The Third Wave of Therapy

Before he was an accomplished psychologist, Steven Hayes was a mental patient. His first panic attack came on suddenly, in 1978, as he sat in a psychology-department meeting at the University of North Carolina at Greensboro, where he was an assistant professor. The meeting had turned into one of those icy personal and philosophical debates common on campuses, but when Hayes tried to make a point, he couldn’t speak. As everyone turned to him, his mouth could only open and close wordlessly, as though it were a broken toy. His heart raced, and he thought he might be having a heart attack. He was 29.

Eventually the attack subsided, but a week later he endured a similar episode in another meeting. Over the next two years, the panic attacks grew more frequent. Overwhelming feelings of anxiety colonized more and more of his life’s terrain. By 1980, Hayes could lecture only with great difficulty, and he virtually never rode in an elevator, walked into a movie theater or ate in a restaurant. Because he couldn’t teach much, he would often show films in his classes, and his hands would shake so badly that he could barely get the 8-mm film into the projector. As a student, he had earned his way from modest programs at colleges in California and West Virginia to an internship at Brown Medical School with esteemed psychologist David Barlow. Hayes had hoped to be a full professor by his early 30s, but what had been a promising career stalled.

Today Hayes, who turned 57 in August, hasn’t had a panic attack in a decade, and he is at the top of his field. A past president of the distinguished Association for Behavioral and Cognitive Therapies, he has written or co-written some 300 peer-reviewed articles and 27 books. Few psychologists are so well published. His most recent book, which he wrote with the help of author Spencer Smith, carries the grating self-help title Get Out of Your Mind & Into Your Life (New Harbinger Publications; 207 pages). But the book, which has helped thrust Hayes into a bitter debate in psychology, takes two highly unusual turns for a self-help manual: it says at the outset that its advice cannot cure the reader’s pain (the first sentence is “People suffer”), and it advises sufferers not to fight negative feelings but to accept them as part of life. Happiness, the book says, is not normal.

If Hayes is correct, the way most of us think about psychology is wrong. In the years since Hayes suffered his first panic attacks, an approach called cognitive therapy has become the gold-standard treatment (with or without supplementary drugs) for a wide range of mental illnesses, from depression to post-traumatic stress disorder. And although a good cognitive therapist would never advise a panic patient merely to try to will away his anxiety, the main long-term strategy of cognitive therapy is to attack and ultimately change negative thoughts and beliefs rather than accept them. “I always screw up at work,” you might think. Or “Everyone’s looking at my fat stomach” or “I can’t go to that meeting without having a drink.” Part mentor, part coach, part scold, the cognitive therapist questions such beliefs: Do you really screw up at work all the time, or like most people, do you excel sometimes and fail sometimes? Is everyone really looking at your stomach, or are you overgeneralizing about the way people see you? The idea is that the therapist will help the patient develop new, more realistic beliefs.

But Hayes and other top researchers, especially Marsha Linehan and Robert Kohlenberg at the University of Washington in Seattle and Zindel Segal at the University of Toronto, are focusing less on how to manipulate the content of our thoughts and more on how to change their context—to modify the way we see thoughts and feelings so they can’t push us around and control our behavior. Segal calls that process disidentifying with thoughts—seeing them not as who we are but as mere reactions. You think people always look at your stomach? Maybe so. Maybe it’s huge. Maybe they don’t; many of us are just hard on ourselves. But Hayes and like-minded therapists don’t try to prove or disprove such thoughts. Whereas cognitive therapists speak of “cognitive errors” and “distorted interpretations,” Hayes and the others teach mindfulness, the meditation-inspired practice of observing thoughts without getting entangled in them, approaching them as though they were leaves floating down a stream (“… I want coffee/I should work out/I’m depressed/We need milk …”). Hayes is the most divisive and ambitious of the third-wave psychologists—so called because they are turning from the second wave of cognitive therapy, which itself largely subsumed the first wave of behavior therapy, devised in part by B.F. Skinner. (Behavior therapy, in turn, broke with the Freudian model by emphasizing observable behaviors over hidden meanings and feelings.)

