Psychiatry & Psychotherapy Podcast - Acceptance and Commitment Therapy with Dr. Steven Hayes

Episode Date: November 21, 2020

We are privileged to be joined by Dr. Steven Hayes for this podcast. Dr. Hayes is a psychologist with a remarkable academic career. He is the author of a number of seminal papers and pioneered Relational Frame Theory (RFT) and Acceptance and Commitment Therapy (ACT). By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. All right, welcome back to the podcast. Today I am joined with Dr. Stephen Hay. Hayes, some medical students, Matthew Hagley, Maddie Ulrich, Kyle Logan, Christopher Neal,

who has graduated psychiatry residency and is doing a great job over there at the county. And today, we are going to have a discussion with Dr. Stephen Hayes. He is the author of many of the seminal papers on relational frame theory and acceptance commitment therapy. He has written many books on acceptance commitment therapy. And this episode, we are going to be interviewing him and gleaning his pearls of knowledge. It's a great episode where we're going to talk about how he would approach different topics, one including how he would approach a therapist in training or psychiatrist in training who has some sense of imposterous. syndrome. And so I wanted to start out by just briefly going through some studies to kind of

discuss what I could find evidence-wise when they compared acceptance commitment therapy to another active therapy. It's hard to just, you know, look at the acceptance commitment therapy when it's standalone. The effect sizes are great, you know, usually one standard deviation or more improvement in different domains such as depression or anxiety. And I thought it would be interesting to find any study that I could that looked at CBT and acceptance commitment therapy when they do them, you know, basically side by side. So this will be part of the introduction, kind of just talking about the efficacy of it. So CBT and ACT had equal efficacy for depression in the studies that I could find. A to Jack, 2018, was a randomized controlled trial of 82 participants for MDD,

and it showed that CBT had an effect size of 1.62, ACT, an effect size of 1.17 for the quick inventory for depression symptomatology, and CBT was 1.19 and ACT1 for the Depression-Hmilton Depression Rating Scale. So both had good improvement, and they put the between effect size favoring CBT, but did not have a significant P value, so it could have happened by chance. And so they concluded that the treatment efficacy did not significantly differ between the two treatment outcomes. In another study, Tam and Nafseneff in a randomized control trial of 19 women with major depressive disorder that did biweekly sessions of both ACT or cognitive therapy,

they found that they both had significant reductions in depression, but there was no difference between the two in severity of depression or in the ruminative response scale. So both of them fared about the same in that study. In another study of 101 individuals with an average number of sessions of 15 for cognitive therapy and 15 for ACT. There was no significant difference among the treatment groups with depression, anxiety,

or participant functioning. So all of the P values were around 0.9 or 0.8. So in that study as well, they showed about equivalent efficacy. In terms of pain, we found one study where it was a randomized control trial of 114 participants with an average length of non-malignant chronic pain of 15 years, and they compared eight weekly sessions of ACT or CBT,

and there was no significant difference between the treatments in terms of a change in pain or depression. Both of them were efficacious. Of note, both improved pain measures, even six months after treatment was done and no significant difference was found between them. So this was kind of cool because it showed that, look, both of these work and they reduce pain

with only eight weekly sessions. That's not like a lot of weekly sessions. And these were people who had suffered for 15 years. When looking at substance abuse, Act did better than CBT in the one study that I could find. So this was 50 incarcerated women with substance abuse. use disorder, and act was superior to CBT at post-t treatment with 27.8% abstinence for the act group and 15.8% abstinence for the CBT group. Further, at follow-up, that percentage increased

with 43.8% abstinence with the ACT group and 26% abstinence with the CBT group. They did not give effect sizes in this study. This was Lanzah 2014. When looking at anxiety, I found mixed results when comparing CBT and ACT. In one randomized control trial, this is Wolitsky-Taylor-at-all 2012. They looked at anxiety disorders over 12 sessions, and there was no significant difference between ACT and CBT treatment, except participants with comorbid mood disorders tended to have greater anxiety. anxiety reduction with act at some, at both time points. And this P value was 0.07, but that's probably still good enough to point towards act being better. And those without comorbid mood disorders

had a better response to CBT, but only at 12 months after treatment. So this study basically showed that they were equivalent with some minor superiority stuff with the act. in terms of if the patients had comorbid mood disorders. So in another study of 128 people, this was Arch et al, 2012. In this study, they looked at people with one or more anxiety disorders, and they randomized them to 12 sessions of ACT or CBT. They concluded, Act and CBT did not differ significantly

at post-treatment on either anxiety-specific or broader outcomes. Of note, Act demonstrated a little faster improvement in clinical severity ratings, which I think is important. So basically, if you look at the curves, ACT seemed to make patients a little bit better faster than CBT. And the authors noted as well that at 12 months later, ACT was better than CBT,

and they also noted that more ACT participants utilized outside psychotherapy during the initial follow-up. However, they also noted that if they took those people out of their analysis, they still showed improved rates of recovery 12 months after. So the people who had this act therapy, they continued to get better 12 months after. The therapy was concluded. And another interesting sort of side note on this study was that CBT participants rated higher quality of life compared to those who went through the act training, the effect sizes

was 0.43. This was Arch 2012. So I will put these all on the blog so that you guys can look at these articles. Once again, these are the articles that I could find comparing Act to an active control arm, not just a wait list. And if you have other studies, let me know. I would love to see them. I think that there's a role for Act and there's things that we can learn. And I think that this conversation will show you just some of the kind of amazing things that Stephen Hayes has to offer, the psychotherapy community. I took away some things, some knowledge. I was, I was blessed by it. I did some role playing, and he played the therapist, and it was a lot of fun. So hopefully you can gain some insights into act and to the theory and to the model and how it helps and how it

practically can be played out. So yeah, maybe let's start. Should I call you Dr. Hayes? Is that how you like to be referred? Steve actually works. Hey, you, we'll get my attention. So you're out there in Nevada, and COVID season has not been a fun season, right? Because you've been stuck probably without.

How far have they moved outside since March? How many trainings a year do you usually give, like around the world? Oh, usually a couple times a month. But what's happened is it's actually gone up because of COVID, not down, because everybody in the universe now can reach out and say, hey, it's just an hour. Yeah, but you do understand I get five a day, you know, so. Oh, my gosh. It's really, I'm exaggerating.

But I probably get two a day. And, you know, you just can't do that. So, but it's good. I mean, we'll act as a worldwide thing. And fortunately, there's a large community. Although I did originate it. I say I'm the co-developer, which is true, because there's so many people who have hands in the work.

And so they don't necessarily need the old bald guy to get good track training. Yeah. So tell me a little bit about the history of how it formed and what kind of maybe the simple explanation for how this is unique compared to other types of therapies. Well, it's been a 40-year development. You're talking to an old man of the first act workshop I did. It was in 1982. So coming up on 40 years. It emerged out of my own panic disorder history and hitting bottom and realizing that some of the things I learned on Hippie Hill, I mean, I'm an old hipster and stuff forth.

I'm more kind of Eastern things, had more traction than the things I was being taught. I was raised in behavior therapy and CBT, but with interests and many forms of psychology, actually more humanistic forms of psychology, got me into the field. And I just thought that was odd, you know, that why, oh, mindfulness work, I guess you'd call it now. Back then, the M-word was hardly used. And I'd lived on a commune, and the religious commune, and I knew that the M-word had been a source of great conflict. I mean, monks have been hitting themselves over the head about the definition of it. So it was the last place I wanted to take evidence-based work. But because of that personal experience and the kind of shock of that, that I quickly turned.

turned in a different direction after a three-year spin and panic disorder. And remember, this is before John Cabot's in, this is before mindfulness-based cognitive therapy. This just seemed nuts, especially for a behaviorist like me. But I said, I got to figure out why this thing has so much traction. So we quick, did three randomized trials, only published one of them, the other ones that would drivel out later. They worked.

