The Third Wave of Therapy

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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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