Melanie became terrified to enter the downtown area of any city. She quit her job as an office manager (the potential for mail-based terrorism was too big) and called me hoping I could help her devise a way of earning money from home.

"Everybody tells me my fears aren't realistic," she said. "But I think I'm the most realistic person I know. It's a dangerous world— I just want to be safe."

There was only one thing for which Melanie would leave her apartment. Once a month, she walked to a rundown neighborhood to meet her drug dealer, who sold her Xanax and OxyContin of questionable purity. I insisted that Melanie see a psychiatrist before I'd work with her, and the worried shrink called me before the impression of Melanie's posterior had faded from his visitor chair. "She's taking enough medication to kill a moose," he told me. "If she slipped in the shower and knocked herself out, withdrawal could kill her before she regained consciousness."

Ironic, n'est-ce pas? Safety-obsessed Melanie was positively devil-may-care when it came to better living through chemistry. This made no sense to me—until I realized that Melanie's objective wasn't really to avoid danger but to prevent the feeling of fear.

Melanie was using a strategy psychologist Steven Hayes, PhD, calls experiential avoidance, dodging external experiences in an effort to ward off distressing emotions. It wasn't working. It never does. In fact, to keep her tactics from destroying her, she would have to learn the antidote for experiential avoidance—and so must the rest of us, if we want our lives to grow larger and more interesting, rather than smaller and more disappointing.

Why Experiential Avoidance Seems Like a Good Idea

Most of us do this kind of emotional side step, at least occasionally. Maybe, like Melanie, you feel skittish on airplanes, so you take the train instead. In the realm of physical objects, dodging situations associated with pain is a wonderfully effective strategy; it keeps us from pawing hot stovetops, swallowing tacks, and so on. Shouldn't the same logic apply to psychological suffering? According to Hayes, it doesn't. Experiential avoidance usually increases the hurt it is meant to eliminate.

Consider Melanie, who, quite understandably, wanted to steer clear of the awful sensation of being afraid. Every time she withdrew from a scary activity, she got a short-term hit of relief. But the calm didn't last. Soon fear would invade the place to which Melanie had retreated—for example, she felt much better driving than flying for a little while, but it wasn't long before she was as petrified in cars as airplanes. Drugs calmed her at first, but soon she became terrified of losing her supply. By the time we met, her determination to bypass anything scary had trapped her in a life completely shaped by fear.

The reason this happens, according to Hayes and other devotees of relational frame theory, is that Melanie's brain works through forming connections and associations. So does yours. Your verbal mind is one big connection generator. Try this: Pick two unrelated objects that happen to be near you. Next answer this question: How are they alike? For instance, if the objects are a book and a shoe, you might say they're alike because they both helpedyou get a job (by being educated and dressing well). Ta-da! Your book, your shoe, and your job are linked by a new neural con¬nection in your brain. Now you're more likely to think of all these things when you think of any given one.

This means that every time you avoid an event or activity because it's painful, you automatically connect the discomfort with whatever you do instead. Suppose I'm having a terrible hair day, and to not feel that shame, I cancel a meeting with a client. Just thinking about that client brings on a pang of shame. If I watch a movie to distract myself, I may be hit with an unpleasant twinge just hearing the name of that movie. This happens with every form of psychological suffering we try to outrun. Your true love dumps you, and to stave off grief, you avoid everything you once shared —your favorite song, the beach, mocha lattes. Now you're bereft not only of your ex but also of music, seascapes, and a fabulous beverage. Your losses are greater, as is your grief. So you go on a hike to cheer yourself up, and what do you think as you gaze at the lovely scenery? Well, duh. You wish your ex were seeing it with you, and you're sadder than ever. When we run from our feelings, they follow us. Everywhere.

The Willingness Factor

In Hayes's book Get Out of Tour Mind & into Your Life, he suggests that we picture our minds as electronic gadgets with dials, like old-fashioned radios. One dial is labeled Emotional Suffering (Hayes actually calls it Discomfort). Naturally, we do everything we can to turn that dial to zero. Some people do this all their lives, without ever noticing that it never works. The hard truth is that we have no ultimate control over our own heartaches.

There's another dial on the unit, but it doesn't look very enticing. This one Hayes calls Willingness, though I think of it as Willingness to Suffer. It's safe to assume that we start life with that dial set at zero, and we rarely see any reason to change it. Increasing our availability to pain, we think, is just a recipe for anguish souffle. Well, yes...except life, as Melanie so astutely commented, is dangerous. It'll upset you every few minutes or so, sometimes mildly, sometimes apocalyptically. Since desperately twisting down the Emotional Suffering dial only makes things worse, Hayes suggests that we try something radical: Leave that dial alone—abandon all attempts to skirt unpleasant emotions—and focus completely on turning up our Willingness to Suffer.

What this means, in real-world terms, is that we stop avoiding experiences because we're afraid of the unpleasant feelings that might come with them. We don't seek suffering or take pride in it; we just stop letting it dictate any of our choices. People who've been through hell are often forced to learn this, which is why activist, cancer patient, and poet Audre Lorde wrote, "When I dare to be powerful—to use my strength in the service of my vision, then it becomes less and less important whether I am afraid."

Once we're willing to confront our emotional suffering, we begin making choices based on attraction instead of aversion, love instead of fear. Where we used to think about what was "safe," we now become interested in doing what seems right or fun or meaningful or ripe with possibilities. Ask yourself this: What would I do if I stopped trying to avoid emotional pain? Think of at least three answers (though 30 would be great and 300 even better). Write them here:

1.

2.

3.

Stick with this exercise until you get a glimmer of what life without avoidance would be like. To paraphrase Dr. Seuss, Oh, the places you'd go! Oh, the people you'd meet, the food you'd eat, the jokes you'd tell, the clothes you'd wear, the changes you'd spark in the world!

One thing none of us will ever be able to calculate is how much we've lost by not having these experiences—something Hayes calls the pain of absence. Being unwilling to suffer robs us of incalculable joy—and the awful punch line is that we still get all the anguish we tried to escape (and then some).

The Consequences of Willingness

What happens when we're willing to feel bad is that, sure enough, we often feel bad—but without the stress of futile avoidance. Emotional discomfort, when accepted, rises, crests, and falls in a series of waves. Each wave washes parts of us away and deposits treasures we never imagined. Out goes naivete, in comes wisdom; out goes anger, in comes discernment; out goes despair, in comes kindness. No one would call it easy, but the rhythm of emotional pain that we learn to tolerate is natural, constructive, and expansive. It's different from unwilling suffering the way the sting of disinfectant is different from the sting of decay; the pain leaves you healthier than it found you.

It took Melanie a huge leap of faith to accept this. She finally decided to turn up her Willingness to Suffer dial, simply because her Emotional Suffering levels were manifestly out of her control. She started by joining a yoga class, though the thought of it scared her witless. She found that her anxiety spiked, fluctuated, and gradually declined. Over the ensuing months, she entered therapy, traded her street-drug habit for prescribed medication, and found a new job. Melanie's worry isn't completely gone; it probably never will be. But that doesn't matter much. She is willing to accept discomfort in the pur¬suit of happiness, and that means she'll never be a slave to fear again.

To the extent that we reject anything we love solely because of what we fear, we're all like Melanie. Find a place in your life where you're practicing experientialavoidance, an absence where you wish there were something wonderful. Then commit to the process of getting it, including any inherent anxiety or sadness. Get on an airplane not because you're convinced it won't crash, but because meeting your baby niece is worth a few hours of terror. Sit on the beach with your mocha latte, humming the song you shared with your ex, and let grief wash through you until your memories are more sweet than bitter. Pursue your dreams not because you're immune to heartbreak but because your real life, your whole life, is worth getting your heart broken a few thousand times.

When fear makes your choices for you, no security measures on earth will keep the things you dread from finding you. But if you can avoid avoidance — if you can choose to embrace experiences out of passion, enthusiasm, and a readiness to feel whatever arises—then nothing, nothing in all this dangerous world, can keep you from being safe.

-------

Martha Beck is the author of Leaving the Saints and The Joy Diet (both Crown).

New Harbinger's interview with Steve Hayes

Interview with Steven Hayes on Get Out of Your Mind and Into Your Life

New Harbinger Publications: In Get Out of Your Mind and Into Your Life, you contradict some of the most central tenets of psychology. You say for example that, “accepting your pain is a step toward ridding yourself of your suffering,” and “we assume that...suffering is normal and it’s the unusual person who learns how to create peace of mind.” How did you come to adopt ideas that are so contrary to earlier models of psychological thought? 

Steven C. Hayes: Actually the idea that human suffering is pervasive is hardly new. Most of our spiritual and religious traditions begin there, for example. And our scientifically based therapy traditions inadvertently do too, though they don’t seem to realize it. Every professional writing a grant or pitching the need for a new treatment program begins with a section documenting how pervasive a given problem is in the community. And you see that work being written up in the popular media all the time with stories about the unbelievably large numbers of people who have, say, been abused, or have an addiction problem, or struggle with relationships, or have a mental disorder, or who are just stressed at work.

To see the truth of the claim I make in this new book, all you have to do is stop and say, “Hey, wait a minute. What if we added up all of these problems? How many people would fail to be in one ‘abnormal’ grouping or another?” When you craft the question properly the answer hits you in the face: it’s pain and struggle that is normal, not happiness. Most people I know have the personal information needed to reach the same conclusion. Just ask yourself this: How many people do you know really well who don’t struggle at times—or even often—in their lives?