They all worked, but I didn't want to get out there and say, hey, this is this great thing, because I didn't understand it. And I spent 16, 17 years in relative obscurity. Almost no one knew what we were doing. Working out the model, the processes, the measures, the components, even the philosophy of science. I thought that was so critical, how to walk into the lion's den of, you know, languaging about language.

That's tricky. And we ended up at the end of that arc with a new theory of language and cognition of the human mind, which has a life of its own in the basement. You know, people who come into the act world, they gradually hear about it and eventually get interested in it. But, you know, we can do things there, like take, let's see, children who don't have a sense of self or on the spectrum, for example, and kind of bring them into a more normal sense of consciousness or raise IQ or help kids who don't know how to language at all do that. We can teach language.

language skills to kids and kind of rescue them from a life of disability. Pretty cool stuff. But all that happened in that era. And we worked out the underlying model. So where we are right now after a 40-year arc and now 411 randomized trials in about 3 to 4 to 5,000, depending on where you do the cutoffs, studies on the processes, the components, and the basic science. I can sit here and say, you know, what we have done, what we're bringing in the therapy world, is kind of a hack of the human mind, number one, and then turning that into principles or processes that you can use. Yes, in mental health, but also behavioral health, but not just that, high performance sports, prejudice stigma, social problems of all kinds.

And you can take that kind of hack, turned it into six basic basic. processes that are all really one thing, six aspects of one thing, that do more in more areas than any other set of processes known in science. Excuse me for the self-praise, but because of the arc of the development, we're here, I think, with a really powerful set of change processes that apply to the relationship and apply to psychoanalytic psychotherapy or humanistic psychotherapy or whatever because it's really not a therapy method. It's a model of how the human mind works and how that clashes up with learning processes that are a thousand times older and with basic biological processes that are even older than that. And so that's what I represent.

And I care more about the model and the processes than the techniques and methods and certainly not the packages, names, trademarks, all please. Oh, please. So there's probably 30 different names for acting. People tweak it and rename it, and that's all fine. Yeah, but it's turned into a pretty central part, I think, of modern evidence-based psychotherapy, especially in the CBT wing, but it's increasingly being viewed by humanistic folks, analytic folks, systems, people, and so forth as being of importance. Yeah, so first came like relational frame theory, right?

that was kind of the first sort of under core? It was as the sort of rollout in this way. I mean, really first came, what's this happening here? Because I really had a transformational moment. I've done a TEDx talk on it. You know, I might call it my night on the carpet where I hit bottom inside my panic disorder. And somehow or another in there, in the desperation, there's no way out. Learning, we're not learning, yes, learning by its result.

leaping into a fundamentally different idea, which is I needed to go in instead of go out. I needed to open up and embrace and feel and sense what anxiety was like and what my mind was doing and to really notice it. And there was the kind of the click out was a sense of separation, almost an out-of-body experience of noticing that you're talking to yourself all the time. You have this voice that seems like you. No, no, it isn't you. the repertoire, it's just has life of its own. It's happening when you're sleeping. It's full of all kinds of crack and prejudice things, crazy stuff, anything you've ever been taught, said to talk

to, remember that's rumbling around there somewhere. And this kind of sense of separation between the observer and the observed and that we're connected in consciousness, I'm aware of it, but I don't have to be dictated to by it. So really, I would say first was the personal experience, then the sort of roughing out of some methods to help clients, finding out very quickly within a month of that moment, I was doing that kind of work with my clients. I was trying to walk them into, first quite crudely, what had happened to me and noticing that things move way faster and lives opened up in ways that didn't look like what I used to be doing in psychotherapy. And then as I systemized that, started getting measures about

a year in, meanwhile, I'm really trying to push why, why, why. My lab were full of clinical students, you know, we called it the basic slide. It was just five students, but we slid all the way down to things like, what is a word? I mean, it was down to that, you know, like, what does meaning mean? And then coming up with an answer to that that was brand new on the planet, and that I think, long run, if somebody's looking at this film, if there's still care about it, 50 years from now and I'm in the ground, my prediction is RFT is a lot more important than act. Because we think we have a different way in, an evolutionarily sensible, evidence-based way in as to what was the pivot point between us as human beings and what the bird is doing outside the window. And I come out of the animal learning tradition.

And a lot of those folks believe there is no pivot points. It's just complexity. That's it. No, it isn't. There's something new. We're doing something really brand new. And yeah, it drove brain size, but it's not due to brain size. Why would the brain suddenly get big?

It doesn't make any sense. It was driven by the basic kind of neurological need to do this incredibly complex thing we're doing with the human mind where we can relate. I've actually done the math. I'll explain it if you get interested in it. But we can relate more. more things to other things than there are molecules in the universe with what's in between our ears. And that takes a little bit of calorie usage and the head almost too big to get out of the

Earth Canal. I mean, it does take that. So, RFT sort of started coming in, 1982 is the first act workshop, 1983 I'm talking about RFT. And so boom, boom, boom. Now many years later, here we are with about. 10,000 people in the main society that develops this in 28 chapters around the world. So, yeah, it's a thing.

Overnight success took four years. Yeah, it's 40 years. That's usually the, yeah, it's like you're in the research, and then there's a process of actually telling people about it, right? And so it's good to have on. And learning and new things and, you know, act is one reason I won't say, I developed act is that these things that come in keep moving it forward. And so, you know, the centrality of things like compassion or this process-based therapy adventure. I'm on with my colleague,

Stefan Hoffman, another thing of sort of really radically moving away from packages and protocols to processes linked to procedures on a geographic basis with the needs of an individual client. All these things are kind of roll out because people have better ideas than I had. And I'm all you're happy to steal them. I'm still thinking that the audience is probably like, what is like relational frame theory, right? Matthew, let's have you read one of this quote from your 2005 article with Fletcher. Sure.

This was helpful, at least in my understanding, quote, a simple referential relation between a noun and object is bidirectional and mutual for normal human beings. RFT theorists have provided an increasingly large set of data showing that this process is learned and extends to every imaginable type of verbal relation, opposition, difference, hierarchy, temporal, dietic, and evaluative, and comparative relations among many others. Okay. Dr. Hayes, can you break that down?

Like, what does this really mean? Okay, so here's the deal. We've tried for 300 years to understand the mind based on association. If you just go in there, mainstream cognitive science, etc., it's either the neurobiological connections, as sort of physical metaphor for association, or a psychological sense in which this is somehow connected to that because they co-occurred together. It's not how the mind works. The way that what happened was is that our basic capacity to learn by consequences, operant conditioning, which has started in the Cambrian period. We know that because every species that evolved since then does it, none that before do it. That means it's 545 million years old that you can learn by consequences and by association, classical condition in the same time.

Habituation, a little earlier. And since then, basically nothing new. I mean, the bird outside the window, that's the way they're learning. So we have your basic biology, you have that learning process. What we did, because we're such a cooperative species, and we already had the beginning. of social referencing, theory of mind, understanding intentionality. You know, cooperation came first

because we're the tribal primates, where cooperation is why we took over the planet. Within the band and tribe, I do. Lots of wars between them. And with suppression of selfishness, so you do those two things. Higher level cooperation works. You suppress lower things,

things can happen. Eukary cells can happen. Mitochondria can make a deal with a nucleated cell and it's a different life form, but we'll work together. That's 600 million years old. And pretty good cooperative

system except every once in a while mitochondria cheats and makes plants only produced by the maternal line so it can pass on its own genes. How many cells you got in your body? Trillions. Anyone decides, hey, I want more of me, you got cancer. But you suppress that.

