Interview with Steven Hayes on second edition of major ACT book

Well-worn with frayed pages and bent covers, an old friend nicknamed “The ’99 Book” reminds me of how I began my journey into the world of ACT and RFT. Acceptance and Commitment Therapy: An Experiential Approach to Behavioral Change, is the name by which I first knew it. My initial introduction to the text came six years ago in my school’s library, after a fellow undergraduate had told me about, “This new therapy that treats thoughts like behavior, and seems kind of dumb.” In my ears, the first part of his sentence overwhelmed the second, and set me off on a great adventure.

After attending several ACBS conferences, I know I am not alone. Many members whom I have met also share a special history with “The ’99 Book,” -- having found its theoretical account of human suffering and therapeutic change to strike important emotional and intellectual chords.

It was with a mix of nostalgia and excitement then that I picked up the newly published second edition, Acceptance and Commitment Therapy: The Process and Practice of Mindful Change by Hayes, Strosahl, and Wilson.

To mark the occasion, I sat down with one of the authors, Steve Hayes, and asked a few questions. We covered the origin of the hexaflex, the relation between CBS and evolutionary science, and a little ACBS history, amongst other things. See the interview below.

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

DOUG: Suppose I have thoroughly read the 1999 edition of this book. What would I gain from this new rendition?

STEVE: A lot is different. We think we've simultaneously created a book that is easier to read, and that is more intellectually mature. It is useful for beginners, and useful for more experienced people. It will help the practitioner but it will also help the researcher and student.

That magic is done in part by improving our writing, but it comes also from how the book is now organized. It is much more focused on processes and the hexaflex. The work on case conceptualization and the relationship is more central. The development strategy (contextual behavioral science) is newly emphasized, but at the end of the book. So we've taken some heavy lifting out of the beginning and found a new, simpler way to talk about very complex issues.

I'm not 100% sure we've pulled it off, but we think we have. It took three years to do and through the process that was the goal. We will soon see if we succeeded in the eyes of a broad readership.

DOUG: In the dedication, you thank Barry and Trudy for helping ACBS. Who are they? What’s the story?

STEVE: Barry and Trudy Silverstein are people in the public with an interest in acceptance and mindfulness methods. As ACBS was just established, our web operations had deteriorated to the point they were almost impossible to fix.

We could not even update the operating system core of our website because Drupal was several generations ahead of where we were and the route forward was too technically complex for us. They sent in a crew of experts to get it done. It took several weeks, but it was successful.

They also funded a camera crew to shoot the London conference, giving members a lot of reasons to go to the site. We gave Barry an award on behalf of ACBS -- the only one we've given. I silently thank them every time I look at the list of ACBS members and see not 1000 people, but 4500. They were there when we needed them.

Barry also encouraged me to think big about the potential of ACT for the world at large. Those conversations gave Jacque and I a multi-part plan (we called it the ACT on the World initiative) and we've been roughly following it for years, with great success, so a lot of what I do was touched by Barry's vision for our work. He believed it in and put resources behind it and that made a big difference.

DOUG: You say something provocative in the preface: “An open, values-based community embracing a common mission can be far more productive than scores of professors in an ivory tower.” Here there seems to be some underlying discontent with how academia operates. Care to elaborate?

STEVE: Empirical clinical psychology has made many errors in how it operates. People develop an intervention method, name it, and test it. Then they immediately started training. Often they start certifying therapists. They make it clear that they control the methods. Often little is know about the processes by which the method works.

But that means the developers are forever in charge, and the method is the focus (not the processes and procedures others might openly use and modify). In essence, evidence based treatments become small cottage industries. The control exerted by founders chases away the best minds and the technological focus slows down the field.

ACBS has a much longer term and broader vision. We want to change psychology from top to bottom. Doing that requires a large community working together, with each person free to take the work in the direction he or she chooses, but with social accountability to the values of the group (e.g., keeping the focus on those we serve and not proprietary interests). 

In essence we've extended the ACT model to the group level. We are creating a community. The community is not about ACT, or even ACT and RFT. It is about an intellectual and practical tradition. If we succeed, psychology will not be the same.