There is almost this conspiracy of silence. Because we’re told that happiness is normal we tend to keep silent about our struggles—it means we’re abnormal. But because most people have the same secret, we walk around feeling isolated and alone. That doesn’t mean you can’t be happy. You can. But you have to learn how to avoid the traps our minds lay for us. The reason why suffering is so pervasive is because we’re so bad at doing anything about it.

The natural, rational thing to do when we face a problem is to figure out how to get rid of it and then actually get rid of it. In the external world, our ability to do just that is what allowed us to take over this planet. But that only works in the world outside of our skin. We don’t at first realize that and so we deal with our own psychological struggles by trying to get rid of our painful feelings, difficult memories, or worrisome thoughts—as if then we’ll be happy. But it doesn’t work.

Modern science is fairly clear that this is one of the surest ways to prevent happiness from ever arriving. Said another way, suffering is so pervasive because our attempts to solve it actually make it persist. We are caught in a trap of our own making. As for how I got there, my position came from three sources. The traditional model didn’t work for me; it didn’t work for my patients; and as I began to research it, I figured out why that was. And our research showed that doing some very counterintuitive things instead did work.

NHP: Can you give us a layperson’s primer on acceptance and commitment therapy (ACT)?

SCH: ACT is based on the idea that psychological suffering is usually caused by running away from difficult private experiences, by becoming entangled in your own thoughts, and as a result of all of that failing to get your feet moving in accord with your chosen core values. ACT is based on a new and extensive basic research program on language and cognition, relational frame theory (RFT), which explains why pain occurs so readily in people and is so hard to solve. Fortunately it also suggests new, powerful alternatives such as acceptance, mindfulness, values, and committed action.

ACT—and this new book—helps people acquire these new skills. They can be learned fairly quickly, and they seem to apply to an amazingly wide range of human difficulties. We teach clients how to back up from thoughts and the world structured by thought and instead to focus on the process of thinking itself: how to feel feelings as feelings, fully and without needless defense, even when we don’t like them; how to show up in the present moment as a conscious human being; and how to begin to act in accord with chosen values. In short, we teach people how to be more flexible in moving toward what they really want and less automatic, programmed, and self-defeating. Get Out of Your Mind and Into Your Life explains how to do just that.

NHP: You claim these ideas apply to almost every psychological problem people face. Can you talk about some of the problems ACT can be applied to?

SCH: Research is showing that ACT methods are beneficial for a broad range of clients. There is almost nothing you can mention that doesn’t have at least some supportive data on the role of acceptance, mindfulness, and values, or negative data on the impact of avoiding your own experiences and failing to act in accord with your values in that same area. ACT teaches people fairly quickly how to alter their relationship to difficult private experiences and how to get behavior change going NOW, rather than waiting to have difficult emotions or thoughts go away before acting.

This empowering message has been shown to help clients cope with a wide variety of clinical problems, including depression, anxiety, stress, burnout, substance abuse, prejudice, smoking, adjusting to chronic disease, and even psychotic symptoms. In the area of anxiety and panic, avoiding your own negative private experiences is one of the strongest predictors of bad outcomes.

Conversely, we now know from research with a variety of anxiety disorders that when you let go of the struggle with anxiety, you’re on the road to a healthier life. This doesn’t necessarily mean that anxiety will go away—it means that its role in your life will diminish, sometimes quickly. If you think about it, you can see why. Suppose I could tell if you were the tiniest bit anxious. You could not fool me. And suppose I then held a gun to your head and said, “Relax completely or I’ll shoot.”

Almost no one would pass such a test. Yet that is the exact situation a panic disordered person has put himself or herself in. Instead of being shot, what is threatened is loss of self-esteem or loss of the view that a good life is possible, but that is pretty much the same thing—and the outcomes are equally predictable. We have several studies now showing that ACT can be helpful with anxiety problems.

Depression is sometimes spoken of as a feeling, but it’s more than that. It’s also an agenda: the agenda of not feeling bad. When you are depressed you are less able or willing to feel, and because of that you are less able or willing to act. Here is one way to put it: depression is what you feel when you are not willing to feel something else. ACT undermines that whole game, and instead focuses on what it is that you really, really want in life, while feeling and thinking whatever you feel and think. It turns out that these feelings won’t be just depression, but perhaps anger, fear, sadness, or loss, among others. If depression has to first go away before a person can move forward, you have an unsolvable problem. But when we learn how to just notice our depressive thoughts, and feel our feelings as feelings, deliberately and fully—it turns out that we can begin to live again, right now, even with depressed feelings or depressogenic thoughts.

And when we do that, we start to move. We’re able to contribute to others. To make a difference. That breaks the back of depression. There are three small controlled studies on ACT and depression, and it makes a big difference. This work is still young, but so far it appears that ACT may actually be more effective than the best current psychological treatment for depression. We will know when bigger studies are done. In science that is the key: replication by others.

Chronic pain leads people to spend their lives trying to find a way to get rid of it, but research shows that this approach to pain makes it more central, more dominant, and more disruptive to people’s lives. Meanwhile there is even a bigger tragedy happening than the pain itself—a life is being lost. It turns out that ACT can greatly improve functioning by helping the chronic pain patient focus on his or her own chosen values and, while being aware of the pain when it’s present, begin to live again.

ACT helps the person with chronic pain step back from the chatter that says he or she can’t live until pain goes away, and without arguing back, simply begin to move forward. I personally don’t have chronic pain. But I do have tinnitus—my ears are screaming 24/7. And do you know what the literature says? Any attempt to cope with it is harmful. What you need to do is to let go of it and focus on living. I now sometimes go an entire day without noticing tinnitus even once—but every time I check, wow! Is it noisy! Chronic pain is like that.

We need to learn to live with it. We are not talking about living with it like putting up with it or tolerating it. We are talking about LIVING with it. It appears that ACT can make a difference in chronic pain quickly. In one study with people just starting to become chronic pain patients, four hours of ACT reduced sick- leave due to pain almost to zero levels; in another with patients who have been in pain for over a decade, three weeks of ACT improved their functioning 20 to 40 percent, depending on the area. So we know we can make a difference with chronic pain.

Most addiction seems to be in large part driven by avoidance and cognitive entanglement. When you use, you are trying to feel only good. Drugs are sometimes called a fix. Fixing means repairing what is broken but it also means to hold something in place. Drug and alcohol abusers are trying to hold “feeling good” in place by chemical means. When you abandon that attempt you will sometimes feel good and sometimes feel bad. If you can do that and focus instead on changing your behaviors, you have a way forward.

We now have controlled ACT studies with several kinds of substance abuse including marijuana and heroin, and they show good effects. ACT has an agenda sort of like that serenity prayer from AA: accept what you can’t change, change what you can. In the prayer, clients ask for the wisdom to know the difference—ACT theory specifies that difference. It’s good to change your behavior; it’s harmful to try to change the automatic results of your history. There are now three randomized trials on ACT for smoking and so far it beats the patch, Zyban, and traditional cognitive behavior therapy.

We also know this: Urges to smoke don’t predict whether or not you can quit. Most people are surprised by that, because urges seem important. But what is missing is the context in which these urges occur. What predicts quitting or not quitting is how much you first have to not feel urges before you can stop. Said another way, the task in smoking cessation is to learn to let the urges and emotions and thoughts just wash over you, while doing nothing at all about them other then noticing them as they are … and to do all of that while not reaching for that cigarette. You do that and you are on the way to quitting smoking for good.

ACT is used in several trauma centers nationwide such as the National Center for PTSD in Palo Alto, CA, or the trauma and substance abuse program at the Baltimore, MA, VA hospital. Entire units are organized around ACT. So the providers in this area see value in what we are doing. Both the basic studies on the psychological process that underlies trauma and early treatment studies show the same thing: it’s not pain that predicts trauma. It’s the unwillingness to feel pain that predicts trauma.

This is an important insight for us all in the modern era because the media has made it possible for all of us to be exposed regularly to horror. We see the bombings in Iraq. We all saw those dots that were not dots coming out of the top floors of skyscrapers on 9/11. World wide we are exposed to amazing levels of painful events every day if we just turn on our televisions. 9/11 is just the clearest example. Now, a few years later, we are learning who was traumatized by those events. It was not those most horrified. It was those most unwilling to feel horrified. And no wonder. If you are unwilling to feel what you already did in fact feel, where do you go? How can you run fast enough? Here is the formula: Pain + unwillingness to feel pain = trauma. The implication of this equation is not mere exposure. We know that poorly timed exposure sometimes actually makes folks worse.

What ACT does is give people the skills they need to willingly carry the pain they have and integrate it into a valued life. You need to learn how to back up from your thoughts and see them as they are; to show up in the moment; to commit to your values. That, plus exposure, will move you ahead.

This is a relatively new area for us but there are now already four studies on compulsions or related phenomena such as skin picking, and ACT appears to be working quite well on these so far. Suppose you have the thought, like Howard Hughes in The Aviator, “aphids are dirty and flowers with these bugs will contaminate you.” That weird thought will produce very unpleasant feelings. So the obsessive person undoes the feeling by throwing out the flowers, by washing his hands, or by other rituals. It produces relief, but it also just feeds the compulsion beast, and it comes back bigger than ever.

ACT cuts that vicious cycle. If you have the thought “aphids are dirty and flowers will contaminate you,” you don’t need to argue with it or make it go away. You need to defuse from that thought. Notice it come and go. Watch it like you’d watch a leaf float by. Do nothing about it, except to think it as a thought. And accept the feelings it produces. Feel them the way you would reach out and feel fabric. And then get back to valued living. You do that and you’ve broken the back of an obsessive cycle. It’s amazing to me that we give people so little help in rising to the psychological challenges of chronic disease.

