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.