DOUG: You mention that the term “hexaflex” seems to have stuck, “for better or worse,” and that it makes you smile despite its serious purpose. What’s the story? How did this term come about?

STEVE: I came up with the organization about 6 or 7 years ago. Originally it was a pentagon (I hate to think what people who call ACT a cult would have thought if it stayed there!). But within a week or so it was as we know it now. I posted it to the ACT list serve and I think in that dialogue the silly name "hexaflex" showed up. I haven't gone back to see if I said it or someone else did -- I'm not sure I want to know! It always sounds to me like a label for a vegetable slicer or something you'd see in a late night TV infomercial ("Popeil's Pocket Hexaflex! It slices! It dices!"). But here we are. It does make me giggle but it fits the irreverence of ACBS so perhaps all is well. 

DOUG: Several times, you use a colorful metaphor for describing a motivation that the CBS community explicitly avoids – the use of science to build a monument to immortality. What would be a good metaphor for the more humble path that is valued in the book? Planting seeds, maybe?

STEVE: I like it. How about planting acorns? In workshop I ask the audience to name the birth names of all 8 of their great grand fathers and mothers. Less than 1% can do it but every person in the room owes 1/8th of their body to each of these people.

This means your children's, children's children will not even know your name. When we create things in our field it is not about ego, and fame, and living on forever. It is about putting something in the world that will be there for other people in other places at other times who will benefit and will know nothing of our contribution but whose lives will be better because of what we do now. 

If we do a good job, when it is a psychologically hot day they will sit under the psychological oak trees we plant now. That is worth our time and effort to plant wisely and to tend to the growth of healthy seedlings. If we put down our ego and our grasping we can work together far more effectively, and that is exactly what seems to be happening inside the ACT / RFT / CBS community.

DOUG: There’s a new thread in this book connected to evolutionary science. How did this come about?

STEVE: Contextual behavioral science has a long tradition -- it goes back to William James who was profoundly influenced by Darwin. The  link between CBS and evolution science has always been there -- it has just not been exploited. The reason is because evolution science took a turn toward an excessive focus on genetic evolution only. But that is now changing and a door is opening. It is time for the grand alliance to be realized.

As a result of progress, especially in molecular biology and especially after the human genome was mapped, we now know that most human problems are not just genetic. A vast number of genes are turned off at any moment. Behavior and symbolic cultural streams have their own inheritance systems -- they evolve -- and they impact gene expression. There is good reason to believe that the "plasticity of phenotypes" itself drives genetic evolution, and it does so far more than mutations.

As this becomes better understood, I think the entire field is going to see an exciting possibility open up. Our wing of psychology and behavioral science has a legitimate seat at the table with the most successful approach to biology on the planet. Those of us interested in learning and language from a contextual point of view are evolutionists -- within these key streams.

Frankly, evolution science has been incomplete without us. By nesting CBS under evolution science not only will we gain greater coherence, we will also do better in understanding human beings. It simplifies our task --  think reader of this new edition will see that. We have just begun but even since we've put the book to bed major pieces on this topic have been written. 

So really this is a return to the beginning. Pragmatism was an intellectual outgrowth of Darwin. Contextual behavioral science has matured enough that it is ready to give back to the tradition that created it.


-------
Interview by Douglas M. Long

University of Nevada, Reno

ACBS Staff Writer

50th ACT Randomized Controlled Trial Published

Acceptance and Commitment Therapy for Emotional Dysfunction Following Psychosis (PACT)

I have a long-standing research interest in how the experience of psychosis can be associated with elevated levels of depression, anxiety and fear, even in the absence of elevated levels of psychotic symptoms. This led to me and my colleagues at Mental Health and Well-being, University of Glasgow, undertaking a trial aimed at evaluating the feasibility of using Acceptance and Commitment Therapy to treat emotional dysfunction following psychosis (PACT). This was the first UK-based randomised controlled trial of ACT for individuals with psychosis. The trial was a single (rater) blind pilot Randomised Controlled Trial (RCT) that ran from the 1^st October 2009 until the 30^th September 2010. The following people were involved in completing the research: myself (Principal Investigator), Prof Andrew Gumley (Mentor/co-investigator), Jackie McTaggart (Research Nurse), Lucy Rattrie (Research Assistant), Deirdre McConville (Research Assistant), and Gordon Mitchell (Consultant Clinical Psychologist/Clinical Supervisor).

