You’ve been down this road before and at least you’ve always survived before. But, sooner or later, you are right back where you started, except now you are weakened. Life is a little bit smaller. More time has gone by, and somehow it’s as if your life hasn’t started. You not only have problems to deal with, they are the same familiar, deadening problems.
How long will this cycle go on? Think of the problems you have been struggling with. When did they start? What if the next five years are like the last five years were in this regard? The next ten years?
In the acceptance and commitment cycle, the sequence is different. You notice the chatter all right, but you don’t become entangled in it. You see that there is a distinction between you, the conscious driver of the bus, and the passengers you carry. You have room on the bus for them. You accept them. You defuse from them. But then you turn your eyes back to the road and connect with that which you really value. You drive in that direction. As a result, your life grows a little, and it becomes a little more vital and flexible.
As you grow, however, you are likely to contact problems again. Often these are not quite the same old problems, they are subtly different. They are new, and perhaps even more challenging. For example, if you move in the direction of loving relationships, you now have problems of vulnerability whereas previously you may have had problems of alienation. If you move in the direction of making a contribution, you now face problems of fear of inadequacy or inability, whereas previously you faced problems of fear that you did not belong or were invalid. Sometimes, these new problems present themselves as even more fearsome than your old ones. Especially if they feel new or more intense, your mind often will scream out in fear that you’ve made a terrible mistake, and you are moving backwards.
Conclusion Figure 3. The spirals of vitality and inflexibility in life.
And there you are. Back at the fork in the road. The whole choice gets to be repeated.
If you consistently choose to go left, life will not become any easier. It will only become more vital. Progress is being made. It is like figure 3. As you keep taking that bus of life off into the acceptance and commitment cycle, you move up in a new direction. What looked like a circle in figure 2 is, in fact, a spiral. You still have problems, even big ones. They occur regularly. But progress is being created. You are living a more vital, flexible, and values-based life. When the other path is taken, you are also in a spiral, but very likely it is one that is spiraling down in a narrower, more struggle-based and less flexible life.
Note that the presence of problems, and perhaps even their frequency or their intensity, could be the same or even greater if you take the acceptance and commitment cycle. What is different is that on the left-hand spiral you get out of your mind and into your life. You hurt, AND you are living. On the right-hand spiral you sink into the mental war of human suffering.
You’ve often taken the right-hand path. Haven’t you had enough? By now its results are extremely predictable. Predictability makes this choice curiously “safe” but doesn’t remove its deadening qualities. Acceptance and commitment offers a path with unknown ends. Its newness makes it a more frightening path but it also makes it a more vital one. To illustrate this point, we rather like the following quote:
Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative there is one elementary truth the ignorance of which kills countless ideas and endless plans: That the moment one definitely commits oneself then providence moves, too. All sorts of things occur to help one that would never have otherwise occurred. A whole stream of events issues from the decision, raising in one’s favor all manner of unforeseen incidents and meetings and material assistance which no man could have dreamed would come his way. Whatever you can do or dream you can, begin it! Boldness has genius, power, and magic in it. (Murray, partially quoting Johann Wolfgang von Goethe, 1951.)
Life is a choice. The choice here is not about whether or not to have pain. It is whether or not to live a valued, meaningful life.
You’ve had enough suffering. Get out of your mind and into your life.
(We are rooting for you).
Appendix
The Values and Data Underlying ACT
ACT comes from behavior therapy, a branch of empirical clinical psychology. As such, the developers of ACT maintain firm commitments to (1) scientific evaluation of well-specified techniques, and (2) the development of basic principles and theory adequate to guide the development of these techniques and to explain their success. Even though this is a book meant for the general public, we wanted to include this short appendix to show how ACT developers maintain these commitments, and to guide readers and professionals to needed resources.
THEORY AND BASIC PRINCIPLES
In several places, we’ve mentioned that ACT is based on a comprehensive basic research program on the nature of human verbal and cognitive processes called Relational Frame Theory (RFT; Hayes, Barnes-Holmes, and Roche 2001). We’ve done what we can to make some of this work accessible. It is technical, extensive, and it is hard to explain in a book meant for a general audience. The research studies on RFT will soon pass one hundred papers, and the methods and concepts are often complex and frankly arcane. Furthermore, because the work is part of behavior analysis, its naturalistic and contextualistic philosophical basis is foreign to the general lay culture.
We’ve dealt with this problem in this book by expressing many of these findings in relatively lay language that is quite different from the language used to develop this knowledge. For example, we’ve frequently spoken of the “mind” or “mental processes,” rather than “your repertoire of arbitrarily applicable derived relational responding” because using technically correct naturalistic terms would have no meaning and would make the book virtually impossible to read. In a scientific context we would speak differently, but because we believe that “meaning is use” we’ve used words that seem more likely to make a difference, even if they aren’t technically correct within the scientific tradition that created and sustained ACT.
