Welcome back to the Healing Pain Podcast with Steven Hayes, PhD

We’re taking a deep dive into Acceptance and Commitment Therapy with its Founder, Dr. Hayes. He is a Nevada Foundation Professor at the Department of Psychology at the University of Nevada and author of 44 books and nearly 600 scientific articles. He developed the Relational Frame Theory, an account of human higher cognition and has guided its extension into Acceptance and Commitment Therapy which is a popular evidence-based form of psychotherapy that uses mindfulness, acceptance and values-based methods. Dr. Hayes has been President of Division 25 of the American Psychological Association, the American Association of Applied and Preventive Psychology, the Association for Behavioral and Cognitive Therapy and the Association for Contextual Behavioral Science. He was listed by the Institute of Scientific Information as of the 30th highest impact psychologist in the world.

On this episode, you’ll learn about how ACT can help people with pain and other conditions that will reach for a meaningful life. How you can develop greater resilience even during periods of intense emotional or physical pain. How ACT can complement and potentially optimize any physical medicine or traditional cognitive behavioral therapy approach to pain care. We will also discuss Dr. Hayes’ book called, A Liberated Mind: How to Pivot Toward What Matters, where he lays out the psychological flexibility skills and make it one of the most powerful approaches research has yet to offer. I had an opportunity to read an advance copy of A Liberated Mind and it is a great book. I recommend to everyone reading this to hop on over to Amazon or whatever retail you order your books from and pick your copy of the book. It’s available in stores now. You can learn more about Dr. Hayes by going directly to his website at www.StevenCHayes.com. I’m excited to share this episode with you, so let’s dive right in and let’s begin with Dr. Steven Hayes.

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ACT Pain And Human Suffering with Steven Hayes, PhD

Turning Pain Into Purpose And Pivoting Towards What Matters

Dr. Hayes, welcome to show. It’s a great honor to have you here.

I’m super happy to be here with you, Joe.

I’m excited to talk to you about all things ACT and your book called A Liberated Mind: How to Pivot Toward What Matters. There are people with chronic pain and other health conditions as well as practitioners that follow this podcast. If you can give us an overview of where ACT is with regard to being an empirically tested psychological or psychosocial intervention.

I’m coming up on around 3,500 best studies on ACT and its elements, even a few really restrict definitions that don’t spread out. We do work on mindfulness. If you put in search terms like that, you’ll pull in thousands of things that are not ACT. If you got the real ones, absolutely for sure ACT, there are about 300 and those are randomized trials. They go across the whole range of mental health problems, behavioral health problems, chronic pain, social issues having to do with the sports performance or a stigma and prejudice and things to that concept. It’s like that for a reason. It’s not one size fits all. We took the time, fifteen to twenty years to dig down to what the underlying processes are that either confined people or liberate people.

On most of the lists, it will be included as an evidence-based therapy and part of the so-called third wave, the acceptance in mind from the swing of cognitive behavioral therapy in an area specifically of pain which I know you focus on a lot. For example, the APA clinical list includes it as the only approach that’s listed for basically any kind of pain as opposed to headache versus back pain versus the rest. There are about fourteen randomized trials and panel with very good outcomes and some of the follow-ups going out now to five years. It’s really long follow-ups and high-quality research and a lot of it is by major research centers around the world. At the Karolinska, for example, or at important academic medical centers that had been heavily committed to ACT. We pretty much know this is helpful to people in dealing with pain interference and living a life with pain, if you’re going to have pain.

I know you’ve done a tremendous amount of work teaching, doing research, writing books and other researchers as well who are looking into ACT. You mentioned mindfulness in your introduction, make the distinction for us between mindfulness such as let’s say MBSR versus ACT. Oftentimes people say, “ACT is like mindfulness,” and it’s not. There’s a key difference and I think it’s important for us to articulate that.

There’s a difference in terms of technology and also processes. Mindfulness-based methods have been pretty heavily committed to the contemplative practice as the primary pathway to the attentional flexibility and ability to be present. It can come from a contemplative practice. In its natural home and namely in the wisdom and spiritual traditions, those kinds of skills which might have been taught by contemplative practice frankly more for the monks than they were for mainstream folks within that. Only the West has tried to put it into our living rooms.

In the natural place from which it came, there was also work on right action and on values which if you remember of a spiritual tradition, your spiritual leaders can tell you about what kind of values you should have and how you should behave but that’s not a psychotherapist role or a person in the healthcare system. A big difference in the ACT as a whole piece on values and the kind of life that you want to live, doing it in a way that can fit the settings. We’re not going to tell you what they are but we’ll help you find out the ones that are really there for you. When you come over to the mindfulness side, although the processes that we’re targeting appear to be the ones that moved by contemplative practice and we will use contemplative practice as part of our protocols.