The clinical outcome measures used in the trial included the Hospital Anxiety and Depression Scale and the Positive and Negative Syndrome Scale. The trial also included measures that have been proposed to assess important mechanisms of change in ACT (i.e. the Acceptance and Action Questionnaire and the Kentucky Inventory of Mindfulness Skills). The Working Alliance Inventory was also used to assess the therapeutic relationship established between the therapist and participants. Individuals were assessed at baseline and 3 months post-baseline. Twenty-seven participants were randomised into the trial: 14 to the ACT intervention and 13 to treatment as usual (TAU).

The trial demonstrated that individuals presenting with emotional dysfunction following psychosis could be successfully identified and recruited. Participants receiving the ten session PACT intervention appeared to find the therapy acceptable; 100% of individuals randomised to the ACT intervention completed the trial. Participants receiving ACT indicated that they could work collaboratively with the therapist to identify goals, set tasks, and form a therapeutic alliance was rated very highly by these individuals. A significantly greater proportion of the ACT group changed from being depressed at time of entry into the study to not being depressed at follow-up. The ACT group showed a significantly greater increase in mindfulness skills and reduction in negative symptoms. Results indicated that individuals randomised to ACT had significantly fewer crisis contacts with mental health services over the study. Changes in mindfulness skills correlated positively with changes in depression. Although the numbers of individuals recruited to the trial were comparatively small, the PACT trial demonstrated the merit and feasibility of conducting further research into the use of ACT for emotional dysfunction following psychosis. We are in the process of beginning to undertake larger trials of this type.

It was with great pride that I learned that the PACT trial was the 50^th RCT of ACT to be published. With ACT being such a versatile form of therapy, it is not surprising that research interest in the approach is growing so rapidly. I believe that ACT, with its hypothesised processes of change, offers real promise for alleviating psychological distress associated with a wide-range of clinical problems. I hope that in being the 50^th RCT of ACT, the PACT trial will serve to stimulate further research investigating ACT and that, in particular, some of this research will focus on the distress experienced by individuals with psychosis.

Dr Ross White

Clinical Research Fellow

Mental Health and Well-being

University of Glasgow
ACBS Member

Ross.White@glasgow.ac.uk

ACT Appears on Top Treatments List Generated by Client Survey

6,100 Patients with Anxiety Report Which Treatments Work Best

Khulinu (Opening up) to ACT in Nepal

One never really leaves Nepal, so they say. I am certainly under its spell. Over and over, I return to walk hundreds of kilometers amidst stillness that only the highest mountains can cultivate, all the while basking in the warmth of Nepal’s beautiful people. My passion to help was ignited in one simple moment several years ago, when a Nepali friend looked sadly at Darcy, my 13-year-old son, and said, “Never forget how lucky you are to have been born in the West”. Ever since, our family has played a role helping a village health service.

The poverty of Nepal is heartbreaking. It is the second poorest country in South East Asia and has a population of 29 million people. The World Health Organization has stated that Nepal is in dire need of mental health training and services. According to a 2006 WHO report, staff in mental health facilities in all of Nepal comprise only 32 psychiatrists, 6 psychologists, and there are no social workers. 

As a psychologist, it seems tough to help them using our Westernized therapies. How can we be sure not to harm other cultures? I decided that ACT, with its contextual approach, would be sensitive to cultures like Nepal. If ACT speaks to the human condition, it has to be useful in some way to the Nepali people. Perhaps we might learn from them too. If only I could work out how to do that.