Take diabetes. Every time a diabetic tests for blood glucose, the implications of this chronic disease become present: it’s a disease that can blind you, lead to loss of limbs, or even kill you. That is a psychologically hard thing to do. And the numbers that come back as you test your blood glucose can be very upsetting—they can be high even when you think they should be low. And each high number once again reminds you that you have a disease that can blind you, lead to loss of limbs, or even kill you.

My wife and I just walked through her gestational diabetes, and it was a roller coaster. We both came away amazed at how hard it was and what a burden people who will deal with this their whole lives must be carrying. We have shown in our lab that just three hours of ACT can double the number of diabetics who are in control of their blood glucose three months later. If that continues, we would reduce loss of limb or blindness by more than half—for only a tiny three-hour intervention.

People are so hungry for help, and the “feel goodism” of the culture just is no help at all. If you can help patients learn to carry their fears, watch their scary thoughts, and focus on valued actions, you are giving them the tools they need to manage their illness. It’s not just a problem of information; it’s a problem of psychological flexibility.

The epilepsy data are even more dramatic. In one recent study a nine-hour ACT program plus medication reduced seizures by over 90 percent at a one-year follow up compared to medication alone. Ninety percent! It seems that the combination of acceptance, mindfulness, and values stopped the self-amplifying loop that kept the stress up, quality of life down, and seizures continuing unabated.

The larger message here is that you have to teach people how to step up to the psychological challenge of physical disease. But you don’t do that by helping people win a war with their insides—you do it my helping them step out of that war and focus of what concrete actions they need to take to live the kind of life that want to live.

ACT is showing good results with stress. Stress is not just the negative results of anxiety or worry—it’s also the effect of control being applied where it doesn’t belong. It’s also the effect of getting lost inside our own minds. In one recent study, we showed that just a few hours of ACT reduced stress several months later, and it did it because people learned acceptance and mindfulness skills.

Burnout is just a more specific type of stress-related result, but it seems especially sensitive to cognitive entanglement. In one of our studies the tendency to take negative thoughts about work literally predicted burnout higher than stress itself. So when you have, say, that judgmental thought about your boss, being able just to notice that thought and focus on your work values can mean the difference between quitting and succeeding in that workplace.

It’s beginning to appear that even the most horrifying private experiences fit with this idea. Medications don’t completely remove hallucinations and delusions for most people with a psychosis. Yet in this country very little else is provided to these patients to help them cope with these frightening and disruptive experiences.

This lack of help is terribly inhumane—there is much we can do. If you have ever seen the movie A Beautiful Mind you understand the basics of what we try to teach in an ACT approach. We teach patients to just watch their hallucinations, to notice their own delusional thoughts, to focus on their values, and to keep their overt behaviors going. That package works. In two separate studies it has been shown that just two to five hours of ACT will reduce rehospitalization by 38 to 50 percent over the next four months. Who knows what we will be able to do with more extensive packages.

Prejudice is probably the single most important problem on the planet. The “War on Terrorism” should not just be a war on terrorism—it needs to be a war on intolerance since that is a big part of where terrorism comes from. Whether it’s killing the infidels, or the Catholics, or the Tutsis, it’s all a form of prejudice. But in the modern era, prejudice has enormously powerful tools at its disposal: bombs, chemicals, biological weapons. And we are not yet up to the worst of the list.

Let me ask you this. If there was a big red button in every home on the planet and if an adult pushed it the world would end, how long would the planet last? Not long. But once we have freely available suitcase bombs…and are we not close to that very situation? And how long before we have those bombs. Ten years? Twenty? Well, whatever your answer, that is how long we have to figure this out because that is the day we have a big red button in everyone’s house.

When a terrorist attacks an innocent human being he or she is revealing the end stage of a process of objectifying and dehumanizing others. But to some degree this same process underlies more usual phenomena such as prejudice based on ethnicity or gender or stigma associated with illness or appearance. Most approaches to stigma and prejudice are either educational—in one way or another telling others what to believe and do—or experiential, learning through direct contact with stigmatized groups. Unfortunately the effects of both are weak and unreliable. In one recent study done in a prison, education about racial differences actually increased racial conflict.

And these methods are not mindful of the issues we have been talking about. If you try to suppress a prejudiced thought you will increase its strength and psychological impact, not decrease it. We need another way forward. Yet we all have prejudiced programming—ethnic and gender biased jokes, for example. Even if our values are not racist or sexist, our minds sometimes are. It doesn’t matter your race or gender; we’re all swimming in this stream.

ACT shows another way forward. We have found that acceptance of prejudicial thoughts (as thoughts) and learning to just notice them mindfully while connecting with our values will increase people’s willingness to engage in non-prejudiced behaviors. We have shown it with prejudice toward substance abusers in recovery, ethnic prejudice, bias toward the mentally ill, and bias against science-based treatments. We will see how far it can go.

Shame and prejudice are really the same thing; one is just inwardly focused. Buying into “I’m bad” is really not different from buying into “you’re bad.” And it turns out that the same methods that help with prejudice and stigma also help with shame and self-stigma. ACT can help people increase job performance, too. Have you ever worked with someone who comes up with excuses anytime he or she needs to learn something new—a new telephone system, a new budgeting process, and so forth?

We’re learning that the same experiential avoidance process that ACT targets is part of this resistance. It’s obvious if you think about it. How did you feel when you first started to learn to dance, when you first skied, when you first put on ice skates, and so forth? Didn’t you feel a bit foolish and awkward? If you can’t allow that, how can you learn? We’ve found that our measures of experiential avoidance can predict what office workers will do at work: Our short questionnaires correlate with keystroke errors a year later because people who are high avoiders don’t learn the software well.

Why? Because they’re never willing to feel stupid or uncomfortable. ACT has been shown to undermine this avoidance, and as a result people are more willing and able to learn. In one recent study we showed that workers who had just been through an ACT workshop were then more willing and able to learn things that had nothing to do with ACT (in this study it was therapists learning to using certain medications in their work). And therapists were using these new methods more at a three-month follow up.

NHP: Some of this work is said to have come from your own battles with anxiety and panic. How did these ideas apply to your own struggles?

SCH: I had a panic disorder. At the height of it, my life shrank until I could not travel, get on an elevator, drive, go to a movie, get on a plane, or even talk on the phone without a tremendous struggle. It was clear to me that I had a choice: I could either lose my life as I knew it or I could learn to step forward into my fear. I went back into my behavioral training, my science training, my eastern training, my human potential training. ACT in some ways is my personal journey—it’s how I faced anxiety. But it’s not just me. Other major ACT researchers and writers are chronic depressives, heroin addicts, or social phobics, and they have poured these experiences into the work. That’s not by accident. When life has beaten you up, the uncommon sense in ACT begins to have appeal.

Sometimes people are just by their nature ready for this approach even when they’re young, but most of us start out thinking we can win the war with our minds and our history. And you might even get away with that view if nothing bad ever happens. When it does, though, you need to take a different path. When futility sets in you have a chance to do something new. I began to learn how to abandon the war with my mind and history.

I personally do ACT everyday. I do acceptance, defusion, mindfulness, and values work continuously. I know right now I might have anxiety attack. It’s been ten years since the last, but I know I can’t control that. It’s not up to me—it’s up to my history and my current situation. But what I can control and what only I can control is whether I will back up from my own experience. My pledge to myself is that I will stand with myself, regardless. If that means I get so anxious I can’t talk, right here, right now, that will be a problem—but if I stay true to my commitment, it will be your problem, not mine.

NHP: A lot of what you’re describing sounds Buddhist-inspired. How does ACT differ from Buddhism, both in theory and in the practice it requires?

SCH: Buddhism has a lot of wisdom in it, as do all of the major spiritual and religious traditions, but it emerged from pre-scientific times. Some of its specific ideas show that lineage; some of its methods require weeks, months, and years to work. ACT is in the same general psychological space, but it’s driven by a scientific theory, and its methods are designed to be quicker and more focused. I find it very encouraging that the two overlap because ACT did not come from Buddhism or any specific religious or spiritual tradition. It came from modern contextual psychology. If things from very different starting points overlap in their end points, to my mind this increases the chance that they’re both on to something.

NHP: How does ACT differentiate between pain and suffering?

SCH: Pain is just pain. We all have it—all the time if you just look. For example, we all know we will die. There is some pain in that knowledge, and you can contact that knowledge anytime, anywhere. But that alone is not suffering. If you add in unwillingness to feel pain, entanglement with your thoughts about pain, and loss of your valued actions—now you’ve amplified pain into suffering. I’ve seen that exact thing happen with thoughts about death, for example. But YOU did it. The pain didn’t do it. You see this in area after area: Anxiety + unwillingness to feel anxiety and keep moving in a valued direction = panic. Sadness, loss, anxiety, or anger + unwillingness to feel sadness, loss, anxiety, or anger while moving in a valued direction = depression. Pain + unwillingness to feel pain = trauma.

NHP: You’re a language researcher and chapter two of Get Out of Your Mind and Into Your Life is called “Why Language Leads to Suffering.” Can you tell us why you suggest that language is a source of human suffering?

SCH: We’ve learned four important things in our research. Human language and cognition is bidirectional, arbitrary, historical, and controlled by a functional context. Because language is bidirectional, words pull the events they’re related to into the present. Anywhere you go you can remember painful things. Just think of them. That is totally new on the planet, so far as we know. No other creature seems to do it. So it means we have orders of magnitude more pain than other creatures. And it’s arbitrary—what we relate isn’t dictated by form. Kick a dog and he’ll yelp—it’s dictated by form.