We include many other little methods, sometimes fairly short that take the core skills that are in mindfulness, such as emotional openness, cognitive flexibility and attentional flexibility. One that’s often missed especially in the more Buddhist range of mindfulness which is from this dimensionless, “I here, now” point that allows us then to notice as an ongoing process what our experiences are. We’ve done the work to try to pull these processes at their joints. We can add this for example. Let’s say in contemplative practice, if a thought comes up, you may need to learn to look at it and not from it in order to maintain, for example, following the breath and being open to what shows up or a focus on a particular mantra if you’re working on that side of the contemplative work.

We might put in methods that would be things like not during contemplative practice but like saying a difficult thought in the voice of a least favored politician or distilling it down to a single word and saying it over and over again. Imagining that it’s floating by on a leaf on the stream. They are simple, structured ways of getting at what the core skills are and the mindfulness. We’re part of the mindfulness community. We’re not as committed to a particular wisdom path but more finding what the processes are, pull them at its joints, get them into people’s hearts, minds and behavior and help them liberate their own lives by applying those processes when they need them.

With that pulling apart of all those processes which you’ve done the work on. Does it then lead to ACT being more efficient than let’s say they see the contemplative practice where someone is meditating day in and day out for 30 to 40 minutes? Not that that’s not helpful and beneficial for people but I think as looking evidence-based medicine, how can we get the fastest result possible for our clients?

We do have data on that. These little bumps, when you see what the processes are, little bumps can make a big difference when they are combined into a new life trajectory. I think there can be a one size fits all approach when you get into a wisdom tradition or a particular form is respected. The average person is not doing the ten-day silent retreat. That’s people who either have money or time. It’s not a person, Joe, on the factory floor. The question that I asked John years ago was, “Is this for the educated leaders or Joe on the factory floor?” He said, “I want it for everybody.” I said, “I’m with you but let’s make sure that we put it into people’s lives in ways that fit their situation.” There are ACT people out there doing behavioral safety literally with Joe on the factory floor with very different words and stuff.

We won’t be talking about mindfulness, we’ll talk about situational awareness. When you’re dealing with the folks, you’ve going to deal them in their own language for their own purposes but not just say, “It has to be this form. You have to do at least this number of minutes every day or get.” Usually, there’s not good data on that, number one and number two, you want to build a big fence around these processes. Could we give them to people in little bite-sized chunks? I get that you’ll get more maybe by 40 minutes per day but the data on that is a shocking amount of progress that happens in the first few minutes. Maybe that’s a place to start and the methods that are in the ACT can allow you to start. One of the things I did in A Liberated Mind is I tried to give people the smallest little things they could do like a little toolkit, to start playing with it and see how they go. Life opens up and if you get interested in that, there’s a vast amount of resources out there. This one book will give you some but there’s so much out there now. People can then create a journey that fits their life in a more efficient way.

I love that about your book is there were almost little brief interventions which let’s say I don’t have the time to go on a ten-day retreat or maybe I don’t even have the time to do fourteen sessions of one-on-one psychotherapy. I can pick up your book and there are these little brief interventions in there that can start to move me in the direction that I want to go in life. If you were to log on to the International Association for the Study of Pain and look up the “official definition of chronic pain,” it’s both a physical and emotional response. The emotional part there interests a lot of people especially people interested in psychosocial interventions. Can we stop emotional pain?

It’s tricky because the word stop itself may be part of the problem but can we change how we deal with emotional pain? We absolutely can and it will have a profound effect, maybe even on some of the physical things. If you look at what happens with stress-related responses where it’s the resistance part that’s amping up your body’s reaction and having an impact on your level of physical response to something. The mental and the physical are not easily pulled apart in that way. I would think what ACT is going to do is to walk into the question of how your own emotional cognitive experiences with regard to pain and other issues but the pain is a really good example. One of the earliest ACT studies were done with pain as a matter of fact, all the way back in the early ‘80s. We saw that connection but of altering how you respond to what your mind and your emotion is going to give you, in a way that opens up a door towards a life worth living that can start now even with physical pain.

If you look at the data on chronic pain, by the time you’re three, four, five years in, you’re looking at a pretty good likelihood that you’ll be in pain for the rest of your life. That’s a fact and there are things you can do to maybe ameliorate it and who knows what will come up. If you look at how the brain lights up, for example in chronic pain, it’s not the same as acute pain. It’s dug into areas that are some of the same places where really painful memories reside and there’s no delete button in the nerve system. There’s no eraser, no minus button. There’s only add, add, add or multiply, multiply, multiply. If we can get into the room that it’s possible to explore different ways of reacting to the pain and the emotional reaction it produces and let your own sense of vitality, presence and opportunity select what works for you. That begins to open doors. The mind doesn’t understand how you could possibly do that. It’s impossible to live with this amount of pain.