This cooperative thing we're doing called language happened, I believe. Because while many, many animals can name objects, hooting away when they see a snake or, you know, call out, call when they see an eagle, and run when they hear it, but it's not coordinated. We get to do things like, this is a cup to a baby. And then you say cup and the baby orients towards a cup without being trained. But that started, I think, because cooperation fed it. If you understand the intentionality of it, if you had a name for an object and you've got a hominin on the other side of a ravine and you can say what it is, Apple or whatever the name was back then, you might be brought in Apple. That would massively expand cooperation, make your troops so much more powerful.

Yep. But once you can do that, you learn it in one direction, derive it in two. and there's no other species on the planet that does that simple thing. That's the smoking gun. You get the name to an object and then say the name to orientate is the object. The language trained chimps, I'm here in Washoe County, Washaw the Chimp. That's Allen and Trixie Garden at my department. You know, the sandlandigan chimps, when they tested it, in Atlanta, for example,

Sue Savage and Dwayne Rumbos chimps, chance level respond. chancel. And these chimps who've had massive amount of so-called language training. But your 12-month-old baby will do it. But once they do that, here's what happens. Just a few months later. Oh, look at the nice metronome. Babies never heard that. Looks around, sees an unfamiliar object,

drives the relation. That unfamiliar name goes with that unfamiliar object. They'll even start calling it. If they can, well, metronome is too complicated for a baby. But, you know, if it's simple, enough, they'll start giving a name. So you get same, then you get different. Then you get comparison. This is better than that. Then you get I you. What do I have? What do you have? And on it goes. Hierarchy, this is part of. This is. So there's a ditty for this. You learn it in one direction. You drive it in two. You put it in networks that change what you do. That's the human mind. Now, here's the deal. Here's why this matters. In addition to the fact, you couldn't train it with kids.

don't have that. You can establish sense of self when you understand what the bi-directional relations are that gives a sense of self. We think we know that. There are you here, there now then, those big three time, place, in person, basically, prospective taking relations. What happens is we now to have this massive generativity. If you had eight events and eight words that went with events in eight possible different ways, you can derive four thousand relations. Eight. to eight with eight different connections, four thousand relations. Just do the math.

How many things you got in your head that you can relate to other things? Well, I'll tell you what, let's just look around. I've got a chapstick, I've got a cup. I'll come up with a relation that's just not very familiar, father of. You've got to tell me, how is a chapstick the father of a cup?

If you don't, this thing's ending. I'm saying goodbye. No podcast. You've got to come up with an answer. How's a chapstick? the father of a cup. Well, if you don't have chapstick, your lips may get too chapped drinking, and so you wouldn't drink from something that you got too chapped from.

Awesome. That's pretty very good. I don't know. What would you say? It's worked. It's apt. It kind of fits. If I was designing the cup, and I didn't have a pen, I could draw it with chapstick. There's other, there's probably, well, how many answers could you get? A father, you probably could get 100 if you had enough time.

ask your med students there. They're going to come up with some. They've already got some good ones. Flip it around the other way. How's the cup, the father of a chapstick? Because you burned your lips and you need the chapstick now. There you go. The thought that came to my mind is I'm going to go to the store,

but I don't have enough room to carry all the chapsticks. I'll take my cup and I'll put them in there and then that'll maybe bring the chapstick home. And when you do that, it looks like it's apt, right? It's based on the actual formal properties. Cups are really like that. You really do burn your lips. It really does help. It's real.

It's not an arbitrary relation. It's in the real things. Here's the problem. Any two things will relate in any possible way, in an apt way, that will apparently be based on the formal properties of the related events. So either God arranged the universe where everything is related to everything else in all possible ways, or this is an illusion of mind, which is what it is. It's an illusion of mind. But now, here's what this means. We can relate to anything to anything else in any possible way, right?

This thing is happening in your sleep. And you think you're going to help people think more rationally. You're going to help them, like, clean up their little cognitive ecology. When they've had, you know, parents saying things to them, like, you ruined my life. That'll be in their head forever. And it relates to everything. You know, so, you know, if you don't know how to back, out of the human mind and just watch it and take what's useful and use the lap I mean take what's

useful and leave the rest you are an absolute desperate straits so yeah we can use it to imagine our universe that's never been we can do incredibly creative things but we can imagine how life would be better when we're dead we can imagine how you know we well yeah we're so successful but we should have been so much more successful. I mean, you can suffer because you have so much money that you can't trust people. You can suffer because you're so beautiful. How can you? I mean, anything can be turned into anything. Yeah, yeah. Get it? Well, that means we've got to rethink how are we going to rein this in, put it on a leash, use it when it's useful, when inventing and creating and things like that, but find a center, but there's more to us than that. And so the hack leads to

methods about reining in the mind, finding a sense of self in which you can do that, using it strategically to open up to your own history, coming into the present moment where things can happen, focus on your values so you know the qualities of what you're trying to produce and then get your behavior organized around that. And those are the six flexibility processes. them in a way. You can't chop them into six, but play back the tape. They're in there. And it's just the way that the human system evolves. You get the flexibility from emotional and cognitive openness. You get the context sensitivity from focusing on the now consciously. And you get the selection and retention processes from values put into action. And various in selection,

retention, and context, that's evolution, dude. That's how it works. And so we evolve, human lives. That's what we do as therapists. Neil, go for it, and then I'll tell you what I was going to say. Yeah, for me, this relational underpinning, although I still probably don't fully understand it, is initially what drew me into looking at this. My pre-med school graduate work involved some historical linguistics, and then I dabbled in functional linguistics. And so when I started to see the underpinnings for this, as I was realizing I was going to go into psychiatry later in med school and wanted to start

learning some psychotherapeutic techniques. This made sense to me, and as I read a little bit about RFT, and it has its own kind of practical applications, and Dr. Hayes might talk about that. I know perspective shifting is a big one that's been important. People, we have friends with autistic kids, and learning that has its own practical applications without even going fully into act.

But then I learned about the sixth quarter. processes of act. And of course, that learning something that I could use in a, you know, I could apply one of the processes where a patient is the most stuck. It's not a linear, manualized approach. I could see, you know, I could shift and move. And when I saw that, I realized this is something I could use in a 30-minute med management appointment. I could use it in an initial evaluation. I could use it with myself and friends, family, and coworkers, and all of that stuff, because there's no point at which any one of us is completely flexible at all times. And so for me, this is what initially drew me in.

I don't know if you want to speak to any of those points. Yeah, there are awesome points. And I usually don't leave with the RFT because it's geeky and it looks like it doesn't immediately land. we actually have, I wrote a whole book with Matthew Belette and Jennifer Lutton called Mastering of Clinical Conversation, just talking about how even the words that you choose and how you talk to your clients are already modifying the relational networks in which they live. And that I was determined to write this book without ever put an action that, you know, just as almost like an exercise.

