The Third Wave of Therapy

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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?

See the top 10 medical breakthroughs of 2008.

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