As your attention moves in different directions and as your life moves in different directions, the pain itself changes its qualities even when it’s still there. I’ve had chronic pain patients we worked with on this. If I asked them how much pain they’re in, I always get the same answer. If I say, “How much did you notice that level of pain over the last day?” You start getting different answers. There are many things to consider. I have tinnitus. It’s pretty bad. Don’t be a punk rocker when you get to be 70, your ears will be like mine. That ringing will never ever stop and it’s loud. I haven’t noticed it in a week. I’m noticing it now because I’m talking about it. When I went through a three-year spiral, I went all the way up to suicidal thoughts before it occurred to me to apply my own life work to it. It took about 48 hours to handle and a week to handle completely and it’s been like this now for many years. It does not interfere with my life anymore. “Does it ring?” “Yes, constantly.”

I don’t want to be too flippant about it. I know hard that is to make that move but I also don’t want to allow us to get in a position in which the kind of lives we want to live is completely dependent upon the injuries that we would experience, the accidents that have happened as if that is the final determiner of the life we want to live. It’s not a final death sentence, you didn’t lose your life when you entered into this world of chronic pain. Let’s see what’s possible and it turns out that quite a few things that are really uplifting are possible inside that different journey.

As you’re talking about your own experience of that unpleasantness of that tinnitus, it makes me think of the concept in your book, The Dictator Within. That voice inside that is either demanding or ruling. Can you tell us how you start to develop that concept? I think it’s really going to resonate with a lot of people. I enjoyed reading about it in your book.

Some of it is personal. I had an anxiety disorder struggle. Thankfully because I was on charging the day ahead to be a workaholic, successful psychologist. I still do work hard, but it’s changed its quality because I got softened by a several-year history of panic disorder. Inside that struggle, that voice within that gives you advice and criticizes you and shames and blames, it got louder and louder. I wouldn’t have even known that. I was complying. I wouldn’t even know there was a separate voice. I was doing what they told me to do which was to run, fight and hide from anxiety because it was impossible to have a panic attack and still function.

It is true. Having a panic attack makes it difficult to function but what you missed is that panic attack includes not just the anxiety, it includes your struggle with anxiety. If you’re not struggling with anxiety, you have an anxiety attack and that’s not exactly the same thing. It’s close, but it’s not exactly the same thing that plays out differently in your life. I have a TEDx Talk where I talk about this moment where I really catch the dictator within when it’s telling me that I’m having a heart attack at two in the morning. I got to call the ambulance because I’m dying. I realized somewhere in there, “No, this is just a panic attack. I’m not having a heart attack.” I set out loud when I caught that this dictator was telling me what to do.

I talked out loud at 2:30 in the morning in a way that was almost as if it was another entity. The exact words I can pretty much remember. They were something like, “I don’t know who you are, but apparently you can make me hurt. You can make me suffer, but I’ll tell you one thing you can’t do. You can’t make me turn from my own experience. You can’t do it.” If you’re interested in seeing me act that out, go check out that first TEDx Talk I gave. That was a pivotal point in my life, basically of catching almost like an out of body experience that had turned my life over to this automatic-programmed voice, which even will tell you I am who you are. You’re a lot more than your verbal repertoire and the various kinds of things you’ve learned along the way from your mom, dad, television and all the rest.

Even little kids, you put a goofy with horns and goofy with a halo on the two shoulders and they understand that. They know already, once you get language going, the arguments going on, the dictator within is getting its voice. I think mindfulness work and diffusion work helps us catch that voice and it’s good that we have it. If I’m having my taxes, I want a little voice saying, “You’ve got a week to do your taxes,” or fix my car or whatever. A little bit of separation between the person listening and the voice itself allows you some choice because it can easily tell you to do things that you know in your heart of hearts are going to be harmful to you. You got another trip around the bush and you’d do it again. Whose life is this, is it you or the voice?

In that, as your voice is talking to you and you’re learning to diffuse from it, you had a really beautiful example there of diffusing and there is context there as well. Does it start to make you think of, “There’s a problem with my own problem-solving skills with regard to certain things in my life, whether it be anxiety or chronic pain or other mental or physical challenges?”

The normal problem solving mode of mind is to parse the situation into its features. Do a little before and after. Imagine the different comparative outcomes and weigh it. When you take that same problem-solving skill that you could use with fixing your car and you apply it to yourself, your mind’s going to tell you that part of your history is no good. You’ve experienced things you shouldn’t have experienced. “What are you going to do with that?” That history is not going away. You can’t run from your own history. Treating yourself as a problem to be solved so easily gets moved over into, “That will only work when I can diminish, distract or get rid of the things I don’t like within that are echoes of my past history.”