And now, it leads so easily that very acty kind of. of interventions. But we just wanted to show that even just the basic cognitive principles will help. But these more middle-level terms of acceptance, diffusion, flexible attention to the now, perspective, taking sense of self, values, and committed action. Those are the six. You can put them into little pillars, learning how to be more open, learning how to be more aware, learning how to be more actively engaged, you can put it into one thing, psychological flexibility. And when you measure them, they all hang out together. They hang out together because evolutionary processes have inherent features to them, various and selection, retention, and context. That's

how it works. So they hang out together because they play off each other. It's like six sides of a box when they put it together makes it a strong box. If you disconnect two or three of the sides, it's not a box anymore. And in the same sense, these processes are not independent. They're features of a complex system that have certain characteristics. But that creating these more middle-level terms of acceptance, diffusion, and so forth, allows you to have kind of a third eye when you're meeting with your clients. And you can see them right in front of you, get entangled with a thought or avoidant of a bodily sensation or emotion or not being here or being able to take the perspective of others or not being

focused on really what's of importance in terms of not just goals, but the qualities of their moments and not be able to mobilize their behavioral resources forwards it. And all psychotherapies mess around with these processes. What we're learning, when we look at the mediational analysis, you know, you actually look at what are the functioning important pathways of change inside randomized trials. I just, with my colleagues, Joe Sorachi and Stefan Hoffman, have reviewed every single mediational study ever done in the history of the universe on psychotherapy. We haven't yet put it out. We looked at 55,145 studies, took us two and a half years, and 50 people working on it.

And I'm giving a talk here later in December at the Evolution of Psychotherapy, a conference called Why People Change, where I'm going to do. just say, okay, here's everything we know about processes of change that are vetted by how most scientists are trying to vet processes now or through mediational analysis. And the psychological flexibility ones, if you get a little friendly about people talking about these things in different ways, sucks up about half of what we know about how psychotherapy works. And there's other ones that kind of relate, it depends on how open you get. You know, like is anxiety, sensitivity really about emotional avoidance, for example? But so I think we're on a cusp of something where we can simplify therapist tasks massively

and get out of these packages and schools and all the rest of it. And in the idiographic way, person by person, personalized medicine, what is it? this person doing psychologically? What are the processes that they're feeding and what do we need to put into the system to perturbate it and then to have it stabilized in a more healthy thing where overtime things get better instead of overtime things get worse? And that would be a really awesome vision of evidence-based psychiatry and psychology instead of syndromes and protocols. we go to collections or processes and procedures that move them. And in successful personalized medicine, that's how it works.

I mean, what are the actual things that are going on that you need to correct with that particular person? And if you have a disease entity and you know something about the etiology, of course, in response to treatment, you have some of those functional units. When all you have is syndromes, you know. You just have topographies.

And so we can go to what now 40, 50 years of evidence-based psychotherapy tells us. We have outcomes. We have procedures and packages. But we also have a lot of mediational evidence. We have a lot of knowledge about processes of change. What would happen if we go there? Because those processes, we know linked to outcomes. We don't know if the five out of nine or the four out of sevens linked outcomes.

we don't. We're just going back topographies with the signs and symptoms that are inside our traditional diagnostic system. So it's an exciting time that goes way beyond act. Act is just one of the first and one of the best because we've got added so long. But I think the whole field's going to move in this direction. Now, I have an example, and I'll share it and you can break it down and use it as maybe a way to talk more about the processes. feel free to critique. I'm open. But, you know, I did one of the trainings with you in Vegas, and you had done this exercise where you showed slides on the screen, but only one person could see that. And we were practicing, doing all the processes at once and how they interact and being flexible and kind of rapid changing, and you have a coach and all that. And that's an interesting model that you used. I think it's called the Portland Group model.

I've talked a couple of residency programs about trying to implement that. in their training. But the outcome of that was shortly after that training, I was at a, this was not a client or a patient. This was a friend of my, my wife. And, you know, she knew what I did and definitely wanted some help. And this person had two years before had experienced the death of her three-year-old daughter. Wow. And she said, you know, Neil, I'm stuck. I keep getting stuck. I keep coming back to the vision of her dying. And I wasn't involved in their life at that time.

So I actually don't know the cause of death. And I don't know that they know completely either. But at the time of the death, this little girl was either seizing just before death or, you know, something like that. But it was very visually disturbing to the mom who was there. And she said, I just need to get. get rid of this. I need to get rid of this pain. I need to get rid of this moment. I want to not be able to remember this ever. Can you help me get rid of the pain? And I realized after the training, I was able to identify there was some fusion there. She was kind of stuck on this idea of

this event is painful. There was some avoidance. I want out of the moment instead of acceptance. there was some self-as-context issues going on with seeing herself as defined by this moment and kind of a bad mom because she couldn't save, you know, her child in that moment. And of course, she was in, well, I think they were in Lomalinda Hospital, so they were surrounded by specialists and experts that were not able to save the child. And they knew that the dying was happening. There was loss of contact with the present moment. And so you talk about in one of your more recent books, this idea of pivot and finding the point of being stuck and literally flipping it on its head.

And this is what I said, for right or wrong in the moment, this is what I said to her. I said, I would never take that pain away from you. Yeah. Because you are only seeing it from your perspective. You're looking down at your daughter, and your daughter's dying, and you want out of that pain. but I want you to flip it around and see it from your daughter's perspective. Your daughter looked up and at her worst moment in her life saw her mom loving for her, being there for her, and caring for her. Wow.

And you would not exchange that pain for anything because you were there. Do you know how many patients I have that do not have a mom like you? Wow. And she cried. I almost cried. People listening were crying. like it completely transformed her definition of the experience. Did it solve all of her pain and grief?

No. But she will tell people, I think to this day, that that was a very helpful process for her. And I caught it in the moment because I've done some reading. I've been practicing this stuff for a few years now to see that she was truly stuck. And she needed your words, not mine, a pivot to move forward in multiple processes at the same time. It's an awesome intervention, awesome example. I mean,

and she was very lucky to have you be the one to hear that story. Because, you know, love and loss is one thing, not too. And the pain she was feeling was a reflection of her love for a daughter.

What moves me about that story is the, it's like the narrative that she had before was, I'm in this pain. This is a great loss. And the narrative was taken out, expressed to you.

She was feeling the deep loss, the deep sadness. You validated it, empathy, right? And then you also inserted in another aspect of the narrative, which was also true, right? this aspect of the narrative that the daughter was comforted by her presence. And she hadn't thought about that. And so that gets inserted into this memory, this very painful memory now. And that changes the overarching, like, experience from potentially being something just purely traumatic, where she's dissociate, she wants to dissociate it.

way from it to something where it's like, you know, that's a beautiful moment. I think that goes back to what you're saying about language, too, how she made, she decided to make the connection that it was a moment of suffering for her and pain, but when you take it from the daughter's perspective, you can write a totally different story about the same event, how it was a moment of comfort and love in her last moment. And I even ended on a values statement. I didn't mention that earlier, but, you know, I said, would you take this event away from yourself knowing that this is the kind of mom you wanted to be? So I was able to reconnect it at the end to values, hoping that in the future,

as it comes back up, as it will, that she will realize it was important enough to her to stay with the pain and not continue to want to get away from it. And she, of course, of course, it was, I knew her well enough to know this was one of her core values. And so it, there's so many of the processes that were involved there. And that's why I think it stuck out to me, in part because it happened shortly after the training, in part because it's a very emotional and very memorable story. It's a beautiful piece of work. And, you know, these kind of moves, what you're able to do is a concept in a relational framework called Transformation of Stimulus Functions, where, you know, we're constant, we're the meaning-making.

species, we're constantly giving meaning to what happens to us. We're fitting it into a narrative. And while you can't control this wild horse of language, you can use it to serve your own purposes. When you connect with the kind of person you want to be and what your values are, that perspective-taking move, which connects you to this more spiritual witnessing self-part of you, from which the hell of your own history is not a threat to you.

and you can see options in the moment. I think what you helped her to do is to see, you could say reframe, but it's not, if you did it in any way of all, well, that's just, or in any way dismissively or manipulatively or something, it would not have worked. You have to go deeply into the experience itself.