Show a person a beautiful sunset who has just had someone very near and dear die and that person may cry, wishing the lost loved one could be here to see it. The crying is not dictated by form—even beauty can create sadness. That means we can’t solve our problem with pain situationally. But because language is historical, we can’t win by changing the content of our cognitions. A person who thinks “I’m bad” and who then changes it to “I’m good” is now a person who thinks “I’m bad, no I’m good.” Where you start from is never fully erased—because you are a historical creature. Your mind is psychological, not logical. We make all of this so much worse by deliberate attempts to get rid of our history and its echoes—the automatic thoughts and feelings that emerge from our past. Because we’re historical creatures, these efforts elaborate whatever we’re trying to get rid of. Because human cognition is bidirectional, it mocks our attempts to change thoughts and feelings.

For example, suppose we need to get rid of anxiety because if we don’t bad things will happen. Anxiety is the natural response to bad things … so our efforts will tend to evoke anxiety, defeating our purpose. Fortunately, our work on cognition shows that the events that cause us to relate one thing to another are different than the events that give these relations functional properties. We take advantage of that in ACT. We change the functions of thoughts and feelings, not their form, and that makes all the difference.

NHP: You also say that research suggests many of the tools we use to solve problems lead us into the traps that create suffering. What does this mean?

SCH: Here’s how we solve problems: We use verbal processes to enable categories, time, and evaluation. “If I did that then this would happen, which would be good.” Notice all three are there: the categories and names of things and their features; time and contingency (if … then); and evaluation (this is better than that). This is great for problem solving. We see an imaginary future and evaluate it—all through the use of arbitrary symbols. It’s because of this ability that we took over the planet. Yet this alone is plenty enough to create psychological problems. “If I go to the mall, I will feel anxious, which is really bad.” Same processes: categories, time, and evaluation. “If my lover leaves me I won’t be able to function.” Same thing. “If I kill myself I will stop hurting.” Same thing. This is why you can’t weed out the processes that cause suffering—these same processes are at the root of our achievements as a species.

We need to learn how to use these processes when they’re helpful and let them lie dormant when they’re not. It’s very hard to do—like the delusions that follow Russell Crowe in the movie A Beautiful Mind— most of our most difficult experiences are there night and day begging us to taken them literally. But once we do we are lost. It’s hard to learn how to do nothing even when it’s only nothing that will do. Humans are terrible at that. We are terrible at letting go.

NHP: One of the premises of ACT is that avoidance of difficult emotions leads to suffering, which is highly counterintuitive. First, why do you say this and second, what do you say to someone who says that avoidance of pain is ingrained and automatic?

SCH: Let me take the last part first. The avoidance of pain is indeed ingrained and automatic. That is the point. So, sure, it’s absolutely normal to needlessly avoid pain. And there is nothing wrong with avoiding many forms of situational pain. There is no need to put your hand on a hot stove, for example. But historical pain is something else. If you have a painful memory, you’ll always have it and avoiding it will only distort your life because memories don’t go away. If you have a thought you don’t like, trying to make it go away is like trying not to think of a piece of chocolate cake … in the effort deliberately not to think it, you just did.

Here is why avoiding that kind of pain is problematic: First, the painful event doesn’t truly go away, it’s just avoided, and the next time it’s contacted it’s bigger and stronger and even more likely to control behavior. Second, it makes us attend all the more to this very pain. Like a noise in the background, as soon as it’s important that it go away, it’s now in the foreground and far, far worse that it was only moments before. Third, the very basis of avoiding painful thoughts or feelings is that the reaction is really bad—but that means that as we deliberately try to avoid things, we’re building them into more and more powerful events because we start this process with the embraced belief that they truly are dangerous.

We literally make our nightmares come true because the real damage is done the moment we take them literally. At that point they transform themselves from mere historical events—mere processes of the mind worth noting—into things that can control our lives. After all if they’re controlling efforts at avoidance they’re already controlling our lives.

NHP: You talk a lot about values in your book, and the “commitment” in acceptance and commitment therapy refers to making a commitment to living a values-based life. What does it mean to live a values-based life and how does it help reduce suffering?

SCH: Values are like directions on a compass. They’re never achieved, but in each and every step they influence the quality of the journey. Values dignify and make more coherent our life course—and they put pain in a proper context. It’s now about something. Let me go back to that movie A Beautiful Mind. It’s only when the hero has to decide between what he values and entanglement with insanity that it’s possible and sensible to accept the delusions; to notice them; and to abandon trying to control them—all in the service of being a husband, father, and a mathematician.

In the same way, we only put down our avoidance, addictions, and mental wars because it’s costing us something dear, whatever it is that we want our lives to be about. Without that cost we would be lost. It’s amazing how often people have never really thought about what they want in their lives. They’ve been fighting a mental war, waiting for life to start, and have never really asked or answered the question of what kind of a life they’re waiting to live.

The joyful vision of ACT is that you can start living that very life NOW, with your thoughts, feelings, memories, and sensations. You start that journey by asking what it is that you really want your life to be about. That is the point on the compass.

NHP: What kinds of techniques do you try to teach in ACT? Can you walk us through an ACT exercise?

SCH: Okay. First think of a painful thought, a self-critical thought, one of those nagging deep down familiar bits of negativity. Do you have one? ACT has scores of techniques that are designed to help you catch the word machine in flight rather than getting caught up in the world seemingly structured by it. These “defusion” techniques help us notice the process of thinking, not just their products.

So let’s try a few with that very thought. I’ll do them in rapid fire, but in the book we present all of this in more detail, and you can take the time you need to explore them properly.

First say that thought very fast over and over again, feeling your mouth as you say it and noticing how odd it sounds when said fast. Now say it slowly, one word on the inbreath and the next on the outbreath until it’s all said. Now sing the thought out loud. Be careful not to ridicule, satirize, or criticize your thoughts. Rather just notice as you sing that these are thoughts. Now say them in the voice of a politician from the opposite political party as you. Be careful not to ridicule, satirize, or criticize your thoughts. Rather just notice as you hear these words that these words are thoughts. You don’t have to do anything about them. Just thank your mind for the thought and notice what shows up.

These are four of literally hundreds of techniques ACT therapists have developed to liberate humans from the grip of their own cognition and emotion—but all without making the cognition or emotion go away. Once you’re on to it, you can come up with your own methods. In this new book we actually walk readers through that process. Once you see the model and its purpose it’s not hard. You can literally create your own methods to get out of your mind and into your life. So the book is not a new belief system. It’s a new context for living with that word machine we call our minds, without turning our lives over to it.

Podcast: Steven Hayes interview by David Van Nuys

Click here.

Psychology Today: How Analyzing Your Problems May Be Counterproductive (February, 2010)

How Analyzing Your Problems May Be Counterproductive
Published on February 13, 2010
By Ray B. Williams

When you're upset or depressed, should you analyze your feelings to figure out what's wrong? Or should you just forget about it and move on? New research and theories suggests if you do want to think about your problems, do so from a detached perspective, rather than reliving the experience.

This answer is related to a psychological paradox: Processing emotions is supposed to help you facilitate coping, but attempts to understand painful feelings often backfire and perpetuate or strengthen negative moods and emotions. The solution seems to be neither denial or distraction, according to research conducted by University of Michigan psychologist Ethan Kross, who says the best way to move forward emotionally is to examine one's feelings from a distance or detached perspective.

Kross, along with University of California colleague Ozelm Ayduk, conducted a series of studies that provide the first experimental evidence of the benefits of taking a detached perspective on your problems. Kross says, "reviewing our mistakes over and over, re-experiencing the same negative emotions we felt the first time, tends to keep us stuck in negativity." Their study, published in the July, 2008 issue of Personality and Social Psychology, described how they randomly assigned 141 participants to groups that required them to focus (or not to focus) on their feelings using different strategies in a guided imagery exercise that led them to recall an experience that made them feel overwhelmed by sadness or depression. In the immersed-analysis condition, participants were told to go back to the time and place of the experience and relive it as if it were happening to them over again, and try to understand the emotions they felt, along with the underlying causes. In the detached-analysis condition, the subjects were told to go back the time and place of the experience, take a few steps back and move away from the experience, and watch it unfold as though it was happening to them from a distance, and try to understand what they felt and the reasons for the feelings-- what lessons are to be learned.

The results of the experiment? Immediately after the exercise the distanced-analysis approach subjects reported lower levels of anxiety, depression and sadness compared to those subjects who used the immersed-analysis strategy. One week later the participants were questioned. Those that had used the distanced-analysis strategy continued to show lower levels of depression, anxiety and sadness. In a related study, Ayduk and Kross showed that participants who adopted a self-distanced perspective while thinking about their problems related to anger, showed reductions in blood pressure.

Kross' and Ayduk's research supports the work done by psychotherapist Dr. Steven Hayes. Traditional cognitive psychotherapy may not be the best intervention according to Dr. Steven Hayes, a renowned psychotherapist, and author of Getting Out of Your Mind and Into Your Life. Hayes has been setting the world of psychotherapy on its ear by advocating a totally different approach.

Hayes and researchers Marsha Linehan and Robert Kohlenberg at the University of Washington, and Zindel Segal at the University of Toronto, what we could call "Third Wave Psychologists" are focusing less on how to manipulate the content of our thoughts (a focus on cognitive psychotherapy) and more on how to change their context--to modify the way we see thoughts and feelings so they can't control our behavior. Whereas cognitive therapists speak of "cognitive errors" and "distorted interpretation," Hayes and his colleagues encourage mindfulness, the meditation-inspired practice of observing thoughts without getting entangled by them--imagine the thoughts being a leaf or canoe floating down the stream.