Underneath every sentence a more technical account is possible, or at least so we believe, and we stand ready to make the translation if our scientific colleagues wish. Many publications are available of that kind as well (e.g., see Hayes, Barnes-Holmes, and Roche 2001). The downside of our approach (beyond the fact that some of our behavioral colleagues will be startled) is that this book may sound at times as though its basic scientific foundations are not strong, or that it is based on a common sense understanding of how language and cognition works. We believe that those with a scientific bent who are willing to explore the area will find that is not the case. A list of RFT studies is available on the RFT Web site (www.relationalframetheory.com).
The clinical theory (the theory of psychopathology and change processes) that is based on RFT and that underlies ACT is similarly scientifically grounded. ACT researchers have studied the impact of experiential avoidance and cognitive fusion extensively. The other aspects of the theory (development of different senses of self; the importance of contact with the present moment, values, and psychological flexibility; mindfulness; and so forth) have received research attention, as well. So far, the data are supportive of the theory, and mediational analysis (that is, analyses designed to determine whether the clinical outcomes of ACT are produced by the processes the theory says are key to success) are also supportive (Hayes, et al., forthcoming). The research program is still young, so we will have to await the data before drawing firm conclusions, but in its broad outlines it now seems clear that this analysis of human problems has scientific support. A list of relevant research studies is available on the ACT Web site (www.acceptanceandcommitmenttherapy.com).
OUTCOMES
None of this would matter if it were not linked to actual positive clinical outcomes. In the few years since the ACT book (Hayes, Strosahl, and Wilson 1999) first appeared, outcome research in ACT has exploded. A rev
iew of the outcome research on ACT written just a short while ago is already completely out of date (Hayes, Masuda, et al. 2004; See Hayes, Luoma, et al. forthcoming for a more recent interview).
Clinical research scientists study the impact of technologies like ACT in a variety of ways, but some of the most important studies are randomized controlled trials and controlled time-series analyses. Right now, the number of completed studies of that kind on ACT are approaching two dozen, most of which are now in the published literature.
So far, all of the studies support the positive impact of ACT, and in all cases of which we are aware, all of the studies that were designed to look at processes of change have provided some support for the theory underlying ACT. A few of these studies have compared ACT to other well-developed and empirically supported methods.
In almost all of the published comparisons so far, ACT has done as well as or (in some cases) better than existing methods known to be effective. So far there are supportive controlled outcome studies in the areas of anxiety, stress, obsessive-compulsive and OCD spectrum disorders, depression, smoking, substance abuse, stress, stigma and prejudice, chronic pain, willingness to learn new procedures, ability to learn new procedures, coping with psychosis, diabetes management, coping with cancer, coping with epilepsy, and employee burnout. If you want to see more about the current state of the evidence, you can visit the ACT Web site.
The fact that these data are themselves so broad is one reason we’ve cast this book very broadly. If the theory underlying ACT is correct, the processes we are targeting are shared among human beings because they are based on core language processes. That is the empirical justification for not targeting specific syndromes in this volume. We felt these issues are relevant to people in general, not just to people struggling with one or another specific problem.
THIS BOOK
For a scientist committed to empirical evaluation, it is important to show that materials can be helpful outside the context of a therapeutic relationship, so, generally speaking, we know that a book like this is likely to be helpful. Several of the specific components in this book have been tested, sometimes in a form very similar to the way you are contacting this material. For example, several studies evaluated the impact of short passages drawn nearly word for word from ACT materials (very similar to what you’ve read) that were recorded on audiotape, read aloud by a research assistant, or were presented to the participants to read.
Typically, these studies focused on the ability of participants to tolerate distress of various kinds, such as gas-induced panic-like symptoms, extreme cold, extreme heat, or electric shock. A few studies looked at the distress produced by difficult or intrusive cognitions, or clinically relevant anxiety. Some were done with patients, others with normal populations.
The specific ACT components that have been examined so far include defusion, acceptance, mindfulness, and values. The techniques included exercises, metaphors, and rationales, including several that can be found in this book (e.g., word repetition, physicalizing, leaves on a stream, the quicksand metaphor, the Chinese finger trap metaphor, and so forth). Thus, it seems fair to say that it is known that at least some of what you’ve read can be helpful at least some of the time outside of the context of a therapeutic relationship, when presented in a form similar to the form in which you have contacted this material.
Examples of these kinds of studies can be found in Eifert and Heffner 2003; Gutiérrez et al. 2004; Hayes, Strosahl, and Wilson 1999; Levitt et al. 2004; Marcks, and Woods, forthcoming; Masuda et al. 2004; Takahashi et al. 2002 (see the list on the ACT Web site for other examples). Partial validation does not mean that this book en toto is validated in this form. The only way to make such a statement is to examine the applied impact of this exact book in this exact form. Such an analysis is underway, but even then, it will be impossible to validate this book for every specific problem to which it might be applied. Thus, as we noted in the introduction, readers need to examine their own experience to see if it is helpful for them.