Yep. And in there, see that there's a deeper meaning here. This is what a loving mom does in a moment like that. And it impacts those around her, including her child is dying. You're actually serving your child. And it's a beautiful example, Neil. Thank you for that.

Awesome. I think that was a really good point, Dr. Hayes, where you talk about like it's it's it's neal's presence is neal really feeling this like it's neal's empathy that allowed that to be something that was actually functional it's not just a trick it's not just a psychological you know like let's look at the silver lining of this horrible thing it's like neal is inserted into that memory he's suffering with her i felt her suffering from you even telling it so i know that you were suffering you even hearing it i think i imagine that audience was here and up here and I certainly was.

But you know, now look at these same processes as applies to you in that moment. Because you're hearing this very painful thing from somebody that you care about, yeah. And for you to step in there in that bold way required you to feel and required a little bit of perspective taking on your part. What does it like to be heard? Probably anyone beginning to hear that story. I think, what would if that happened to me, if it was my, you know, and you're willing to go there.

Your values of stepping in there and saying some things that are bold and you're not sure how they're going to land, but they seem apt, they seem real, they seem true to your own experience and to hers. And so, you know, I don't think it's that complicated. I think we actually know these moves. We know it's healthier to be whole, to feel. to see, to care about, to take perspective. We know that. But we can easily get into the problem-solving mode of mind, which is trying to diminish and eliminate instead of empowering us to be here now as whole human beings.

And so if you couldn't have done that, if you were trying to avoid, you couldn't have done it. You would have tried to find a way to minimize or diminish in an order to manipulate yourself. And in so derving, you wouldn't serve her. Right. Yeah. Well, and for the number of psychiatrists that are listening, it's not all psychiatrists listening to this podcast, but a number of people are interested in it. And, you know, we learn, quite frankly, we learn the exact opposite processes. We learn, you know, solve this problem, move away, take this, you know, medication to remove and act as a evidence-based way of giving another option for dealing with these. And they do work. They are natural. once you realize, I think, what they are. That doesn't mean they're always easy to apply. But they are there, and they're there for us as well.

We are involved in the process. I actually, at this moment, I can laugh about it now, but I couldn't always. I was out for a run on New Year's Day, and an elderly gentleman lost control of his car and came up on the sidewalk. and just a few inches away from killing me, ended up with a compound fracture and emergency surgery. And as I was recovering in the rehab hospital, I was finding myself having to learn to be flexible

and practice my acceptance processes and not solve the problem of how fast can I get back to work and how fast can I get off these pain meds and all of this stuff. And literally trying to see myself, well, quite frankly, from the perspective of the driver who hit me and how scared he must have been losing control of his car. This was not an intentional act, you know,

but he, you know, he lost control of the car. We actually made eye contact before he hit me and just shifting back and forth between that and not trying to solve the problem, but sit with it. And honestly, the most helpful thing I did emotionally while I was in rehab hospital was using some of these processes myself.

Well, and we have pretty good data in rehab and walking through injury and recovering post-operatively and opiate use and, you know, the psychological flexibility literature is vast, but pretty good evidence that when people are able to walk through rehab in a way that is healthy, they're used some of these same processes. And they're in our culture. They're kind of in that we, but we can put them more into our patients' skill set and reaps and benefits from it. So, yeah, there is that same message.

One of the cool things about this focus on process is the things you learn over here apply over there because this skill set is applicable to almost any kind of psychological challenge. And so why not go to the kind of gatekeeper moments, whether it's a physical injury or a relationship loss, the death of somebody close to, you know, some sort of, you know, a panic attack. You know, thank God for my panic disorder, man. I mean, you would not want to be around me if it hadn't happened. You know, I was a, you know, just crazy driven, you know, get my Vita, get that grant, get that, you know, and part of me said, no, I'm just not going to let you do that. And thank God for that, you know, because it gave me another way to move forward.

And the Bill Grants still came and the Vita still built, but I didn't have to objectify and dehumanize myself and treat myself as a horse to be whipped. as I think a lot of people do inside. So we found that the psychological flexibility processes will relate to how successful you're going to be a business, how good of a therapist are you going to be, how much stress are you going to burn out?

I mean, so I don't want to make it seem like it's one size fits all. You have to figure out a way to put these in the situation. But one awesome thing is that the processes change first, the outcomes come second. If you learn the processes, learn how to read them, you can come out of a

sense, out of a session with a gut sense of I just did something important. Because you can see the change immediately in front of you. You can see that little opening to an emotion that was previously run from, or that little stepping back from a thought that was entangling, or that little connection to something that's really of importance or those perspective-taking skills. You can feel them in yourself. You can see it in your client. And you can rely on them, you can trust them that when those things happen, you're doing something useful. So it gives you a guide, almost session by session. Your patients become your teachers.

You know, we're just before this episode's coming out, we're going to be launching an episode on openness with Maddie here. And we looked at, you know, one of the big five traits of openness. And first of all, I would estimate Dr. Hayes, your own. openness levels, probably at least two standard deviations above the mean. That's a talk to my wife. What's that? You have to talk to my wife. Oh, okay.

But I would also say we just did an episode on conscientiousness and your achievement striving is probably two standard deviations above the mean, just like Neil and mine as well. But it's probably been tampered by your sort of psychological growth is what I'm hearing. from you. Just like what are your values? You know, things that you will not, things that you will not sacrifice, right? At the, at the altar of achievement striving, so to say, you know. Well, in almost any domain of life, you go in and you say, just, you know, Google it.

Take a, like parenting. Go to Google Scholar, put in parenting and psychological flexibility. It just, you know, and you're going to find there's hundreds of things out there. I mean, people are on to it. almost any domain of life, whether it's running a business or learning something or being a good parent or being. There was just a meta-analysis came out yesterday with relationships and with being a good parent, that combination, with 43,000 participants in 133 studies, and there it is, psychological flexibility. So, you know, learning how to be more flexible will just pay dividends for you.

and it's worth the time and attention because it's applicable in so many ways. If I can tell a story, that transition doesn't necessarily come automatically. In a liberated mind, this trade book that I wrote that summarizes the whole literature, a recent book that just came out. I tell the story of developing tinnitus or tinnitus, I'm never sure how to pronounce it. People pronounce it two different ways. But I'm an old punk rocker.

Not a good idea to stand in front of 50-foot-tall speakers. from people who are, you know, singing like aircraft engines, because then you get to be 72 years old like I am here enough in years. And when it first started really showing up, I mean, I said, oh, make it go away, make it go away. I say, oh, I hate this, I hate this. And then I had the thought, I'll just shoot myself, and then the noise will go away.

And this other voice kind of says, dude, that's a suicidal thought. maybe you should apply your life's work to this. Oh, yeah. That'd be three years. And I went out for a walk. I came back. It was like 60% handled by the next day.

It was 80% handled by the next day. It was gone. We've now done randomized trials. It wasn't gone like the noise is gone. What was gone is the disruption. I never noticed it anymore. Why? I don't attend to it.

I'm noticing it now because I'm talking about it. But my point being, when you have a skill set, you may not be so smart to necessarily apply it everywhere, but they do transfer over. And so why not take what Western science gives us of these simple sets? And there's more we can add to it. It's not everything. It's not all of psychological knowledge.