These Third Wave Psychologists would argue that trying to correct negative thoughts can paradoxically actually intensify them. As NLP trained coaches would say, telling someone to "not think about a blue tree," actually focuses their mind on a blue tree. The Third Wave Psychologists methodology is called ACT (Acceptance and Commitment Therapy), which says that we should acknowledge that negative thoughts recur throughout our life and instead of challenging or fighting with them, we should concentrate on identifying and committing to our values in life. Hayes would argue that once we are willing to feel our negative emotions, we'll find it easier to commit ourselves to what we want in life.

This approach may come as a surprise to many, because the traditional cognitive model permeates our culture and the media as reflected in the Dr. Phil show. The essence of the conflict between traditional cognitive psychologists and psychotherapists is to engage in a process of analyzing your way out your problems, or the Third Wave approach which says, accept that you have negative beliefs, thinking and problems and focus on what you want. Third Wave psychologists acknowledge that we have pain, but rather than trying to push it away, they say trying to push it away or deny it just gives it more energy and strength.

Third Wave Psychologists focus on acceptance and commitment comes with a variety of strategies to help people including such things as writing your epitaph (what's going to be your legacy), clarifying your values and committing your behavior to them.

It's interesting that that The Third Wave Psychologists approach comes along at a time when more and more people are looking for answer outside of the traditional medical model (which psychiatry and traditional psychotherapy represent). Just look at a 2002 study in Prevention and Treatment, which found that 80% people tested who took the six most popular antidepressants of the 1990's got the same results when they took a sugar pill placebo.

The Third Wave Psychologists approaches are very consistent with much of the training and approach that many life coaches receive, inclusive of Neuro-Linguistic Programming (NLP), and many spiritual approaches to behavioral changes reflected in ancient Buddhist teachings and the more modern version exemplified by Eckhart Tolle (The Power of Now and A New Earth). The focus of those approaches reinforces the concepts of acceptance of negative emotions and thoughts, and rather than giving them energy and fighting with them, focus on mindfulness, and a commitment to an alignment of values and behavior.

What's fascinating is how brain science and psychological research is supporting ancient spiritual practices. Perhaps now the East and the West, science and spirituality, are coming together.

-----------------------------------------------------------------------

Blogs: Wired for Success
How to fulfill your potential

Ray Williams is Co-Founder of Success IQ University and President of Ray Williams Associates, Inc., providing leadership development, personal growth, and executive coaching services.

accessed from http://www.psychologytoday.com/blog/wired-success/201002/how-analyzing-your-problems-may-be-counterproductive

Psychology Today: Negativity: Don't Even Think of It (October 2005)

Negativity: Don't Even Think of It

By: Kathleen McGowan

Summary:

With practice, you can learn to recognize your repetitive and negative thoughts. And keep them from becoming all-consuming. Life would be much easier if we had perfect control over our thinking -- especially where emotions are concerned. We could quickly forget about the people who make us frustrated or angry and allow disappointments to fade into the past without recriminations. But in reality, this kind of emotional equanimity is rare. Most of us spend a lot of time thinking over unpleasant feelings and mulling over regrets and resentments.

Unfortunately, many of these mental interpretations of our feelings make us feel worse about the situation. What started out as a small hurt or frustration, amplified by a thought process that focuses on pain and anger, may balloon into a major preoccupation. Our minds often repeat painful thoughts or scenarios over and over, even when we'd much rather let them go.

If you start paying attention to your interior monologue, you may find that you are dwelling on the ways your parents let you down, angry at someone who has hurt you, afraid of the challenges you face in the future, or ashamed that you haven't yet done the things you'd planned to in life. You'd rather stop all of these thoughts in their tracks -- but that's much easier said than done. Instead, you're left feeling as if there's something wrong with you: Why can't I just get over it? Why can't I just relax and be happy?

Generally, when you try to squelch one of these distressing trains of thought -- or "just get over it" -- your strenuous efforts to suppress it only make things worse. Research has shown that if we actively try to prevent anxiety-provoking or frightening thoughts, they generally become more powerful and harder to ignore. As a result, mental "fix-it" strategies generally backfire, whether that's trying to deny your unhappiness, avoiding the situations or people that make you anxious, or drinking to numb the feelings. Accepting the negative feelings and learning to distance yourself from the thoughts that amplify them can be a much more effective coping strategy, says psychologist Stephen Hayes of the University of Nevada in Reno.

In his book Get out of Your Mind and Into Your Life, he outlines a number of techniques from cognitive psychology that can help you resist getting lost in painful thoughts. With practice, you can learn to recognize your repetitive thoughts, and hold them at arm's length.

A few of Hayes' suggestions:

• Practice noticing your thoughts. Try to be conscious of where your mind leads you, and label the type of thought you're having to yourself. For example, if you've made a mistake at work and are feeling bad about it, think to yourself: "I've noticed that I'm focused on my error right now." If you're feeling stupid about the mistake, say to yourself: "Right now, I'm criticizing myself."
• If you find that one particular thought or phrase is running through your head -- I'm a loser" or "She screwed me over," for example -- try saying your troubling thought out loud, and either very slowly or in a funny voice. It seems silly, but by doing this, you're actively separating yourself from your mental soundtrack. You remind yourself that these thoughts are being generated out of a mental habit.
• Try thinking of your mind as just another organ of your body. If you find yourself preoccupied by fears, imagine that your brain is just like your hungry stomach when it rumbles, or your feet when they're tired after a long day. Think: "There goes my mind again, worrying about something trivial."
• Think of your self-destructive or self-critical thoughts as Internet pop-up ads. Don't criticize them or yourself for having them. Just think of them as unnecessary, meaningless noise. All of these tactics are ways to become aware of your inner mental monologue without either getting caught up in it or trying to shut it down. Distancing yourself from your difficult thoughts can help you learn to stop turning small problems into dilemmas that seem all-consuming or hopeless.

Psychology Today: The Pursuit of Happiness (February, 2009)

The article below isn't an "ACT" article per se, but it discusses "happiness" with a few quotes by Russ Harris, the author of The Happiness Trap which is a terrific self-help book using ACT techniques.

The Pursuit of Happiness
by Carlin Flora
Psychology Today Magazine, Jan/Feb 2009

Welcome to the happiness frenzy, now peaking at a Barnes & Noble near you: Last year 4,000 books were published on happiness, while a mere 50 books on the topic were released in 2000. The most popular class at Harvard University is about positive psychology, and at least 100 other universities offer similar courses. Happiness workshops for the post-collegiate set abound, and each day "life coaches" promising bliss to potential clients hang out their shingles.

In the late 1990s, psychologist Martin Seligman of the University of Pennsylvania exhorted colleagues to scrutinize optimal moods with the same intensity with which they had for so long studied pathologies: We'd never learn about full human functioning unless we knew as much about mental wellness as we do about mental illness. A new generation of psychologists built up a respectable body of research on positive character traits and happiness-boosting practices. At the same time, developments in neuroscience provided new clues to what makes us happy and what that looks like in the brain. Not to be outdone, behavioral economists piled on research subverting the classical premise that people always make rational choices that increase their well-being. We're lousy at predicting what makes us happy, they found.

It wasn't enough that an array of academic strands came together, sparking a slew of insights into the sunny side of life. Self-appointed experts jumped on the happiness bandwagon. A shallow sea of yellow smiley faces, self-help gurus, and purveyors of kitchen-table wisdom have strip-mined the science, extracted a lot of fool's gold, and stormed the marketplace with guarantees to annihilate your worry, stress, anguish, dejection, and even ennui. Once and for all! All it takes is a little gratitude. Or maybe a lot.

But all is not necessarily well. According to some measures, as a nation we've grown sadder and more anxious during the same years that the happiness movement has flourished; perhaps that's why we've eagerly bought up its offerings. It may be that college students sign up for positive psychology lessons in droves because a full 15 percent of them report being clinically depressed.

There are those who see in the happiness brigade a glib and even dispiriting Pollyanna gloss. So it's not surprising that the happiness movement has unleashed a counterforce, led by a troika of academics. Jerome Wakefield of New York University and Allan Horwitz of Rutgers have penned The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, and Wake Forest University's Eric Wilson has written a defense of melancholy in Against Happiness. They observe that our preoccupation with happiness has come at the cost of sadness, an important feeling that we've tried to banish from our emotional repertoire.

Horwitz laments that young people who are naturally weepy after breakups are often urged to medicate themselves instead of working through their sadness. Wilson fumes that our obsession with happiness amounts to a "craven disregard" for the melancholic perspective that has given rise to our greatest works of art. "The happy man," he writes, "is a hollow man."

Both the happiness and anti-happiness forces actually agree on something important—that we Americans tend to grab superficial quick fixes such as extravagant purchases and fatty foods to subdue any negative feelings that overcome us. Such measures seem to hinge on a belief that constant happiness is somehow our birthright. Indeed, a body of research shows instant indulgences do calm us down—for a few moments. But they leave us poorer, physically unhealthy, and generally more miserable in the long run—and lacking in the real skills to get us out of our rut.

Happiness is not about smiling all of the time. It's not about eliminating bad moods, or trading your Tolstoy-inspired nuance and ambivalence toward people and situations for cheery pronouncements devoid of critical judgment. While the veritable experts lie in different camps and sometimes challenge one another, over the past decade they've together assembled big chunks of the happiness puzzle.

What is happiness? The most useful definition—and it's one agreed upon by neuroscientists, psychiatrists, behavioral economists, positive psychologists, and Buddhist monks—is more like satisfied or content than "happy" in its strict bursting-with-glee sense. It has depth and deliberation to it. It encompasses living a meaningful life, utilizing your gifts and your time, living with thought and purpose.