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Hayes and other third wavers say trying to correct negative thoughts can, paradoxically, intensify them, in the same way that a dieter who keeps telling himself “I really don’t want the pizza” ends up obsessing about … pizza. Rather, Hayes and the roughly 12,000 students and professionals who have been trained in his formal psychotherapy, which is called acceptance and commitment therapy (ACT), say we should acknowledge that negative thoughts recur throughout life. Instead of challenging them, Hayes says, we should concentrate on identifying and committing to our values. Once we become willing to feel negative emotions, he argues, we will find it easier to figure out what life should be about and get on with it. That’s easier said than done, of course, but his point is that it’s hard to think about the big things when we’re trying so hard to regulate our thinking.

The cognitive model permeates the culture so thoroughly that many of us don’t think to name it; it’s just what psychologists do. When Phillip McGraw (“Dr. Phil”) gives advice, for instance, much of it flows from a cognitive perspective. “Are you actively creating a toxic environment for yourself?” he asks on his website. “Or are the messages that you send yourself characterized by a rational and productive optimism?” Cognitive approaches were first developed in the 1950s and early ’60s by two researchers working independently, University of Pennsylvania psychiatrist Aaron Beck, now 84, and Albert Ellis, 92, a New York City psychologist. The therapy’s ascendance was rapid, particularly in the academy. Although many therapists still practice an evolved form of Freudian analysis called psychodynamic therapy, it’s difficult to find a therapist trained in the past 15 years who didn’t at least learn the cognitive model.

The debates between cognitive therapists and third-wave critics are sometimes arcane and petty, but few questions seem as elemental to psychology as whether we can accept interior torment or analyze our way out of it. Hayes was received at last year’s Association for Behavioral and Cognitive Therapies convention in Washington with reverence—and revulsion. It wasn’t uncommon to see therapists gazing at him between presentations as though he were Yoda. (Hayes is given to numinous proclamations: “I see this acceptance conception, this mindfulness conception, as having the power to change the world.”) But skeptics dog him everywhere. “He certainly has a following and even an entourage,” says Providence College psychology professor Michael Spiegler. “But I do think some of what he does is cultlike in terms of having that kind of following, of having to agree wholeheartedly with it, or if you don’t, you don’t get it.”

Sunset.

When you just read that word, no event occurred other than that your eyes moved across the page. But your mind may have raced off in any number of directions. Perhaps you thought of a beautiful sunset. And then maybe you thought of the beautiful sunset on the day your mother died, which might have evoked sadness.

Hayes uses such exercises to make the point that our thoughts can have unexpected consequences. Get Out of Your Mind & Into Your Life illustrates that unreliability by quoting a 1998 Psychological Science study in which 84 subjects were asked to hold a pendulum steady. Some were told not only to hold it steady but also not to move the pendulum sideways. But the latter group tended to move the pendulum sideways more often than the group told merely to keep it steady. Why? “Because thinking about not having it move [sideways] activates the very muscles that move it that way,” Hayes and Smith write. To be sure, cognitive therapy doesn’t ask people to suppress negative thoughts, but it does ask us to challenge them, to fix them.

By contrast, ACT tries to defuse the power of thoughts. Instead of saying “I’m depressed,” it proposes saying “I’m having the thought that I’m depressed.” Hayes isn’t saying people don’t really feel pain (he has felt plenty of it), but he believes we turn pain into suffering when we try to push it away. ACT therapists use metaphors to explain acceptance: Is it easier to drag a heavy weight on a chain behind you or to pick it up and walk with it held close?