It's not all of therapy. It's not. But it's a good start. And when you do see how it lands, stories like this awesome story, you know, just told. become possible and easy. So with your tinnitus, first of all,

I've had a couple patients with that as well, and they can be so monolithically focused on it. And often the rage and attached to the narratives with a couple of them, like vets that I had patients, you know, the narratives were the great injustices of the war of having to harm children in one story and having to, you know, leave their family and have their girlfriend go on with another guy. So all these stories get attached to that sound.

I'm wondering if that's kind of what you're talking about. There was some sort of other alternative narrative that was attached to it that you had to disconnect. Well, there was a little piece of how stupid could I be to, you know, be, you know, part of that music scene. I look at these kids walking around with their earphones from their smartphones, and I know how cranked up that music is. And I'm thinking, you just wait. You know, when you get my age, you're going to have an issue. But, yeah, there was a narrative piece in there more around my stupidity of not taking care of myself.

It's not like anybody would not know that it's unwise to. But it's hard to be so self-critical of yourself, you know, for something that. that is a noise that's just ongoing that you know you're critiquing your younger self for making choices and and it's hard to sit with that you know well these narratives pull us into in the fusion piece what rFT says what drives these relational networks and makes them rigid is coherence they fit together they make sense but they become a gravitational force which is why schemas happen. You have these narratives and, you know, if you have a paranoid narrative, let's say, if you're inside a, you know, if had a psychotic break or something, it starts, it becomes

gravitational. It starts sucking so many things to it. You know, everything starts making sense in terms of it. And so it becomes its own life form almost. It's like a virus or something. And so diffusion is this matter of not directly trying to contradict it. That, that, sort of amplifies your focus on it, but finding a way to step back, notice, but also diminish the unhelpful impact. Use it when it's useful, leave it when it's not. And that kind of allows a softer narrative to come in. And often you can find new narratives that work a lot better. like I would guess Neil that there's a new narrative

inside that mother about what her pain means. It's in a different network. It's still there. You could repeat it. You could be remembered. You could tell the story. But it's now has different functions

as part of it. Yeah, I think so. I think she would say that. I think she has said it to other people that there's a new way of looking at it. I mean, you have to keep, she probably has to repeat the work from time to time or maybe she comes up with better stuff, you know, with someone else in the future. But she has certainly an additional option in her narrative that was not present before. And there is a new meaning and new connections that she can make now to that because of it.

Now, if you tried to force the new narrative in without softening, back up, connecting in this deeper way, and connecting with this sense of self that you get from, perspective taking that is more able to open up to new ways of thinking and to direct attention in new ways. I think you would have just, you know, ended up either in an argument or in her feeling invalidated or not understood. If you were me, you wouldn't ask me to do that. Don't be telling me that I can just sort of change the meaning of this pain. I mean, I'm going to, I should never, how could I possibly, you know, and all the rest. Who in their right mind would want to accept this pain and go deeper into it?

Just remove it. Of course no one wants to feel this level of pain. But instead, I think what we were able to do together in that moment was help her to see. But there was no way out of the death. And her daughter was there too. And that new connection there. Not to the death and the pain, but to being present. with her daughter.

And that was worth it. The first word in act is acceptance. What's inside acceptance, the way we mean it, is not tolerance or resignation or putting up. It's nothing like what people are told by people around them, well-meaning, but invalidating. You just need to accept it. It's nothing like that.

The original root of the word meant to receive is just to receive a gift. And we actually still use it in English. We say, here, when you give a precious gift to somebody, will you accept this? Why do we say that? We don't say, will you tolerate this gift? Will you resign yourself to seeing this gift? That's not what you mean.

You mean, will you willingly take in what I'm offering to here? This is so precious. I want you to choose to take it. I'm offering it, yeah? Well, there was a precious gift in the pain here. It's the love she has for her child. I mean, it's one thing. Love and loss is one thing.

If you just say those words, it wouldn't mean anything, but we connect to it from the perspective of her daughter. You sort of see, you know, my tears were a gift in this, my fear even. Well, in the same way. Here's a, oh, yeah, sometimes say to folks, when they come to me and say, I just want to get rid of this anxiety, I want to get rid of this sadness,

I want to get this expression, and say, okay, You got kids? Are you going to have kids? Yes. Okay, here's the deal I'll make with you. I will remove this anxiety 100%. But here's the deal.

When your children come to you and say that they're afraid, when they come to you and say that they're sad, you will have absolutely no idea what they're talking about. It'll be like they're from Mars. you're going to make this deal. And, you know, I've never met a parent who wants to make that deal. Magically, they want to know about fear without feeling fear. They want to know about sadness and be able to give that to the people that they love without

knowing about sadness. It doesn't come that way, dude. The reason that we can be there for our kids is that we're a whole human beings and we've been there ourselves, yeah? And there's an example. the precious gift. It's just like physical pain. Do you really want to be a leper? Do you really want and I have feeling in your fingers? What will happen is that it'll get, you know, people literally, not just from the necrosis, but they will accidentally put their fingers in a fire and not

remove their fingers. Feelings, you wouldn't do that physically. I'll just remove all physical pain. That is a medical condition that's going to create physical damage to you. It's the same thing psychologically. You're not going to be able to negotiate a whole human life, but you're also not going to be able to be there for others. A couple things that I do to, because it does sound so harsh. And if they miss the initial point of you got to tell someone to accept things, of course, that doesn't go well at all with clients or patients because you're not actually working the processes by forcing them to just say something's good. So I use the analogy. I may have gotten it from one of the books or the trainings, but you talked about the gift, and I talk about holding the gift, rather

than saying, this is good. I just talk about holding it, realizing you have the other hand to do something while you're holding it. And then the other thing that I've used in training residents is one of the exercises from Self as Context. You talk about the I Am exercise, and we take a minute or two and write all the words you can come up with. And if I have to feed them a couple of domains like relational domains, I am, you know, I am a wife, I am a husband, I am a friend, I am this.

And then you might give them, you know, different roles that they've had. You might give them different diagnoses or symptom clusters. And so they end up writing all kinds of things in one to two minutes. It's done different ways. And you look down and when you first look at it, of course, you're seeing all these words, I am depressed. I am a resident. I am underpaid. You know, who knows what's on the on the page.

And then, of course, I have them draw now a frame around that. And I am is in the frame. And all of the words are inside the inner box. And then I'm a little direct and harsh at times, but I say, you've lied to yourself. You are none of these things. You are the you that notices that some, Sometimes some of these words apply to you. You are the you that can decide if you want to change some of these.

You can quit being a resident today. I don't advise it with your med school loans, but you could do it. You could get out of a relationship. You could add a new relationship. You were the you. You were not depressed. You were the you that notices that sometimes you have thoughts about depression. And of course, you could speak more to the processes that occur there,

but there's emotional distancing that's occurring. and then the self as context rather than self as content that's occurring. And I find that those two exercises, I think, get the conversation going because it's powerful when they realize they're not defined by the words they've been calling themselves. Yeah, you are the one observing what you put in or take out of the box is what I've sort of Yeah, exactly. And, you know, in our wisdom traditions, our spiritual traditions, they all have practices that help people find this sort of deeper sense of self that's just awareness, pure awareness, period, end of story.