It's maximized when you also feel part of a community. And when you confront annoyances and crises with grace. It involves a willingness to learn and stretch and grow, which sometimes involves discomfort. It requires acting on life, not merely taking it in. It's not joy, a temporary exhilaration, or even pleasure, that sensual rush—though a steady supply of those feelings course through those who seize each day.

There has been real progress in understanding happiness and how to get it. Here are the greatest hits, as it were, that jump out from the research.

Some People Are Born Happy
Some lucky souls really are born with brighter outlooks than others; they simply see beauty and opportunity where others hone in on flaws and dangers. But those with a more ominous orientation can alter their outlook, at least to a point. They can learn to internally challenge their fearful thoughts and negative assumptions—"she thinks I'm an idiot," "I'm going to get fired," "I'll never be a good mom"—if not eliminate them altogether. Engaging in positive internal dialogue is actually a mark of the mentally healthy.

Getting What You Want Doesn't Bring Lasting Happiness
You think happiness would arrive if you were to win the lottery, or would forever fade away if your home were destroyed in a flood. But human beings are remarkably adaptable. After a variable period of adjustment, we bounce back to our previous level of happiness, no matter what happens to us. (There are some scientifically proven exceptions, notably suffering the unexpected loss of a job or the loss of a spouse. Both events tend to permanently knock people down a notch.)

Our adaptability works in two directions. Because we are so adaptable, points out Sonja Lyubomirsky, a professor of psychology at the University of California, Riverside, we quickly get used to many of the accomplishments we strive for in life, such as landing the big job or getting married. Soon after we reach a milestone, we start to feel that something is missing. We begin coveting another worldly possession or eyeing a social advancement. But such an approach keeps us tethered to the "hedonic treadmill," where happiness is always just out of reach, one toy or one notch away. It's possible to get off the treadmill entirely, Lyubomirsky says, by focusing on activities that are dynamic, surprising, and attention-absorbing, and thus less likely to bore us than, say, acquiring shiny stuff.

Pain Is a Part of Happiness
Happiness is not your reward for escaping pain. It demands that you confront negative feelings head-on, without letting them overwhelm you. Russ Harris, a medical doctor-cum-counselor and author of The Happiness Trap, calls popular conceptions of happiness dangerous because they set people up for a "struggle against reality." They don't acknowledge that real life is full of disappointments, loss, and inconveniences. "If you're going to live a rich and meaningful life," Harris says, "you're going to feel a full range of emotions."

The point isn't to limit that palette of feelings. After all, negative states cue us into what we value and what we need to change: Grief for a loved one proves how much we cherish our relationships. Frustration with several jobs in a row is a sign we're in the wrong career. Happiness would be meaningless if not for sadness: Without the contrast of darkness, there is no light.

Mindfulness Brings Happiness
Mindfulness, a mental state of relaxed awareness of the present moment, marked by openness and curiosity toward your feelings rather than judgments of them, is a powerful tool for experiencing happiness when practiced regularly. "If you bring mindfulness to bear on negative feelings, they lose their impact. Just let them be there without struggling against them, and you'll eventually feel less anxiety and depression," Harris says. Don't banish your negative feelings, but don't let them get in the way of your taking productive actions, either.

Happiness Lies in the Chase
Action toward goals other than happiness makes us happy. Though there is a place for vegging out and reading trashy novels, easy pleasures will never light us up the way mastering a new skill or building something from scratch will.

And it's not crossing the finish line that is most rewarding; it's anticipating achieving your goal. University of Wisconsin neuroscientist Richard Davidson has found that working hard toward a goal, and making progress to the point of expecting a goal to be realized, doesn't just activate positive feelings—it also suppresses negative emotions such as fear and depression.

Yes, Money Buys Happiness—At Least Some Money and Some Happiness
Money does buy happiness, but only up to the point where it enables you to live comfortably. Beyond that, more cash doesn't boost your well-being. But generosity brings true joy, so striking it rich could in fact underwrite your happiness—if you were to give your wealth away.

Happiness Is Relative
Whether or not we are keeping up with the Joneses—a nagging thought known as status anxiety—affects how happy we are. Some are more obsessed with status than others, but we're all attuned to how we're doing in life relative to those around us. To stop status worries from gnawing at your happiness, choose your peer group carefully. Owning the smallest mansion in a gated community could make you feel worse off than buying the biggest bungalow in a less affluent neighborhood.

Options Make Us Miserable
We're constantly making decisions, ranging from what to eat for dinner each night to whom we should marry, not to mention all those flavors of ice cream. We base many of our decisions on whether we think a particular preference will increase our well-being. Intuitively, we seem convinced that the more choices we have, the better off we'll ultimately be. But our world of unlimited opportunity imprisons us more than it makes us happy. In what Swarthmore psychologist Barry Schwartz calls "the paradox of choice," facing many possibilities leaves us stressed out—and less satisfied with whatever we do decide. Having too many choices keeps us wondering about all the opportunities missed.

Happiness Is Other People
Positive psychologist Chris Peterson, a professor at the University of Michigan, says the best piece of advice to come out of his field is to make strong personal relationships your priority. Good relationships are buffers against the damaging effects of all of life's inevitable letdowns and setbacks.

Do Your Happiness Homework
You can increase positive feelings by incorporating a few proven practices into your routine. Lyubomirsky suggests you express your gratitude toward someone in a letter or in a weekly journal, visualize the best possible future for yourself once a week, and perform acts of kindness for others on a regular basis to lift your mood in the moment and over time. "Becoming happier takes work, but it may be the most rewarding and fun work you'll ever do," she says.

Happiness Hinges on Your Time Frame
Feeling happy while you carry out your day-to-day activities may not have much to do with how satisfied you feel in general. Time skews our perceptions of happiness. Parents look back warmly on their children's preschool years, for example. But Daniel Kahneman of Princeton University found that childcare tasks rank very low on the list of what makes people happy, below napping and watching TV. And yet, if you were to step back and evaluate a decade of your life, would a spirited stretch of raising children or a steady stream of dozing off on the couch each day in between soap operas illustrate a "happier" time? Evaluate your well-being at the macro as well as the micro level to get the most accurate picture of your own happiness.

You're Wrong About What Will Make You Happy and You're Wrong About What Made You Happy
Harvard psychologist Daniel Gilbert discovered a deep truth about happiness: Things are almost never as bad—or as good—as we expect them to be. Your promotion will be quite nice, but it won't be a 24-hour parade. Your breakup will be very hard, but also instructive, and maybe even energizing. We are terrible at predicting our future feelings accurately, especially if our predictions are based on our past experiences. The past exists in our memory, after all, and memory is not a reliable recording device: We recall beginnings and endings far more intensely than those long "middles," whether they're eventful or not. So the horrible beginning of your vacation will lead you astray in deciding the best place to go next year.

Gilbert's take-away advice is to forgo your own mental projections. The best predictor of whether you'll enjoy something is whether someone else enjoyed it. So simply ask your friend who went to Mexico if you, too, should go there on vacation.

Happiness Is Embracing Your Natural Coping Style
Not everyone can put on a happy face. Barbara Held, a professor of psychology at Bowdoin College, for one, rails against "the tyranny of the positive attitude." "Looking on the bright side isn't possible for some people and is even counterproductive," she insists. "When you put pressure on people to cope in a way that doesn't fit them, it not only doesn't work, it makes them feel like a failure on top of already feeling bad."

The one-size-fits-all approach to managing emotional life is misguided, agrees Julie Norem, author of The Positive Power of Negative Thinking. In her research, the Wellesley professor of psychology has shown that the defensive pessimism that anxious people feel can be harnessed to help them get things done, which in turn makes them happier. A naturally pessimistic architect, for example, can set low expectations for an upcoming presentation and review all of the bad outcomes that she's imagining, so that she can prepare carefully and increase her chances of success.

Happiness Is Living Your Values
If you aren't living according to your values, you won't be happy, no matter how much you are achieving. Some people, however, aren't even sure what their values are. If you're one of them, Harris has a great question for you: "Imagine I could wave a magic wand to ensure that you would have the approval and admiration of everyone on the planet, forever. What, in that case, would you choose to do with your life?"

Once you've answered honestly, you can start taking steps toward your ideal vision of yourself. You can tape positive affirmations to your mirror, or you can cut up your advice books and turn them into a papier mache project. It doesn't matter, as long as you're living consciously. The state of happiness is not really a state at all. It's an ongoing personal experiment.

Psychology Today Magazine, Jan/Feb 2009

Roots of Compassion: Steve Hayes at ABCT (November, 2008)

Please click the link to view the video recorded at the annual convention of the Association of Cognitive and Behavioral Therapies in Orlando, FL, November, 2008.

Russ Harris Interviewed on RadioNZ August, 2010

Russ Harris on RadioNZ

SELF Article about ACT for Trichotillomania

Below is a link to the SELF article describing ACT for Trichotillomania.

http://www.msnbc.msn.com/id/22248069/

Salon.com Interview with Steven Hayes (February, 2006)

Below you will fin a link to the Salon.com interview with Steve.

The direct link will only work if you have logged on to Salon already. http://www.salon.com/mwt/feature/2006/02/25/happiness/index.html

More likely, you will need to go to http://www.salon.com and search for "Steven Hayes" -- the first article should be this one.

Steve Hayes Interview with Rich Presta (December, 2009)

There is an interview from Steven Hayes to motivational speaker Rich Presta recorded in December, 2009 available by clicking here.