The commitment part of acceptance and commitment therapy—living according to your values—sounds weightless at first. Many people are so depressed or lonely or caught up in daily life that they aren’t sure what their values are. ACT therapists help you identify them with techniques like having you write your epitaph. They also ask you to verbalize your definition of being a good parent or a good worker. The therapist helps you think about what kind of things you want to learn before you die, how you want to spend your weekends, how you want to explore your faith. The point isn’t to fill your calendar with Italian lessons and fishing trips but to recognize that, for instance, you like to fish because it means you spend time with your family or in the mountains or alone—”whatever is in fishing for you,” says Hayes. One task in Get Out of Your Mind asks you to give yourself a score of 1 to 10 each week for 16 weeks to show how closely your everyday actions comport with your values. If you really enjoy skiing with friends but end up watching TV alone every weekend, you get a 1. (But if you really love holing up with reruns of The O.C., go for it; ACT is pretty nonjudgmental.)

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Now seems like a good time to stipulate that all this can sound vacuous and gaggingly self-helpy. But the scientific research on ACT has shown remarkable results so far. In the January edition of the journal Behaviour Research and Therapy, Hayes and four co-authors summarize 13 trials that compared ACT’s effectiveness to that of other treatments after as long as a year. In 12 of the 13, ACT outperformed the other approaches. In two of the studies, depressed patients were randomly assigned to either cognitive therapy or ACT. After two months, the ACT patients scored an average of 59% lower on a depression scale. Those were small studies, just 39 patients total, but ACT has shown wide applicability. In a 2002 study, Hayes and a student looked at 70 hospitalized psychotics receiving the standard medication and counseling. Half were randomly assigned to four 45-min. ACT sessions; the other half formed the control. Four months later, the ACT patients had to be rehospitalized 50% less often. They actually admitted to more hallucinations than those in standard care, but ACT had reduced the believability of their hallucinations, which were now viewed more dispassionately. Hayes likes to say ACT effectively turned “I’m the Queen of Sheba” into “I’m having the thought that I’m the Queen of Sheba.” The psychotics still heard voices; they just didn’t act on them as much. They learned to hold their thoughts more lightly, increasing their psychological flexibility.

ACT has also shown promise in treating addiction. In one study, drug addicts reported less drug use with ACT than with a 12-step program. And ACT worked better than a nicotine patch for 67 smokers trying to quit. ACT encourages addicts to accept the urge to do drugs and the pain that will come when they stop—and then to work on figuring out what life means beyond getting high. ACT has also been used to help chronic-pain patients get back to their jobs faster. But perhaps the most noteworthy finding was that 27 institutionalized South African epileptics who had just nine hours of ACT in 2004 experienced significantly fewer and shorter seizures than those in a placebo treatment in which the therapist offered a supportive ear. Even Hayes, who is not usually overburdened with modesty, was startled by that finding. He could only hypothesize about why ACT might reduce seizures: “You teach people to walk right up to the moment they seize and watch it.” Somehow, he suggests, that helps reduce biochemical arousal in those critical moments before the trigger of a seizure.

Obviously, Hayes isn’t sure exactly how ACT is working in all those cases, but he believes it has something to do with learning to see our struggles—even seizures—as integral and valid parts of our lives. Recently, a San Francisco patient in ACT therapy e-mailed a plea for help to Hayes. “Just HOW I do that (live a valued, meaningful life) in the midst of disabling and oppressive private experience (anxiety, depression, lack of energy, inertia) is not clear to me. Does one just say the hell with it I will CHOOSE to live, to get into the life I value despite feeling awful 24 hours a day??”

Hayes had opened the e-mail at 3 a.m., after his newborn’s cries had awakened him. At 4:04, he sent a long response that said, in part, “You are asking, ‘Can I live a valued life, even with my pain?’ Let me ask you a different question. What if you can’t have the second without the first? What if to care the way you do care, means you will hurt. But not the heavy, stinky, evaluated, categorized, and predicted hurt that has crushed you. Rather the open, clear, knife-through-butter pain that comes from a mortal being who eventually will lose all and yet who cares.

“Imagine a universe in which your feelings, thoughts, and memories are not your enemy. They are your history brought into the current context, and your own history is not your enemy.”