As you do that, you’d get dumber. It means you can’t use your past history. You can have conditions called alexithymia, “I don’t know what I’m feeling because I’ve been running so hard.” It predicts bad outcomes as far as I can see because being in tune with your body’s giving you emotions which are essential to being able to learn from your history and be wiser this time. If you were abused in the past relationship and now you’re in the early phase of a new one and the little bell is ringing and saying, “This guy looks really sweet but there’s something off here.” If you don’t read that, you might find yourself in another abusive relationship. You need those feelers now. If you’re not going to treat yourself as a problem to be solved, how can you treat yourself?

It turns out people know how to do it and if I give you the easiest metaphor for it, it’s if you had a sunset tonight that was spectacular, you’d look at it and you’d say, “Wow,” and you would not say, “It’s a little too pink, God.” It wouldn’t occur to you. “That cloud over there should be over here, it’d be even better,” but it’s not because it’s sweet and pretty. If you’re in front of a crying child talking about some horrific thing that’s happened, I bet you’d say the same thing. You’d say, “Wow,” and you’d hug the kid. You’re not going to say, “Snap out of it. What’s the matter with you? Don’t be a big crybaby.” It wouldn’t occur to you to do that.

It will occur to yourself when you get up in the morning and start brushing your teeth and look at the person in the mirror. You are like, “You made such a mess yesterday. What’s the matter with you?” That critical, harsh and avoidant voice will come out. Could we treat ourselves the way we do inside the wow of observing and appreciating the whole of it? That we know how to do when there’s a sunset and we know how to do it when there’s a crying child. Could we bring at least some of that mode of mind to our own life? We may find that there are different ways to grow that don’t fit a problem-solving formula, but they do fit the wow formula.

I’ll give you an example. If you’ve been rejected recently and you’re yearning for connection, loyalty, etc., you will feel both fears for vulnerability and fear of being rejected again when an opportunity opens up. That little spark as you see something that is uplifting to you, “This is a person who gets me or understands me. I enjoy being with them.” You’ll get both because in your pain you find your values and in your values, you find your pain. They’re flip sides of the same thing. We only hurt in areas that we care and if we can bring that little bit of wow, that wow-fullness in, we’ll catch the little spark that might be a better guard than the “Oh God,” than the “Oh no” one that connects you right back to that previous rejection. How much it hurts to be stabbed through the heart in that way.

It isn’t that one particular way is the way. I’m not saying chase any little shiny object in relationships or something. I’m saying, “You want the whole of you onboard when you’re interacting in your world.” Bring in your best and your best is not going to be this analytic, judgmental, critical problem-solving mode of mind always. There are times on itself and there are times on the thought. Let’s put that part of our minds on a leash. Let’s find other parts of modes of mind that we have and then let’s deploy them into our situations based on what we’re trying to do in that situation. That’s exactly what ACT and its underlying skills allow us to do it. It’s putting all those elements together so that you can do that.

There is a lot of earlier research around chronic pain that’s a lot around and you’ll read it in studies as well as it exists in clinical practice. Helping people control their pain or giving them the ability like they feel like they have control over their pain. There’s a piece of that which is important, but once you’ve had chronic pain for five years plus, there’s a good chance that pain is going to be around in one form or another. The ACT is a more beneficial way to help people cope with that rather than teaching them to control that pain. Along those lines, in your book you talk a lot about exposure. I was happy to see that as a practitioner who teaches people how to cope with pain. There’s one camp that we’re moving toward more exposure toward pain and there’s one camp where we’re still not so comfortable on the exposure piece of pain. Can you tell us how has ACT developed more effective exposure treatments for not just pain, but other unpleasant emotional experiences?

There are a couple of things. One is it looks like ACT methods help people engage in needed exposure when they see that there’s something there. After all, at some level, as you begin to expand your life out, you’re going to expose yourself to new situations. If you’ve been engaging in very defensive behavior physically with regard to your pain and you may have a provider saying, “That predicts long-term problems.” Those kinds of physical avoidance patterns or defensive bodily things that at times, those things can exacerbate an injury. It can make it more difficult to do the physical things that might help you be more flexible and effective physically.

If you’re going to change your life, you’re going to hit some of those places where you’re afraid. I’m like, “Am I going to feel it again? Am I going to endure it again?” ACT will give you some of those skills to help you into needed exposure in a way that’s emotionally and cognitively open. The thing is that I’ll give you a value-based reason to do it at all, which helps you persist and walk through. Another one is this broader, more open attentional process can help us square this circle. Which was, on the one hand, you may be asked to walk into exposure and on the other hand, you’re being asked to still respond to your body and not push yourself beyond a safe limit.