Steve Hayes Podcasts on Weight Issues for Yale University (March, 2009)

Principles and Applications of Acceptance and Commitment Therapy

Compliments of the Rudd Center Seminar, at Yale University.

Click here for podcast.

Applications of Acceptance and Commitment Therapy for Weight Issues

Click here for podcast 2.

Sunday Telegraph in the UK: Human Pain and Human Vitality (March, 2006)

Here is a column that appeared in the March 5, 2006 Sunday Telegraph

Human Pain and Human Vitality

Nearly 30 years ago I had my first panic attack. A productive and reasonably successful young academic, I soon found myself struggling to give a lecture, to speak on the phone, or to ride in an elevator. From the outside I appeared calm – but on the inside I felt I was dying. Literally. Sitting still on a park bench my heart beat 165 times a minute as I fought a battle, not with a physical challenge requiring such blood flow, but with the word machine between my ears.

Some of my experiences at the height of this struggle now seem so alien that it is only with difficulty that I can imagine the mindset that produced them. I’ll share one, knowing for many it may simply seem incomprehensible. An airline attendant stood at the front of a plane and described how to use the passenger seatbelts. I watched with a sense of amazement and incredulity, as one might gaze at an impossibly athletic feat during the Olympics. I remember thinking “how can she do that without being terrified?! She has to say all of those specific words, and they have to be right, and do it in front of a plane full of people!”

Each of us compares our insides to others’ outsides, and our picture of the human condition is ever distorted as a result. That difference makes it believable that it is our birthright to be psychologically healthy, happy, and carefree – and that feeling good is the measure of a life well lived. Commercial interests are only too pleased to feed this vision, assuring us that we will approach it readily through the right car, home, or vacation. The pharmaceutical industry will provide the right pill; the media the latest “feel good” therapy; and the local bar both the ideal beer, and the setting to find the right romantic partner. It is seemingly only the abnormal person who suffers.

The outsides of others provide superficial evidence of the validity of this vision. But what if everyone has a secret? And what if the joke is that we all have the same one?

The fact is that almost all people are in pain somewhere in their lives much of the time. It is hard to be fully human. Almost all will struggle and suffer, and find that easy methods of feeling good bear little relationship to living a meaningful, valued, vital life.

Anyone who reads the popular media, never mind the voluminous scientific literature on this topic, probably realizes that human problems are pervasive in the developed world. Few, however, seem to face the implications of such statistics considered as a whole. Over 30% of the population will have a psychiatric disorder sometime in their lives. Nearly 50% will struggle with thoughts of suicide for two weeks or more. Divorce rates reach similar levels; second marriages are no better; and the relationships that remain are often restricted or empty. If we add in the rates of emotional or physical abuse, sexual concerns, loneliness, burnout, problems with children, or 100 other such problems we need to consider the possibility that it is human pain is that is nearly universal. In effect it is abnormal to be “normal.” The treacle of modern “feel goodism” is simply false.

That was my starting point, 25 years ago. Unable to control my anxiety, and sinking ever deeper into panic disorder as I tried to do so, I began to explore what it would be like to approach what I was struggling so mightily to avoid. I began to research whether it was the emotional and cognitive objects of my struggle that were my enemy, or struggle itself.

We now know that one of the most pathological things a human being can do is to attempt to avoid their own thoughts and feelings, and to link their overt actions to this attempt. Researchers such as Frank Bond (University of London) have discovered that the psychological inflexibility that results from this effort produces bad outcomes almost everywhere you look. It predicts more anxiety, depression, worry, and trauma. It undermines your ability to learn new things, enjoy your job, be intimate with others, or rise to the challenges of physical disease. Lance McCracken (University of Bath) has shown that these processes predict far more disability due to chronic pain than the amount of pain or injury itself.

Turned outward, the human mind is highly effective. We can predict the future and remember the past; we can evaluate outcomes based on imagined courses of action. It is these symbolic problem-solving abilities that have lead us to dominate the planet, despite being weak, slow, and vulnerable. But these same abilities also entangle us needlessly in a struggle with our own thoughts and feelings.

If we don’t like dirt on the floor we can vacuum it up and the dirt will be gone. Conversely, if we don’t like a painful memory and try not to think it –we will make it more of a focus, more frequent, and more impactful. If we fear a future lack of food we can grow plants that will later nourish us. But if we fear the harm produced by future panic and thus try to avoid it, we will have brought that imagined harm into the present and amplified its role in our lives.

The human mind has in effect been turned on its owner, merely by allowing it to do what it normally does, but in the wrong domains.

It turns out that this is not necessary. We have developed methods to train people in a healthy alternative: accept feelings and be mindful of thoughts without arguing, coming instead into the present moment more consciously and fully, focusing on values and taking actions that move in their direction. For example, if the thought “I’m bad” is present, trying to change it only confirms that there is something unacceptable about you. In our approach we might instead say “bad” 100 times aloud, or sing the thought, or print it on a T-shirt and wear it, or say it in the voice of one’s least favored politician. Like the movie A Beautiful Mind, this defanged thought is then willingly brought along into valued actions, such as being a loving person, or contributing to others.

Controlled research shows this these methods are helpful in areas as diverse as anxiety, burnout, diabetes management, smoking, pain, and depression among several others. I walk through these concepts and techniques in Get Out of Your Mind and Into Your Life (New Harbinger; 2005) which was the number one self-help book last week in the United States on Amazon. The basic and applied psychological science behind these methods will be presented for students, therapists, and researchers at a week-long “world conference” July 22-28 at the University of London (see www.contextualpsychology.org).

For the first time in human history, we are trying to raise an entire generation on the message that feeling good equals living well. It is not true. It has never been true. And now we are seeing the sad results in our homes and on our streets. Our task as human beings is to learn how to carry pain without needlessly amplifying it into suffering, while creating a values-based life.

Steven C. Hayes
University of Nevada, Reno

Time Magazine (February, 2006): Happiness is Not Normal

John Cloud wrote this article for Time magazine in 2006, in which he described the contrast between 'third wave' approaches (specifically Acceptance and Commitment Therapy) and more traditional cognitive behavioral therapies.

Click HERE for the pdf copy of the Time article as posted on the New Harbinger website.

Click HERE for the article on the time.com site, though you may not be able to access it for free.

Time Magazine (July, 2009): Self-Help Through Negative Thinking

Cloud, J. (2009). Yes, I suck: Self-help through negative thinking. Time Magazine. Time, Inc.: New York, NY.

In the past 50 years, people with mental problems have spent untold millions of hours in therapists' offices, and millions more reading self-help books, trying to turn negative thoughts like "I never do anything right" into positive ones like "I can succeed." For many people — including well-educated, highly trained therapists, for whom "cognitive restructuring" is a central goal — the very definition of psychotherapy is the process of changing self-defeating attitudes into constructive ones.

But was Norman Vincent Peale right? Is there power in positive thinking? A study just published in the journal Psychological Science says trying to get people to think more positively can actually have the opposite effect: it can simply highlight how unhappy they are.

The study's authors, Joanne Wood and John Lee of the University of Waterloo and Elaine Perunovic of the University of New Brunswick, begin with a common-sense proposition: when people hear something they don't believe, they are not only often skeptical but adhere even more strongly to their original position. A great deal of psychological research has shown this, but you need look no further than any late-night bar debate you've had with friends: when someone asserts that Sarah Palin is brilliant, or that the Yankees are the best team in baseball, or that Michael Jackson was not a freak, others not only argue the opposing position, but do so with more conviction than they actually hold. We are an argumentative species.

And so we constantly argue with ourselves. Many of us are reluctant to revise our self-judgment, especially for the better. In 1994, the Journal of Personality and Social Psychology published a Joel Cooper of Princeton asked participants to write hard-hearted essays opposing funding for the disabled. When these participants were later told they were compassionate, they felt even worse about what they had written.

For the new paper, Wood, Lee and Perunovic measured 68 students on their self-esteem. The students were then asked to write down their thoughts and feelings for four minutes. Every 15 seconds during those four minutes, one randomly assigned group of the students heard a bell. When they heard it, they were supposed to tell themselves, "I am a lovable person."

Those with low self-esteem — precisely the kind of people who do not respond well to positive feedback but tend to read self-help books or attend therapy sessions encouraging positive thinking — didn't feel better after those 16 bursts of self-affirmation. In fact, their self-evaluations and moods were significantly more negative than those of the people not asked to remind themselves of their lovability. (See pictures of couples in love.)

This effect can also occur when experiments are more open-ended. The authors cite a 1991 study in which participants were asked to recall either six or 12 examples of instances when they behaved assertively. "Paradoxically," the authors write, "those in the 12-example condition rated themselves as less assertive than did those in the six-example condition. Participants apparently inferred from their difficulty retrieving 12 examples that they must not be very assertive after all."

Wood, Lee and Perunovic conclude that unfavorable thoughts about ourselves intrude very easily, especially among those of us with low self-esteem — so easily and so persistently that even when a positive alternative is presented, it just underlines how awful we believe we are.

The paper provides support for newer forms of psychotherapy that urge people to accept their negative thoughts and feelings rather than try to reject and fight them. In the fighting, we not only often fail but can also make things worse. Mindfulness and meditation techniques, in contrast, can teach people to put their shortcomings into a larger, more realistic perspective. Call it the power of negative thinking.

---------

View this original article online here.

Also click our link to access the 2006 Time article by John Cloud referenced in the above article.

ACBS Professional/Student Members: Once you are logged in, you can view the original Woods, et al (2009) article here.

ACT in Private Practice

This will serve as the main entry point for issues related to using ACT in private practice settings.