Hayes talks like that at workshops around the world, and the mixture of his proselytizing and ACT’s solid early performance in journals has created ACT votaries in at least 18 countries. Hayes expects 400 at ACT’s London conference in July. (There are ACT therapists in most states; they are listed at contextualpsychology.org. ACT is being used in a Tucson, Ariz., clinic, a Jefferson City, Mo., prison and an anger-management program in Minneapolis, Minn. A therapist in Spain has used it successfully to treat a 30-year-old with erectile dysfunction; a therapist in England has used ACT with a stalker.

But should it really replace the gold standard in psychotherapy?

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The most prolific cognitive therapist has long been Beck, the University of Pennsylvania psychiatrist who first formulated the role of thoughts in depression in articles in 1963 and 1964. The recipient of virtually all his field’s awards, Beck and his 51-year-old daughter Judith Beck, herself an esteemed psychologist, run the Beck Institute for Cognitive Therapy and Research from a corporate building near Philadelphia. Decorated with handmade Amish quilts, the nonprofit feels more like a rural dentist’s office than the headquarters of an international psychology movement. But the institute carefully guards the reputation of cognitive therapy. Because of the organization’s influence, it can be difficult for cognitive therapists to get referrals without certification from the institute’s in-house academy, which involves a $400 application.

Like ACT, cognitive therapy shares a personality with its co-founder. Beck’s biographer, Brown psychologist Marjorie Weishaar, writes that in his younger years, Beck had public-speaking anxiety and a phobia about tunnels. He solved both problems by correcting misimpressions he had developed: “One day, approaching the Holland Tunnel, he realized that he was interpreting the tightness in his chest as a sign he was suffocating,” Weishaar writes. He wasn’t, of course, and when he “worked that through cognitively,” the phobia vanished. Similarly, his stage fright eased “with continued practice and challenging his automatic thoughts.”

When I first saw Beck at the therapy convention in November, I mistook him for a diffident patrician, an image he seemed to project with his neatly trimmed white hair, bow tie, tweed jacket, gray socks and grandfatherly laugh. In fact, Beck—the son of a Ukrainian socialist father and a “rather dominant” Russian mother, according to Weishaar—is a tireless defender of his therapy. He spoke to me with bemusement about the new wave of therapies. “I don’t think you call something a revolution until it’s actually happened,” he said, chuckling. “You get new, popular approaches that come in, and then they often die out, and they don’t have the empirical validation.” He compared the new therapies to “touchy-feely type things” in the ’60s and ’70s. (Hayes critics have compared his workshops to the faddish, cultish est seminars of the ’70s, which drew hundreds to hotel ballrooms to get rewired by a former used-car salesman named John Rosenberg, who called himself Werner Erhard.)

Beck did say mindfulness therapies are “worth a try,” and he noted that he has always said acceptance of difficult thoughts can have a role early in therapy. But in the weeks after the convention, the debate between Beck’s followers and Hayes’ turned acrimonious. Having just returned from the conference, Robert Leahy, president-elect of the Academy of Cognitive Therapy (current president: Judith Beck), posted a message on the academy’s listserv saying Hayes’ language theory “sounds less like a ‘science’ than a frame of reference for a new religion … Haven’t we all been down that dark pathway before?” Another cognitive therapist, Bradford Richards, responded, “It reminds me a lot of a pseudoscientific cult of personal will.”

For his part, Beck co-authored a paper in the most recent Clinical Psychology Review noting that cognitive therapy “is one of the most extensively researched forms of psychotherapy.” The paper summarizes the results of 16 studies of a collective 9,995 subjects and finds a large effect for cognitive therapy in the treatment of unipolar depression, generalized anxiety disorder, post-traumatic stress disorder, social phobia and panic disorder—Hayes’ condition. Cognitive therapy was also shown to be somewhat superior to antidepressants. After sending me the paper, Beck e-mailed derisively, “The last time there was a claim for a New Wave … was the proclamation of ‘transpersonal psychology,’ which purported to demonstrate some mystical forces between individuals, including, I believe, transmigration of the soul.”