That’s very tricky when you’re dealing with something physical, something like chronic pain. The experience of being able to be more open, to be able to read your body in a little more open way and to be able to read this present moment can be supported by the practices that allow us to get into this more mindful or wowful. I had to go back on what I said on the mode of mind. We do have data that people are more likely to persist if its values based and accepting. They’re more likely to try in the first place and that they’re more able to stay within the self limits. The other part is that it turns out the providers need that, too. There are a couple of the studies now showing that providers get to avoid their own emotions, etc. They start making excuses for their clients in areas where they really need to step into an exposure space, but that’s not easy. It’s not easy to ask somebody to do that.

It’s can be frightening to you. What if you’re making a mistake? What if you’re pushing too hard? If you can enjoy and being able to be with somebody when they’re worried or suffering is hard. Being able to do that in a values-based way that is emotionally open and yet sensitive, not just an easy formula, not just Nike’s “just do it,” but one that’s more open to nuance is good for the provider as well. We’ve shown that it helps providers have a greater sense of personal accomplishment and less burnout, but also being able to be more willing to use evidence-based methods like exposure when it’s needed. You don’t want to be the client who goes in and what’s needed is determined by the emotional health of your provider. You don’t want to be that client, where what you need is what you get. We have an obligation as providers. That’s true with physicians, nurses, OTs, PTs, psychotherapists, social workers and psychiatrists. It’s true in the helping professions.

A real topic is that all of us who work in pain rehabilitation, as you mentioned, many professionals. If you think back to school and we were in school learning, we thought we would come out of school and take away people’s pain over time as you practice, especially as you start to read some of the literature on long-term outcomes of chronic pain. You realize, “I’m helping people expose themselves to things that are uncomfortable or helping them with their life in ways that are valuable for them which is a complete paradox.” A lot of practitioners have great challenges with that. I’m not even sure how practitioners are aware of that on a daily basis. I often wonder how many go home exhausted at night and burnt out. The burnout rates and professionals who work with people with chronic pain are very high. I think it’s important to have that.

That in turn predicts physical prehealth problems, issues of depression, suicide, etc. This is a train wreck. If we’re going to ask people to step into the challenge of the modern world in which all of us are exposed now much more regularly than ever in the history of the world to painful images, painful experiences. Just turn on your TV or that computer in your pocket and you can see what happened over the last few minutes around the world and constantly being exposed to comparisons. Other people are doing better. They have gold plated door knobs on their bathrooms. You can look inside the homes of the rich and famous. There’s that and then this constant flow of judgment, this problem-solving mind gone on steroids where it’s everywhere. It’s judge, judge, judge and news programs are now isolated.

We only get to listen to the people who judge other people the way we like to listen to. That combination of pain, comparison and judgment predict horrible outcomes and it’s a daily diet to your twelve-year-old. All of these different ways but I’m lifted up by with the ACT work and one thing I hope for with this book because it’s the first real full story of the science story and on the personal story. The more how-to story that targets all the places where psychological flexibility can land, the message that’s inside that is that we need to really take care as a human community, to create modern minds for this modern world. That includes the practitioners and providers. The last time I checked, they are people too. They’re not little robots that are out there to work. People burn out and you don’t want to be working with a provider who is burnout. They get poor outcomes. It’s going to be harder for them to be with you and give you the services they need.

Everywhere we look that a kinder, gentler, more open, more empowering way of being with ourselves and others is needed and I think we all know that. We don’t know how to get there and science can give you some guides to do that. The fact that it comports with our wisdom, traditions and things like that to me lifts it up. There is a metaphor, if you’re out on a walk through the forest and you came to a clearing and there are all these people there, each of whom had taken a path to get there maybe that’s an important clearing, maybe it’s an important thing in there. I’m really pleased that our spiritual, religious traditions are in the clearing, that evidence-based psychotherapy has taken us and that is now applied out to all these other professions, not just the psychotherapists. It can be put in to help with the providers in softening our culture and maybe getting us talking about cross political divides. I don’t want to be Pollyannish but we need something. Science can be part of the solution.

I want to come back to some of those societal questions. I know the piece in there for us to talk about, but first I have some questions from some of our colleagues from ACBS, that’s the Association for Contextual Behavioral Science where ACT is a part of that. There are many special interest groups and chapters. There is a pain special interest group. There is a physiotherapy special interest group. There’s an OT. This is something for everyone there. A couple of questions from there and some other colleagues that I have, “What can ACT offer a traditionally trained CBT therapist?”

This is something I’m actively exploring right now with my colleague, Stefan Hofmann. He was one of the monsters in traditional CBT. He won the Beck award and all of that. What I think ACT can offer as a process-based alternative because it turns out that these core processes, the psychological flexibility are in all of our traditional methods to a degree, number one. Number two, they can be expanded out a little bit by looking at what’s in some of the alternative traditions. When you do that, you don’t have to think of CBT like a protocol. You can think of it as a set of intervention kernels that are linked to processes of change in these areas of cognition and affect attention, of motivation meaning and overt behavior. ACT is a proof of concept of a process-based approach to behavioral and cognitive therapy and the message there isn’t just adopting ACT.