I was fortunate to meet Chhori, the manager of the Friends of Needy Children Service in Kathmandu, and following months of planning I arrived in July 2011 to commence the first introduction to ACT workshop.  Nineteen psychologists, counselors, and students attended 3 days of training. They were working with: young girls who had been trafficked, formerly indentured girls, children with HIV, street kids, orphans, women who were abused, adults with drug and alcohol abuse, and patients in the psychiatric hospital.

I was incredibly nervous about being understood. Even though Nepali professionals must learn with English textbooks, I worried that they may not understand my Aussie version. I needn’t have worried, despite language difficulties the trainees were warm and welcoming. We laughed a lot. At least Chhori did not need to resort to her solution of tying a string around my little finger and pulling the string whenever I spoke too fast!

More importantly, I wondered if the assumptions of the ACT model would resonate with them. How did their culture influence their desires for happiness, or their attempts to end suffering? To this, I also needn’t have worried. We began by sharing the Nepali assumptions of what happiness and suffering look like in Nepal. Their answers were similar to workshops anywhere in the West. The exception was that food and shelter were common problems for their clients.

We slowly translated the ACT model using Russ Harris’ triflex, so that being stuck became gumsinu and opening up became khulinu (spoken with hands palm up). Upon learning that the word for raisin was kismis, I began to teach them a mindfulness exercise, only to have the group collapse into fits of giggles every time I said the word ‘kismis’. Puzzled, I had to ask what was so funny, “was I mispronouncing it?” No, indeed I was saying it correctly, but they were hearing me in English, Kiss – Miss. A nice example of verbal relating.

At the conclusion of the training they took many photos (I felt like the paparazzi arrived) received certificates and made speeches. Finally, I heard the best training request ever when they asked, "can we dance to celebrate?" Ending the training with Nepali folk music and dancing is just one more example of the warmth of these people.

They were very heartened when I read out an ACBS message from Steve Hayes, welcoming them and explaining that as a community ACBS wants to help developing countries and that we care about what happens (a room full of pleased exclamations). When I explained the ACBS network of sharing of resources through the website, training, supervision etc. they were clearly overwhelmed. They were very uplifted to think that we will come back and do more.

I too am uplifted by the ACBS community, on my return I have had people in the ACT community volunteer -  to return and do more training, to help with the email listserv, to help Nepali people join ACBS.

Thank you. I am left feeling that the ACT model is a big model to learn, and so I need to continue what I started. Any help would be gratefully appreciated.

by Dr Louise Hayes

Clinical Psychologist

University of Melbourne
Secretary, Sanjiwani Australia a not-for-profit health mission in Nepal
ACBS Charter Member

“Holy cow, these guys are applied evolutionists!”

This quote is from evolutionary scientist David Sloan Wilson at this year’s ACBS World Conference in Parma. After reading some of his delightful book, Evolution for Everyone, on my trip across the Atlantic, I was eager to hear him speak. There is a clear functional contextual current in his thinking which makes him seem right at home in ACBS.

In Evolution for Everyone, Wilson considers a staggeringly broad range of phenomena -- ranging from horns on ground beetles to human cooperation – all the while demonstrating the awesome scope, precision, and depth of evolutionary principles. His analyses of complex events often begin with simple questions, not unfamiliar to the behavior analyst: “What are the conditions under which these phenomena might occur? What function might they serve?” These roots appear to engender the sort of cognitive flexibility which we so value in the ACT/RFT community. “We know there is a problem, but that doesn’t mean that we can solve it by a simple act of willpower using our wonderful intelligence. Our so-called rational mind simply doesn’t have that much control over the rest of our mind and body,” he writes (p.55).

The conference did not disappoint. In a panel discussion with Jean-Louis Monestes, Anthony Biglan, and Steven Hayes, Wilson spoke of a “unified science of change.” That has a nice ring to it, no? In the Q & A following his invited address, he imparted this wisdom (now one of my favorite quotes) to the audience, “Facts without values are meaningless. Be explicit about values, respectful of facts, and make it more than just an intellectual exercise.” Thanks for so much for joining us, David Sloan Wilson! I'm looking forward to seeing the relationship between contextual behavioral science and evolutionary science evolve.

by Douglas M. Long
University of Nevada, Reno

ACBS Staff Writer