But even some cognitive therapists admit that despite 40 years of research, some fundamental questions about the therapy haven’t been resolved. That’s partly because cognitive therapy involves a variety of techniques. In addition to questioning negative thoughts in the therapy office, cognitive therapists use behavioral homework assignments—for instance, phobic patients may be asked to expose themselves to fears (like Beck going through the tunnel). Depressed clients are asked to schedule regular activities. But if cognitive therapy is all those things, critics say, maybe getting better is a matter of merely changing old behaviors, not questioning negative beliefs.

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Beck hypothesizes that the cognitive parts of the therapy—challenging thoughts, developing new beliefs—add value to the changes in everyday behavior and routine that the therapy encourages. But he acknowledges that no trial has proved that. In fact, a team at the University of Washington has shown in two studies that the cognitive elements of the therapy add nothing. Among more severely depressed patients, behavioral techniques like setting up new routines and scheduling activities worked as well as an antidepressant and significantly better than cognitive therapy. When I asked Beck about the studies, he called them “intriguing” but—since no other lab has yet produced similar results—”not yet proven.”

Reno, Nev., does not immediately come to mind as home base for a mindfulness guru, but Hayes has taught at the University of Nevada campus in Reno for 20 years. Driving to his house took me past a number of sad old casinos where you can find haggard gamblers trying their luck at 6 a.m., the lights from the slots lambent in their expressionless eyes.

Hayes is tall, completely bald and fond of odd sartorial combinations. One day when we met, he wore black leather shoes with an unfashionably large buckle, gray pants that were too short and a gigantic double-breasted jacket. He once lived on a commune, and he still wears an oversize ring that he said was made by Zuni Indians. “I traded it for some contraband in the ’60s in Taos,” he told me. His critics will be delighted to learn that Hayes attended two est trainings in Atlanta years ago. He admits that he also dabbled in meditation seminars, “eco-freak” rallies, druggy parties and all the other appurtenances of a radical ’70s lifestyle.

Although he has an anti-Republican bumper sticker on his car, the car is a red-state Chevrolet Avalanche. The most prominent feature of his office is a set of gym equipment, and he has one of those Sharper Image massage chairs. His days off are spent gurgling over his fourth child, 5-month-old Steven Joseph, or—not infrequently—building additions to his house. These days Hayes is a bit embarrassed by the excesses of his youth.

Hayes’ reputation as more mystagogue than scientist is reinforced partly by how he and his colleagues teach ACT workshops: they do the hard science, but they also ask the participating therapists, usually roomfuls of Ph.D.s, to do things like repeat the word milk over and over (to show how meaningless words can become—try it with I’m depressed). And although Hayes teaches mindfulness at ACT workshops around the world, he epitomizes “the absent-minded professor,” according to Barlow, the psychologist who taught Hayes at Brown in the ’70s. Hayes is famous at Nevada-Reno for passing students in the hall without so much as a nod. But it’s worse than they think. According to Hayes’ wife Jacqueline Pistorello, in December the couple went to the mall to buy Christmas gifts. They split up so they could shop for each other, but at one point Hayes literally bumped into his wife. He didn’t notice her, even though she was cradling their newborn in her arms. (“I call those his black holes,” says Pistorello, a clinical psychologist for the university. Hayes sheepishly explains: “I was just in my place.”)

Pistorello is Hayes’ third wife; his panic attacks began not long after he and his first wife separated in 1977. Hayes grew up in El Cajon, Calif., as the younger son of parents who had a loving but somewhat volatile marriage. His Irish-Catholic father was a salesman who washed out of semi-pro baseball and drank too much. Hayes says his first panic attack was “not too different from some spaces that are very old, in the sense of watching destructive things happen at home—hide under the bed while Dad throws things.” Hayes’ father died in the ’70s; his mother is remarried and lives in Arizona. Ruth Sundgren describes the young Hayes as a sensitive kid who always said things like, “Mom, can I get you a pillow?”

It took Hayes about three years to realize that his panic disorder got worse when he tried to process it cognitively. “Unfortunately, the wrong things that you need to do to build [panic disorder] are the logical, sensible, reasonable things—focus on the situations in which it might happen, and try to control them. Well, you might as well put your finger in a wall socket.”