When you say that word, it doesn't mean much of anything, but we're living inside this all the time. I mean, there's a part of us that there's noticing what we notice. If you have a physical pain, the pain didn't notice itself. An organism, a being called you, noticed it, a conscious being, an aware being. And so from that perspective, our point of view, many, many things are possible. And acceptance is simply to take in, to receive the gift, to say yes. I have a little exercise as I do, and people listening to me right now could easily do it. If you want to sense what acceptance is like, just look around the room and everything you see, say no,

and find something you can criticize about it. Oh, that's a cheesy clock. what you spent all of $15 on that one, you know, or whatever. Look at how dirty this is. Look how badly that's designed. And then feel what it feels like to be yourself looking at these things around you. Don't do it to human beings, by the way. It's not kind.

And say no to me. Well, then do the same thing. Now, flip it around and say yes. Yes, it's just like that. You know, yes, it has a function. And yes, at least it's still working. Yes, old friend clock that's been there for perhaps too many years. Yes, familiar object.

Find a way to say yes, not just judging it positively, but being open to the experience of that object being just like that and you're connecting with it. And when you do that, you have a sense of fog lifting or space opening up. You can feel it literally in your body. you know, if you actually do biological measures, you are changing things all the way down to epigenetic regulation of stress-related gene systems.

You know, that five minutes of this kind of meditation will up and down regulate something about 1% of your genes through epigenetic processes. That's the study's been done. Herb Benson at Harvard did it. It's very rapid.

It's literally happening right now. But so could you say yes to your own experience? Is your own experience your enemy? If it is, you better learn how to run at light speed and break out of this universe and some other one because your experience is following you, dude. It's with you right now. So could we do something that's kinder and more self-validating?

It gives you a foundation, a place to start from. I don't know how to start from where I'm not, but I do know how to start here. And my experience right now is this. When I say yes to it, it doesn't mean I like it, doesn't mean I want it, doesn't mean it's going to persist. It doesn't mean I got up in the morning saying, hey, I want to have anxiety today. It just means, yes, I feel it like that. Now what I'm going to do with that?

Well, I don't know. What do you want to be doing with that? There's lots of different things you can do with your experiences. And so, yeah, that habit of being here whole and free is something you can inculcate in yourself and with your clients. And it empowers a human life. Could we maybe just pick one example and walk through all six of the processes just for those who haven't? Because like I definitely haven't used act before. Yeah.

Can I pick the example? Sure. I know a lot of people who listen to this are people in training. And one of the things that people in training have is like imposter syndrome. Sure. So let's say I'm one of those people and I feel as I go along my work, I'm not good enough. I don't know enough. I'm not doing what I'm doing well enough.

And maybe I'm even listening to this episode and I'm thinking I have no idea a lot of these things. I'm not doing any of that. I'm an imposter. I'm not good enough or smart enough or, you know, like all of those things. Okay. Well, so I would, let's walk around. And so I'm going to suggest micro exercises to do with an imposter syndrome. So let's start out just with the thought I'm an imposter.

And allow that to sort of get that clear in your mind. And I would ask you, how close is that thought to you when it's showing up? me physically, like show me with your hand. Is it up here when it shows up really close to you, or is it out there? If it's up here, you know, it's very difficult to see what's around you, if that hand's right in front of you. If you can put it out a little bit, you can have that thought and still be able to see other things. So how could we, would you be willing to sort of do something that would help put it out there? And let me give you an example of something you might do, I want you simply to say that thought to yourself in the voice of your least favorite

politician. Or pick a cartoon character. Just do it. Or sing it to the tune of happy birthday. Just do it. Okay. Okay. So you've got that thought. It can land in different ways. I'm not meaning for it to go away. Now, I'd ask you to imagine that the, you think, you that your life has unfolded in a powerful way. And you're looking back at this point in your training where you felt like you were an imposter. Let's take this out, it's 10 years from now. And you've given your whole effort into your training,

you've really focused on what you came here to do in terms of serving your clients. And you're looking back at yourself sitting here right now with that almost hand right up in front of your eyes saying I'm an imposter. And from that perspective of a point of you actually take the time to put yourself out there? What might you say to yourself

about how to be with yourself with that thought in a way that doesn't interfere with what you came here to do? What advice would you give yourself? Whatever the person says, do you have one that comes to mind? What you might say?

Maybe don't be so hard on yourself. You're trying the best you can. Okay. And so let's come back, come back in your body now with this, don't be so hard on yourself. We've done our little singing of the I'm an imposter. So take the part. Neil, can you do the singing for us? Can you give us, what would that sound like?

No. No singing. No? Okay. Well, I'd like you to do this. Let's create that thought of an apostor on purpose. but now coming back with the don't be so hard on yourself. And I want you to watch what your body does when you have that thought.

What shows up? Do you clench your jaw? Do you clench your fist? Do you tighten your stomach? Whatever it apply, don't be so hard to yourself on that moment. Is there anything else you could do with your body? When you notice that, I don't mean that you have to change it necessarily. But can we just notice that one of the things shows up is that you tense it almost as if isn't a true?

you're going to have to defend yourself? Do you need to be hard on yourself in that way? What would happen if this is something that it's okay to have? You're learning something new. It's a challenge. You have a thought I'm an imposter. And part of it is this physical feeling. How would we even know that we're touching into this space?

Can you tell? I ask you this question. What emotion shows up? in association with them and a posture. We know a little bit about their bodily sensations, what emotion shows that. Probably more fear, like this image of running naked on a football field

with a football and people are chasing you. Awesome. I had that dream years ago. Awesome. And so you know that you've been dealing with fear and with this sense of inadequacy and shame or whatever, the brain naked. I've imposed maybe in that.

And so could I ask you this, would you be willing to sort of feel that fear? If you could meet yourself at a younger age where you had that fear, you're going to not, you're going to be running naked down the football field. How old were you? When I, I was, I think I was a third, third year resident, yeah. So that was, what, about 10 years ago? So here, I give you a option here. Would you be willing to sort of feel what it felt like then to have that fear?

But to do it with a posture of self-kindness, of not being so hard on yourself, of maybe even kind of a lying with yourself, sort of the way you might, if you were sharing with a friend, what it's like to feel fear. Is fear your enemy? Have there ever been times when fear has been helpful to you? No, I think fear has served me sometimes when I was rowing. I rode for cow bears and a little bit of fear at times would make you pull harder. Okay, awesome.

Okay, awesome. Awesome. And so could we do something with that fear that would more fit into your experience, that there are times where fear has sort of helped you? So let's just take the fear of my posture. let's sort of bring it in, bring it on board. And then my question to you would be, what would you want to do in your training

with that fear that would serve the people you came to serve? What is your training about? Helping people. This is in the service of. What do you hope to accomplish with your training? Maybe I could use that fear to buy some more books. Okay.

And read some more books. to prepare to prepare to prepare to help people more okay awesome so if it's not to get rid of the fear but it's to prepare and what is that to prepare to do what do you want to do i think if i know more then maybe i'll be able to be able to help people more what kind of help you want to be to them i want to be able to hear their story and after half an hour an hour be able to maybe make changes to their medications or be able to guide them in therapy in a way that would actually be helpful. And if your next client comes to you and says, I fear that I'm an imposter and it hits me

so hard that it like freezes me in place, would you be willing to take in that fear if it helps you sort of put yourself into the perspective of the next client you're going to see? Yeah. maybe I could feel to some degree what I had felt and feel some of their fear. Yeah. And it might be able to help me, help them. Could you imagine even sharing that story? If it was apt, you don't have to necessarily self-disclose, but could you imagine

that maybe even sharing that story would be of use to your client? Yeah, I mean, I hope if someone's listening to you know, to this right now, even though they're not in the room with me, maybe they hear parts of my story. Maybe that helps them. And that makes me feel good, thinking that we might be able to decrease collectively the fear of many people who might also have this sort of same conflict. Yeah, because isn't it so that we run around with these secrets of these, I'm an imposter, people will see it, they'll see me naked, right? That metaphor. for her. Yeah. What if the big joke is, we're all walking around the same freaking secrets?