There is a great deal of activity occurring in academic settings--both in research on RFT and ACT and in the practical application of the products of this labor. In the meantime, many therapists are translating this work into a wide variety of therapeutic environments. Therapists in private practice, in taking ACT out into the mental health "marketplace," face issues and challenges particular to this setting. In the pages that follow, we can explore some of these issues and have an arena to move the work forward.

ACT in the US Department of Veterans Affairs

If you're a VA employee doing ACT or interested in beginning to incorporate ACT into your clinical practice, please send me an email to my VA email account: sonja.batten@va.gov. Please give me your name, location, and most importantly - your VA Outlook email address. Due to the vagaries of the VA system, I cannot add your name unless you have an Outlook account.

Thanks in advance for your interest!
Sonja V. Batten, Ph.D.
Coordinator, Trauma Recovery Programs
VA Maryland Health Care System

ACT with Children, Adolescents, Parents, Teachers, Etc.

Hi all. I am attaching a Word file that provides information about ACT and/or ACT-related work with youth. There are some quick to review charts and lists, manuscript summaries, and references, as well as contact information for individuals working with "kiddos" or parents, teachers, etc.

There is some admitted overlap and also some non-repetition between those things - so, for example, some (but not all) of the stuff listed in charts is listed in summaries and some citations are in summaries but not the reference list, etc. I ask that you just read it all carefully and overlook the imperfections. One of my students (Andrew Scherbarth) and I spent a good deal of time and have worked quite hard to get it looking as good as is does. A lot of information is there.

We have excluded work that is only basic in nature. Therefore, it does not address RFT, stimulus equivalence studies, or the like UNLESS there was a clear clinical application in the title or abstract of the article, chapter, etc. I think that would be a great addition to the RFT section of this website (hint, hint). We are doing some of that in my lab now and may get around to posting it later, but if someone else could do it sooner...

We did include in-press, in-review, in-preparation, ongoing, and even upcoming studies that I know of in addition to the published stuff. We included people doing clinical work without research components, but not in much detail. I did my best to include everything and mention everybody that I know has done or is doing this work. Please, please, forgive me if I forgot anything/anyone. If I wrongly included you, or you don't want to be included, I apologize. Please, let us all know. Also, if I did not know about you/your work and it should be included, please, take an active role in speaking and stepping up. We need more ACT stuff with these groups! What I hope is that people interested in clinical or research work with youth and related populations will "make themselves known" by adding their contact information and interests to this list. Ideally, new communication will be fostered and known contacts will be stregthened in efforts to advance this work. I provided some suggestions at WorldCon2 about where I think we need to go. If you take up those topics or others with youth, please let us all know!

Thanks and take care,
Amy

Psychiatrists in ACT

There are a number of psychiatrists world wide doing ACT work. Often this is in combination with pharmacotherapy. If you would like to be on a small list serve of psychiatrists considering the intellectual and professional issues involved in doing this work, contact Cynthia Cushman, M. D. and let me know of your interest and professional background. She can add you to the list. you can email Cynthia at

cynthia.cushman@stonepathcenter.org

MICA: Trauma and Addiction Clinic looking for 4 additional Social Workers

Buffalo General Hospital's Community Mental Health Clinic is looking for 4 licensed social workers trained in DBT, ACT, and trauma processing: Prolonged Exposure, EMDR, or Cognitive Processing Therapy to work in a state of the art clinic which features 3 phases of group therapy for individuals with dual diagnosis of PTSD or Complex trauma and addiction. Candidates with training in Mindfulness Based Cognitive Therapy a plus. The new social workers will join a seasoned staff of 8 social workers trained in the above modalities. Ample supervision, both group and individual, competitive salary and a benefit package are offered as well as plenty of snow.
Please contact Marcy Brimo, LCSW-R at mlbrimo@buffalo.edu for further information. Feel free to send a resume.

An example brochure on an ACT-focused treatment program

This was donated as a model brochure by Dianne Salvador that she uses for "prospective clients of my ACT service within a General Practice medical setting. Constructive criticism gratefully accepted."

Example brochure for ACT in collaboration with primary care physicians

Robert Purssey donated the sample flyer below that he has used in his practice and says that people are free to borrow it and modify it for their own use.

Marketing Brochure for Group Treatment

I was gifted the graphic design for this brochure and wanted to pass the windfall on. It's in pdf, so I think you can alter the brochure, but if you take it to a printer, they can do the word processing before they print it as well.
My best,
Joanne

State of the ACT Evidence

• ACT state of the evidence (July 2008, PowerPoint)

• Effect Sizes for Primary Outcomes in ACT Research to Date (August 2005, Excel file)

The ACT / RFT tradition is committed to a high standard of empirical evaluation, including not just controlled assessment and evaluations of outcomes but also specification and evaluation of the putative processes of change, and linkage of these processes to a basic program of research that seeks to explain them in terms of functional behavioral principles, including those drawn from RFT.

The efficacy and effectiveness data on ACT are positive, but preliminary. A recent (July 2008) PowerPoint presentation of the evidence can be downloaded above. Also above is a table showing effect sizes for the ACT outcome literature. The most recent meta-analysis, Hayes, Luoma, Bond, Masuda, & Lillis, 2006, was published in Behaviour Research and Therapy in January 2006 and is available in the publications list or by clicking on the emboldened link.

ACT is not yet formally an empirically supported treatment on EST lists, though it is approaching or perhaps exceeding the standards for that status in some areas, such as smoking, pain, and psychosis, awaiting appearance of publications in press or under submission and on review by authorities responsible for such lists.

We recommend ACT on an experimental basis with any problem that fits the underlying model (e.g., the problem appears to involve cognitive fusion, or experiential avoidance, or a lack of clarity of values, and resulting inactivity, inflexibility, and ineffectiveness) provided it is used with systematic evaluation and there is a good reason not to use existing ESTs first (e.g., if they have already failed; client rejects their use). We think that approach is particularly appropriate for the problems in the following table, since at least some efficacy or effectiveness data are available. The stronger the data are in a given, the stronger we can make this recommendation.

This table lists only published data though if additional major studies are coming and we have actually seen the data in detail they may be mentioned as well. We have divided the data into randomized controlled trials and other types of studies – e.g., pre-post designs or single case designs. Only outcomes studies with real patients are included, not analogs. "Published" data include theses and dissertations. See the publications page for detailed information. This table is current as of July 2008 but the literature is moving quickly and it takes a while to update pages like this. For a more detailed list of outcome studies and other empirical research you can download the "ACT Handout" and/or check the research summaries posted on the website, which are updated regularly:

ACT Data

Depression	4 RCTs; 3 other. Some indication that it is superior to CBT in some settings. Evidence of a distinct process.
Anxiety / Stress / OCD	4 RCTs; 11 other. Data supporting the application of ACT with a number of different problems related to anxiety and stress. Some indication that it is superior to CBT in some settings, but also data that it can be beaten by traditional BT in minor anxiety problems. Evidence of changes in ACT processes.
Psychosis	2 RCTs; 5 other. Not yet compared to other psychosocial methods beyond support but effects are good for amazingly small interventions. Done in addition to antipsychotic medication. Mediated by ACT processes.
Substance abuse	2 RCTs; 3 other. Some indication that it does better than existing pharmacotherapy methods, or supplements their effects.
Smoking	2 RCTs; 1 other. 1 other RCT under review also found good outcomes. Indication that it does better than existing pharmacotherapy methods, or supplements their effects.
Chronic Pain	2 RCTs; 7 other, including three decent sized effectiveness trials. Good outcomes. No good head to head comparisons with empirically supported alternative methods yet. Works through ACT relevant processes.
Prejudice and burn out	2 RCTs; 1 crossover. Beats multicultural counseling and education alone. Works through ACT relevant processes. Helps in both stigma and burnout. Other good studies completed and on the way.
Marital problems	1 other. Very limited data.
Eating disorder	1 other. Very limited data.
Sexual deviation	2 other. Very limited data.
Dually diagnosed	1 RCT (sub-analysis). 1 other. Promising but limited data.
Self Harm / BPD	1 RCT that mixed ACT with DBT. Extremely good outcomes but no follow up. Did move ACT relevant processes.
Epilepsy	2 RCTs. Very good outcomes on both seizures and quality of life. 1 year follow up. Mediated by ACT processes.
Diabetes management	1 RCT. Good outcomes at follow up on self management and glucose control. Mediated by ACT processes.
Weight maintenance	1 RCT. Good outcomes which were mediated through ACT processes.
Augmenting training in other therapies	2 RCTs. Found ACT can increase the adoption of evidence-based psychotherapy methods by clinicians and is mediated through ACT processes.
Coping with cancer	1 RCT; 1 Other. Preliminary data suggests ACT can improve coping with cancer. One other completed RCT shows ACT is more helpful than traditional CBT in dealing with end stage cancer and works through a different process.
Sports performance	3 Other. Very limited data suggesting ACT can improve performance in various sports.

There are some data on effectiveness (see the "publications" section and effectiveness study summary page). Thus, we feel that we can recommend ACT to systems of care provided they use it under the limitation suggested above and will work with us to train it properly, and to evaluate its impact.

ACT-Specific Measures

A number of instruments have been developed to measure ACT-specific processes. This section of the site will provide more information about these instruments, including downloads when available.

Measures are being developed very rapidly, and we encourage developers to contribute updates to this section of the site as often as possible. Interested parties are also encouraged to join the ACT listserv to learn of updated measures. Click on an instrument below to learn more about it.

ACBS Members: If you have an ACT-specific measure you would like listed here, click on the "add child page" link at the bottom of this page. When adding your content, remember that you can attach relevant files and documents.