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Instead, the scientist in Hayes found a way to “square the circle” of all the wacky ’70s stuff he had tried, particularly est and meditation. “Something in that mixture of Eastern thinking and the human-potential movement clicked for me,” says Hayes. “It was goofy … But what I saw in what they did in there was the possibility of really pursuing this acceptance side.” Accepting that his panic would happen allowed him to be able to distance himself from it. Hayes learned to be playful with his thoughts, to hold them lightly: You feel panicky? Or depressed? Or incompetent? “Thank your mind for that thought,” he likes to say.

But just as cognitive therapy didn’t simply pop into Beck’s head when he learned to master his tunnel phobia, ACT is more than the sum of Hayes’ experiences. As Hayes’ anxiety condition improved in the ’80s, he worked with scores of clients and students in his lab to develop the therapy. The lab did studies showing how humans narrow the range of their behaviors based on rules they hear, even in situations where rules hurt them. For instance, Hayes conducted experiments showing that subjects who could have earned more money for doing simple tasks (like moving a light around a small maze) didn’t earn as much because they were trying to follow given rules. Those studies helped lead to an account of language called Relational Frame Theory, which suggests that when we try to solve problems verbally, we are using the same language skills and cognitive processes that can lead us back to avoidance and pain (“sunset” … “beautiful sunset” … “mother’s funeral”). And that led to ACT’s focus on reducing the impact of thoughts regardless of their content (“I’m having the thought that I’m depressed about Mom”). It took a decade of research for the term acceptance and commitment therapy to first show up in a scientific paper, in 1991.

Hayes is often asked if acceptance isn’t just a gimmick that would fail for those with serious mental illnesses. He usually responds by pointing to the studies in which ACT has been used successfully with psychotics. But one of the things that troubles me about ACT is the convenient plasticity that allows it to treat everything from schizophrenia to a chronic backache. Most psychologists slowly build research out from one or two disorders, but Hayes and his followers seem to be offering ACT as a sort of psychological Rosetta stone, a key for interpreting all interior events. At the very least, as Hayes’ mentor Barlow has pointed out, ACT seems to lack the scientific virtue of parsimony.

Similarly, living by your values sounds great, but if no thought is good or bad, and no belief requires changing, what happens when the values are immoral? Should pedophiles live in accordance with their desires? Should an abused wife accept her husband’s assaults? Eager to debate, Hayes has ready answers. “If somebody’s gonna tell me, ‘My value is sexually educating 8-year-olds,’ I will not do therapy around that issue,” he says. But while Hayes believes some people truly have pathological values, he says he has never had such a patient. “I’ve worked with rapists and things of that kind, but inside that I see people getting pushed around by their urges even when it’s deeply against their values.” The ACT theory is that once the pedophile stops trying to ignore or change his urges, he can defuse their power and make psychological room to think about what he can really do with his life. As for an abused spouse, Get Out of Your Mind says, “‘Acceptance of abuse’ is not what is called for. What may be called for is acceptance that you are in pain … and acceptance of the fear that will come from taking the necessary steps to stop the abuse.” Acceptance, it turns out, can mean a lot of change.

For a time, in the 1990s, we seemed to think that curing mental illness was a matter of manipulating a couple of brain chemicals. But after decades of side effects and the recent debate over whether antidepressants carry suicide risk for teens, we have seen only marginal gains in public mental health. A 2002 study in Prevention & Treatment found that approximately 80% of the response to the six biggest antidepressants of the ’90s was duplicated in control groups who got a sugar pill. So we may be ready for something different.

Hayes will have to do a great deal of research to show that ACT, like cognitive therapy, not only solves problems in the short term but prevents relapse. Hayes and his team believe they will get there, but even if they do, it seems likely that for ACT to go mainstream, it will have to shed its icky zealotry and grandiose predictions. (“We could get Muslims and Jews together in a workshop,” Hayes said in Washington. “Our survival really is at stake.”) Even so, Hayes may be crazy enough to pull it all together.

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