ACT THERAPY
We are aware that some who read this book will want to seek out an ACT therapist, and indeed this book was designed in such a way that it could be used either as a stand-alone text or as part of a professional psychological intervention. Although several thousand therapists have at least some training in ACT, no comprehensive list of ACT therapists exists, and the ACT community has decided not to certify ACT therapists for fear of ossification and centralization. A short voluntary list of ACT therapists is available on the ACT Web site, but if that doesn’t work we suggest the following.
In the United States, a list of behavior therapists and cognitive-behavior therapists is available at the Web site for the Association for Behavioral and Cognitive Therapies. An Internet search will lead you to it (it has recently changed its name, so the Web site address is changing as this is being written). In most major countries around the globe, similar societies maintain similar lists. These are empirically oriented therapists, which is good if you believe, as we do, that people should receive evidence-based care.
Because ACT is becoming increasingly well-known within that community, these are also people who might know something about it. Find a therapist in your area or (perhaps even better) a therapist who is also affiliated with a local university. Call that person and ask about a competent local person experienced in ACT or other “third wave” behavioral or cognitive behavioral interventions. If one exists, this method is the most likely way to find such a person. If they do not know of one, at least you will be talking to a scientifically oriented person who may be able to give you sensible advice about how to find other local treatment resources for your problem.
TRAINING IN ACT
We are also aware that some professionals will contact ACT through this book and will want training in these methods. There is controlled evidence that training in ACT seems to make clinicians generally more effective (Strosahl et al. 1998), so quite apart from self-interest, we can recommend it. Trainings take place regularly at major behavior therapy associations such as the Association for Behavioral and Cognitive Therapies, as well as through freestanding workshops. The ACT/RFT community is committed to the open development of this theory and technology, and we are committed to doing so in a way that is primarily focused on benefit to others.
On the ACT Web site, there is a growing list of trainers available to help you or your agency in addition to a growing set of other training resources. Listservs for behavioral health professionals are available in both ACT and RFT. Links are on the Web sites. ACT and RFT are growing, developing behavior analytic approaches, but they are not for the faint of heart. ACT is challenging, intellectually and personally. If you don’t have a behavioral background, you will find it especially challenging, both because it will not fit preconceptions, and because the underlying theory and technology take time to master. If you are a professional wanting to learn, however, you will find an open door into a supportive, nonhierarchical, values-based, and scientifically focused community committed to the alleviation of human suffering through the development of a more adequate scientific psychology.
USING THIS BOOK AS AN ADJUNCT TO A PROFESSIONAL PSYCHOLOGICAL INTERVENTION
The chapters in this book were organized in such a way as to fit the normal phases of ACT. ACT can be done in different sequences, and despite the sequential nature of this book as a book, we’ve tried to write it so that you can assign chapters in different sequences without fear that your patients will be unable to follow the material. For example, if you do values work first, the three values chapters can be read immediately without much confusion. Just tell your clients to pass over the few parts they will not understand.
References
Barks, C. 1997. The Illuminated Rumi. New York: Broadway.
Barnes-Holmes, Y., D. Barnes-Holmes, and P. Smeets. 2004. Establishing relational responding in accordance with opposite as generalized operant behavior in young children. Internat
ional Journal of Psychology and Psychological Therapy 4:531-558.
Barnes-Holmes, Y., S. C. Hayes, and S. Dymond. 2001. Self and self-directed rules. In Relational Frame Theory: A Post-Skinnerian Account of Human Language and Cognition, ed. S. C. Hayes, D. Barnes-Holmes, and B. Roche, 119-139. New York: Plenum Press.
Begotka, A. M., D. W. Woods, and C. T. Wetterneck. 2004. The relationship between experiential avoidance and the severity of trichotillomania in a nonreferred sample. Journal of Behavior Therapy and Experimental Psychiatry 35:17-24.
Bond, F. W., and D. Bunce. 2003. The role of acceptance and job control in mental health, job satisfaction, and work performance. Journal of Applied Psychology 88:1057-1067.
Brown, R. A., C. W. Lejuiz, C. W. Kahler, D. R. Strong, and M. J. Zvolensky. Forthcoming. Distress tolerance and early smoking lapse. Clinical Psychology Review.
Chiles, J. A., and K. D. Strosahl. 2004. Clinical Manual for Assessment and Treatment of Suicidal Patients. Washington, DC: American Psychiatric Association.
Cioffi, D., and J. Holloway. 1993. Delayed costs of suppressed pain. Journal of Personality and Social Psychology 64:274-282.
Dahl, J., K. G. Wilson, C. Luciano, and S. C. Hayes. 2005. Acceptance and Commitment Therapy and Chronic Pain. Reno, NV: Context Press.
Dahl, J., K. G. Wilson, and A. Nilsson. 2004. Acceptance and Commitment Therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy 35:785-802.
Get Out of Your Mind and Into Your Life Page 29