What I say to the ACT folks is you take something like cognitive flexibility. Traditional CBT, we’ll use methods like cognitive reappraisal. Reappraisal, we now know from the literature, done right is meaning when it’s most effective has an element of diffusion and cognitive flexibility. It isn’t, “Don’t think that, think this.” That’s an invitation to fight that can be unhelpful. It’s some getting more like, “In addition to thinking that you could also think this. How would that work? How would that land?” That has a little element of diffusion. You’re now looking at thoughts, not from thoughts. That’s always been in CBT. Aaron Beck called it distancing. The first name for ACT was comprehensive distancing. We thought, “What if we take that and put that on steroids?” It sounded dissociative. We have a better name now with ACT, but we were never hostile to traditional CBT. We just want to know what the processes are.

All those flexibility processes work, but they also help explain like reappraisal is very close. You can even show in some studies that diffusion moves with reappraisal done well and it mediates. It’s part of the function, an important pathway to that technique landing well. I can say to my colleagues who are in more traditional CBT, “You don’t have to give up anything. You don’t have to give up your heroes. Nobody has to win a war. We’re not in a war. If we’re in a war, it’s with ignorance, not with each other and let’s beg, borrow and steal from each other around a coherent application of processes of change.” You’ve read the book, that’s the dominant theme of A Liberated Mind. In a way, it’s not even an ACT book. It’s a liberation processes book.

You can take that same spirit and put CBT methods in it. You can add CBT concepts to it. I even give examples in the book, like the example of cognitive appraisal. One that people usually pick would be like, “That’s anti-ACT.” “It’s anti-ACT done crudely. Don’t think that, think this.” Frankly, there’s no good evidence that it helps. In a component analysis, in meta-analysis arguably doesn’t add anything to CBT outcomes, but yet the appraisal can. You can also do it the way I think good CBT folks have always done it, which is in addition to thinking that you could also think this. What would be more helpful to you? That’s something an ACT person can use and it fits right inside an ACT model. The thing I think we’d have to offer is a new vision of what it means to be a CBT person that allows you to use all the different waves and generations of that tradition and even go beyond CBT to look at what the humanistic existential analytic and other traditions are doing that is useful.

The next question is from an ACT-informed physiotherapist. It’s a little bit of a long question, but it’s a really interesting one. I think it’s going to lead us into a conversation on values and his question is, “Do values have a saturation curve? In an ACT-based pain management program, we use values in what seems to be a continuous reinforcement of behavior, which takes the patient in the direction of their values. As I understand it with other reinforces such as chocolate, you get to a point where eventually you’ve had enough, but values don’t seem to work like this. If your value of being authentic is reinforcing your value of maintaining fitness because you want to be an authentic physiotherapist who practices what he preaches. You don’t seem to reach a point where you say, ‘I’m authentic enough, therefore I can stop exercising.’ Why don’t values become saturated or satiated like other reinforcers?”

It’s because of values is an area where we get to take this wonderful verbal skill that we’ve had developed to put out qualities of our behavior in the role of being a reinforcer. We know that intrinsic reinforcers tend not to satiate in that particular way. I’ll give an example. A pleasant music, you might need a different tune or something, but you can have background music on through your whole day if it fits the situation or something, a comfortable temperature in the room. You can show that it functions as a reinforcer. If it gets cold, you work to get it warmer or if it gets too hot, you work to get colder. It becomes continuously part of supporting your interaction. That’s handled in the same way. What values do they put the reinforcer into an intrinsic quality of the behavior as an ongoing ACT, not as a goal? It’s something that can be achieved, like an object that can be held and finished.

There are goals along the values-based journey, but values are not goals. Goals are concrete things that you can have and possess. Values are only things you can instantiate and show because they’re intrinsic to an action. What I usually say is look for the adverbs. Behaving lovingly, let’s say. You’re right, there’s no satiation on that. It’s not like when you’ve done enough love, you say, “Now it’s time to hurt somebody.” It just wouldn’t occur to you because it’s a continuously available reinforcer. It’d be like giving yourself a pat, a hug or something. You could do it at any time and it’s there. The wonderful thing about that is the problems that come with maintenance in terms of satiation leading to behavior falling off. If it is true that you have continuously available reinforces that doesn’t satiate and that are always available to you, which I think it really is. We’ve taken this evolutionary, the more recent stream of language and cognition that creates so many problems for us with treating our lives as a problem to be solved. Yet it creates such an opportunity for us of meaning by choice.

