From the desk of Dr. Steven C. Hayes
Reno, Nevada

Dear friend,

As therapists, we share the exciting goal of helping clients deal with adversity and foster lives of greater prosperity.

This is a huge undertaking as well as a tremendous privilege…

And it comes with challenges, not the least of which is this question:

Are our clients actually getting better?

If we’re honest with ourselves, so far we have had to answer: we don’t know!

It’s difficult to judge the effectiveness of our work amid the complexities of real-life, multivariate therapy situations.

Any practitioner can remember a time when a session went very well, ending with sincere thanks from the client… but despite that sincere praise, the client ultimately sank deeper into the problems we thought had been addressed.

Conversely, it’s possible for your work with a client to appear unsuccessful on the surface, only to receive a letter several years later from the same person crediting you with their subsequent positive transformation.

All of this means, in psychological intervention, something is going on at a deeper level — beyond the surface content, beyond the praise of a client, and beyond how “smoothly” a session goes.

To combat this uncertainty and to satisfy our desire to help our clients, more and more practitioners have moved to evidence-based therapy forms.

Knowing that a protocol has been tested with a specific syndrome or population gives us at least some reassurance that we are helping.

However, while the promise of evidence-based protocols has been appealing, it can lead to a “by the book” approach that can feel restrictive and undermine clinical creativity. As any therapist can attest, following these protocols still doesn’t always guarantee long-term results or make it easier for us to know how a client is doing.

To understand how we ended up in a protocol-dominated therapy world and to illuminate an exciting new path forward, let’s take a look at a little bit of history…

Over the last half-century of psychology theory, we’ve tried to adapt to the modern world as a community of mental and behavioral health practitioners by “medicalizing” human suffering.

This means we got good at categorizing people into syndromes and subsyndromes, the DSM-5 has ballooned into nearly 1,000 pages of diagnosable disorders and conditions, and subsequent reported rates for mental disorders have skyrocketed across all populations.

To treat this wandering target of syndromes and subsyndromes, we (as a field and set of professions) created a corresponding path for producing evidence-based therapies that looks something like this:

In spite of our best intentions, however, this “medicalized” approach hasn’t paid off.

The burden of mental and behavioral health problems has only grown, effect sizes have stagnated, and we still don’t really know if our clients have improved.

All too often this leaves us feeling stuck and “shooting blind” because we have only limited ways of knowing whether the protocols we’re using are making any difference on an individual basis.

But if syndrome-based protocols leave us feeling confined and are not even producing the results they promise, what should we do instead?

Of course we are able to apply our intuition and relational connectivity to our client interactions, even without a scientific framework.

But in order to provide therapy with lasting impact, we need underlying scientific guidance to give direction and greater certainty to our creative therapy endeavors… which leads us to the big question:

I first asked this question nearly 40 years ago…

In 1982, we did the same thing every other evidence-based therapy school did.

We had a couple of new ideas. We generated therapy protocols. We tested them and found that they worked.

Instead of rushing them out the door, however, we file-drawered most of the studies and invested the next couple of decades in a different strategy — one we felt would be much more widely applicable and that now decades later has allowed us to finally move beyond protocols and syndromes:

We looked at the changes that were taking place when people were actually getting better, not at a surface level, but at a deeper level of the underlying processes.

During therapy, a lot may be going on, but we found that what really matters is improvement in a small handful of “core processes” of change.

It is changes in these processes that accurately predict long-term outcomes.

Even more encouraging was the ultimate realization that, by looking at the processes, we could go beyond diagnosing syndromes and assigning protocols.

When referring to processes of change we mean predictable, empirically-established sequences of modifiable biopsychosocial events that lead toward desirable client outcomes in a dynamic, progressive, and multilevel way.

To show the benefit and simplicity of looking at the processes rather than only at symptoms, let’s compare the two approaches.

For example, a group of people who share the same surface-level problem (such as anxiety) might share the same kinds of symptoms, but the processes at the root of their respective difficulties might be completely different, such as being overly fused with certain thoughts, or avoiding anxiety-inducing stimuli, or losing touch with the present moment and constantly being pulled into worries about the future or replays of past negative experiences.

Conversely, several clients might all struggle with the same underlying process (such as an unwillingness to experience unpleasant emotions), which might manifest as a wide variety of surface-level symptoms (such as addiction, workaholism, or an eating disorder).

That’s why a protocol for an eating disorder sometimes works, because it happens to address the right underlying processes for one person, but the same protocol applied to another person might fail because it doesn’t address the right underlying process for that individual.

We ultimately identified 6 core psychological flexibility processes which could be directly addressed through therapy to produce dependable lasting effects. These psychological processes in turn were nested within biological and social/cultural levels (each of which also contain change processes).

At the psychological level the more of these flexibility processes a person exhibits, the better they will do in the long run.

These 6 processes are:

Acceptance

The inverse of experiential avoidance, acceptance involves the active and aware embrace of experiences without unnecessary attempts to change their frequency or form. Acceptance (like its partner, defusion) in ACT is not an end in itself, but is fostered as a method of increasing values-based action.

Defusion

Defusion attempts to change the way an individual interacts with (or relates to) thoughts by creating contexts in which we can look at thoughts instead of from thoughts. This allows their unhelpful functions to be diminished. Using a wide variety of techniques, defusion can be used to help a person separate their innate identity from their thoughts.

Present Moment

The desired end of present moment work is to experience the world inside and out more directly, and to allocate attention to what the present moment contains flexibly, fluidly, and voluntarily. This goal is reached by contemplative methods and training in attentional flexibility that support ongoing non-judgemental contact with psychological and environmental events as they occur.

Contextualized Self

Human language leads to a sense of self as a locus of perspective and provides a transcendent, spiritual, socially-interconnected side to human awareness. This sense of self is important, in part, because it fosters all of the other flexibility processes and provides a sense of belonging and connection that empowers our life journey.

Values

Values are chosen qualities of purposeful action that cannot be obtained as an object but can be only instantiated moment-by-moment. Life directions in various areas (such as family, spirituality, career, etc.) can be chosen, undermining avoidant, compliant, or judgmental forms of motivation that are weakly linked to real behavior change.

Committed Action

Developing ever-increasing patterns of values-based action is the ultimate goal of ACT. Whenever behavior change efforts lead to contact with psychological barriers (e.g. becoming experientially avoidant or fused with certain thoughts) they can be addressed through other ACT flexibility processes. As a result, concrete goals that are values-consistent can be achieved more readily.