What that means is when you walk through life and things happen. I’m 71. I can see it happening around me, people of my era, but I can see it in my own body. I’m not going to be the same strong guy. I’m pretty strong right now, but you give me ten years, I’m not going to be the same. In five years, I might not be able to walk. I don’t know. Things happen but the data on that isn’t. If people are willing to be flexible in how they achieve their values, as long as you’ve got a breath, as long as you’re alive, you can be living a values-based journey. Would you choose it? No, but there are people writing novels, directing their eyes to a screen and picking letters one at a time. Are you going to say, “That’s not a life worth living? Are you going to say that?” I think intrinsically we’d say, “No. That’s like a hero.” That’s the point. What if we’re on a hero’s journey and we are? We’re all on a hero’s journey.

It’s right inside the flexibility processes where you have this sense of self that says that we’re too narrow, not able. We face these challenges or mindsets. We’re not up to it. Emotion show ups that are hard. If we can come into our present moment and this way, it’s more open and see the resources around us. People who are willing to support us, allies who would be willing to be with us, but also the resources within and find a different sense of self that allows us to orient towards what’s important, what we really want to put into our life, what our values are. Then mobilize our behavior as best we can around that to whatever capacity we’ve got. That’s Star Wars. That’s the Lord of the Rings. That’s every major epic poem ever written. The reason we read those things and go, “The reason we go to see those movies and we go, ‘Wow,’ is that we sense this is the journey we’re on and our clients are on this journey too.”

It’d be like blowing up Luke Skywalker’s farm. You have your car accident, you’re now in a situation where, “Maybe this leg will never work again,” but it did. “Now, what?” Are you on a hero’s journey here? Life’s asking you to be on a hero’s journey and hero’s’ journey is not, “I just did it.” If it was a movie where like when the dragon showed up, the master archer does say, “I can have solved all that,” and shot them all down. Nobody wants to see that movie. There are people that’s so confident. They handle their problems, I presume. No. We want to see something that’s more like our journey. It’s hard and we don’t know what to do. We feel up to it and sometimes it’s being so unfair that that life would ask that of us when we’ve had a death or a betrayal or an injury, but there’s this opportunity and we know it. The best parts of us know it. “Are you going to write a tragedy and then I was the victim or are you going to write a hero’s journey?” Let’s get together and support each other in writing a heroic journey person by person, but also work site by work site and city by city and country by country. Because at every level, we faced the same challenge as a human community.

I want to touch base on that. As you moved from values in the single person, you brought in doubt to workspaces and society. On this podcast, we often talk about paying from a biopsychosocial perspective versus the biomedical model, which has not served many people in certain situations with regard to chronic pain. There’s a lot of attention being pointed more toward the social part of pain because of chronic pain and the numbers of people with chronic pain effects physical and mental well-being. The addiction problems that we have, problems with lost work and the socioeconomic impacts of all these. How does ACT contribute to our society or to solving that social part of not just chronic pain, but within that umbrella of chronic pain, so much falls underneath that.

We have a little bit of data on that. We have data now on presurgical ACT training and then postsurgical ACT support leading to things like much less use of analgesics, lower levels of addiction to opiates or other kinds of painkillers, etc. If you look at how many people are in chronic pain, unless they’re on opiates who came in through the mismanagement of acute pain, that’s a tragedy. It was unnecessary. It didn’t have to happen. Acute pain or chronic pain are not the same things, but you can take acute pain and walk it into chronic pain if the wrong things are done. I’m not blaming people by saying that. People are doing the best they can. It’s up to the providers to know better. If you take something, if you’re going to say, “If you hurt, take this,” as opposed to time-based and dose-based. “In three hours take this and then you start reducing it.”

Why? Now, you’re directing people towards the clock and following what seems likely. If you have a sensitive provider and the nurses are watching to see what works as opposed to, “Am I in too much pain now?” That focus and then I can knock it back with an opiate. That cycle you went through, if you’re unlucky, it will eat your life. That cycle can build a life of its own and get into parts of your brain that is going to be there for the rest of your freaking life. I’m not saying that alone is what’s building the chronic pain situation we’re facing. I’m saying we have a cultural problem with conversations about any difficult emotion.

We run the other way with sadness. We run the other way with anxiety. We run the other way with pain and in doing that we’ve, made more of a problem. If you look at even the medications that we’re using, if you caught a freshwater fish, you just ate some antidepressants because the sewage systems don’t filter it out. One out of four women were on antidepressants last year. The data would suggest that’s several times beyond anything that makes rational sense. People were being sold a bill of goods that a successful life is a happy, joy life. What some of these things do, it doesn’t really produce happy, joy, but it produces the happy numb. The happy numb is not happy. Numb is not where you want to be in your life.

Sometimes, yes, I would rather be numb. I’m okay with that but chronically, no. I think our cultural conversation about difficult emotions and difficult sensations and so forth has to shift in this fifth vital sign pain era that we went through. Did it make things worse or better? There is no question that it made things vastly worse. Some of it was driven by commercial interest. It was dirty and that makes me so angry at some folks who knew better. They knew what they were doing. Even the CDC wants to say, “He never said you should be using opiates now.” I read this out of fear of the impact of Tylenol on your liver, we should be using opiates.

That was nuts. I wrote a book about chronic pain where it includes your whole section before this train wreck of the opiate thing saying, “Here’s what you’re going down to.” Myself, Kelly Wilson and JoAnne Dahl wrote this book on it. It is giving warning as to what’s going to happen. I did other things too as to be a self-help thing. Sure enough, it blew up. If you’ve got something like back pain, you’re much more likely to be thinking about the back surgeons, then you aren’t thinking about the OTPT work you can do. Over and over again, we make the same mistake. The culture has to change.

I want to point people toward your book called A Liberated Mind: How to Pivot Toward What Matters. If you had a crystal ball ten years from now and you look back, what do you hope this book will do?

What I hope it will do is bring psychological flexibility into the cultural conversation so that policy makers and people making choices about the programs that they put into their clinics, etc. Individuals and the providers they seek and the self-help books they read, begin to take seriously the possibility that the mainstream cultures, feeding us the goods, that’s harmful to human life. That you’re not going to avoid enough, distract enough, push out enough, stay away enough, self-soothing enough and etc. in ways that are harmful. That it will ever lead to a vital, committed human life. There are a small set of psychological skills that have been vetted in thousands of studies. There’s not the end-all and be-all, but it is a really good start on how to create a life worth living one step at a time by detecting the processes that move you in a negative direction or a positive direction in your life.

Learning how to embrace these liberation processes, these flexibility processes and put them into our families and work for sites, churches and schools. Not into some finger-wagging advice way, but in this kinder cultural change way where we do what we’re saying. You don’t just say what to do. We saw often the interactions within us and between us. I see there’s so much yearning for that and there’s science that can be part of the solution. It isn’t just our wisdom, traditions or self-help programs that are disconnected from data. Let’s find a way so all gets on that same page. If we get it into the cultural conversation and people try these things out and learn how to move their processes better, then whatever the data decide, I’m cool with that. I think there’s so much evidence now that we need to give this a good honest cultural tribe. This is my attempt to put it out there for people to consider.

Dr. Hayes, it has been a tremendous honor to have you on the show and to talk with you. This episode is going to help a lot of people, both practitioners and people with pain. They can find your book A Liberated Mind: How to Pivot Toward What Matters in all bookstores, whether it’s a brick and mortar bookstore or online. How can they learn more about you? Where can they find out more information about you?

I can send them a little seven-item mini thing on the ACT if they go to StevenCHayes.com and give up their email. I try not to spam people, but I will send them newsletters and things like that. That’s an easy-peasy way. If they bought the book and they go in there, there’s a whole section on A Liberated Mind. It has some cool little things, like a little cartoon book on ACT that my daughter painted and some little exercises, audios and things that are little freebies that support the book. Check it out.

I want to again thank Dr. Steven Hayes for joining us. Make sure to share this episode out with your friends and family on Facebook, Instagram, Twitter or whatever your favorite social media handle is. If you have a big social media group or following where they’re interested in ACT or chronic pain, drop it into that Facebook group so everyone can check this episode. Make sure to check out A Liberated Mind at a store near you.

Thank you, Joe.

Important Links:

• A Liberated Mind: How to Pivot Toward What Matters
• International Association for the Study of Pain
• TEDx Talk – Psychological flexibility: How love turns pain into purpose
• Association for Contextual Behavioral Science
• https://www.YouTube.com/watch?v=o79_gmO5ppg
• https://www.YouTube.com/watch?v=GnSHpBRLJrQ
• https://StevenCHayes.com
• https://www.Amazon.com/Liberated-Mind-Pivot-Toward-Matters/dp/073521400X
• https://www.Facebook.com/stevenchayesphd
• https://Twitter.com/stevenchayes?lang=en

About Dr. Steven Hayes, PhD

Steven C. Hayes is Nevada Foundation Professor at the Department of Psychology at the University of Nevada. An author of 44 books and nearly 600scientific articles. He is the developer of Relational Frame Theory, and has guided its extension to Acceptance and Commitment Therapy (ACT) a popular evidence-based form of psychotherapy that is now practiced by tens of thousands of clinicians all around the world.

Dr. Hayes has been President of Division 25 of the APA, of the American Association of Applied and Preventative Psychology, the Association for Behavioral and Cognitive Therapy, and the Association for Contextual Behavioral Science. He was listed by the Institute of Scientific Information as the 30th “highest impact” psychologist in the world.

The Healing Pain Podcast brings together top minds from the world of pain science and related fields to discuss the latest findings and share effective solutions for persistent pain.

If you would like to appear as an expert speaker in an episode of The Healing Pain Podcast contact [email protected].