You know, what's funny is after I became an attending and I started seeing medical student after medical student, resident after resident, I realized that that was true. I was like, wait, I went through medical school and I had some of these feelings, but why didn't anyone ever talk about it? And so out of that value of helping. people, but you also have a value of being a trainer, yeah? Would, if you see something in there, is there something of importance to softening, for example, the training environment in which we create an environment, we get to share even some of these fears and do some healthy things with them in the interest of the clients that

we serve, but also in the interest of learning that we have to do? Like, is that of importance to you as a trainer? to be the kind of person who could share some of those stories and put yourself inside their skin. And so here's a final question. Would you be willing to sort of think of some concrete thing you might do over the next week that with your clients and with your trainees

would give form and substance to this idea that you're willing to notice your thoughts and not buy into them and to notice the emotional reactions they have? And even what happens in the moment with your own body and maybe be able to create a softer environment where people can have experiences like that and not have to enter into a cul-de-sac of hiding or of struggling or of trying to eliminate and before they can move on. To create a world where it's okay to be a human that has things like that happen to. Yeah, I'm thinking of a committed action that I could take

of today we'll do continuous case conference with the residents, 30 years and 40 years, and we'll watch them doing psychotherapy. And so maybe I could find some increased empathy into the experience of the resident who's doing the therapy. It's always a nerve-wracking thing to put yourself out there, let other people see what you're doing. Awesome. Well, the six processes are in this conversation. You know, we started out with a little bit of diffusion, you know, trying to, just take the thought and be able to just notice it when it's so loud and dictating,

you know, but then we came into the present moment, but then we kind of connected with values, and then we did some perspective taking, and then we opened up a little more emotionally, and then we looked back over into what commitments you might make out of the values. So we're dancing around this hexagon of these opening processes of acceptance and diffusion, these centering processes of the moment, attention to the now, this part of you that can move consciousness around time, place, in person, like going out to the distant future or going behind the eyes of your trainees or your clients, and then finding what you want to reflect in your behavior, the intrinsic qualities you want

to put out in the world, those are the values, and then committing to doing that. So this is just a conversation. We weren't really trying to do elaborated clinical work. I find these conversational things quite important with myself and with the people I love. I think it solidifies as well kind of like some of these more theoretical things. I like to make it more concrete because I imagine not all people are as high ideation as myself, right? So I think it's good to bring it concrete. And we'll write this all down in the article.

We'll put on the website, Psychiatrypodcast.com, if you want to check. that out and we'll go through. We'll put it there so people can re-go through it. They can see, they can see your, uh, your hexagon of, uh, what's helpful about it for early career and trainees is that it is six processes. They're all interconnected. And you have certain leanings and you have certain tendencies that you're going to be good at and you might pick up on those earlier, but then knowing that these other processes are there. you will also find things that will be beneficial for your clients and patients that you may need some reminders to work a little harder on. You know, in the act circles, they talk about left-sided and right-sided clinicians.

I'm a right-sided clinician, which means, yeah, I do great on taking the next step and I do great on helping them find their values. But I need to work a little harder to not forget, you know, keeping them in the present moment. and the bodily sensations work. But what's been so helpful is that the model includes these other things that both that I am naturally good at and that I naturally need reminders of to pursue. And what's amazing is those things that didn't come as natural to me in my training end up being often more beneficial than my initial intuition for them because I'm not, because I do try to work towards all processes as they show up in the session.

those stuck moments, those inflexibility processes. And then you just, you catch which one is, they're not flexible on. And that's the one you pause and do work on it. And then, and then you move on. And so for me, again, as a conceptual model, as a trainee, and then moving into being an attending, it was helpful to learn it. But it was also helpful to correct, correct the deficiencies in my intuition. Yeah, they form a whole set. Some of us are naturally better at one versus the others.

Some clients come in with skills in one area and not the other. And that's the kind of personalized medicine kind of quality of it. And some people are really good making values choices and following through, for example, with behavioral commitments and so forth are really not so good at being able to be emotionally open or take the perspective of others. And so the model fits together and supports each other. That's an empirical fact. We've actually done randomized trials with only the left and right comes from the hexagon.

You know, the left ones or the acceptance and diffusion, center ones, self as context or perspective taking and then now and then values and committed action on the right. And we've done randomized trials with only the center in the left or only the center in the right. and all together and altogether is better and you can predict that the level of processes of change, the ones you target are the ones that change, and you can predict what's going to happen in terms of problems. If you work only on the left, people might not yet get around

to actually putting it into a behavior change readily. If you work only on that and on values sooner or later, you hit something where you don't know how to open up or step back or notice. and so you then progress stops. So you need all six, and by having them, it kind of bumps you out of your comfort zone.

A model is only needed when you're not fully in the flow and everything's working. If what you already know how do is working, just do that. But when things are not working, you need a model because it's going to push you out into areas you need to learn. That's going to be outside your comfort zone.

I'm wondering also, sometimes you refer to act as a third wave. And I don't know if I do this right, but when I talk about, when I talk with trainees, I talk about, you know, the water being kind of everything we inherited from our wisdom traditions and religious traditions and Freud and all the stuff that happened. And then the first wave is behaviorism. And the second wave is the cognitive move. And then the third wave is act and some other things. And I wonder what is so third wave about it, what's so process about? it, what is there to learn from this, the next step coming, whether it's act or contextualize

schema therapy or process-oriented CBT or what's coming in? What do we need to learn regardless of our current training? Maybe we've only learned CBT, maybe we've only learned, you know, some other types of therapy. So what's third wave, what's process, and how does it relate to these other areas? Yeah, third wave is a term I used back on. 2004 because I noticed that acceptance, mindfulness, all these kinds of things were coming in. And they all, instead of trying to change the content, we're trying to change your relationship to content, which many of the deeper clinical traditions that already had, really, but inside the CBT tradition, and mainstream evidence-based therapy, not so much.

I think it's outliving its usefulness because things, I think the whole field has kind of gotten on board, with regard to that, I don't know if I want to use the wave metaphor, but I do think, and you can see it with Ardok and what was happening with NIMH and so forth, I do think evidence-based care needs a different model, and we're going to have to go from protocols for syndromes to something new. And the attempt to try to do the Ardoch experiment that Tom Insull did was an attempt to get the processes that would link to the developmental neurobiology that was assumed to underline mental illness.

I think we need a broader, a little more Catholic, small C perspective that is open to any of these processes. Some of them are maybe sociocultural things and some of them are psychological things. Some of them are neurobiological things. You know, some of them may be epigenic, genetic kinds of things. I mean, we need one whole biological organism

that's also psychological and part of the social, cultural group. So I do think where we're headed is more idiographic, personalized, and process-based. I think that's true in mainstream medicine, and I think it's true in psychiatry and psychology. And it turns out we've got quite a bit of pretty good leads as to where we can go, and once we direct Western science towards that,

I just think we're going to make a lot more progress because we're just on the cusp of how far can you go? I mean, I love these studies, for example, that look at what happens neurobiologically when these acceptance and diffusion processes are put into a client. You know, and there's some really good evidence that it changes how information is even processed by the brain in a very fundamental way. And so in all of these different disciplines and these different theories, let's get out of the school-based. thing that's focused on tools that you can use that are linked to processes of change that matter and

see how far Western science can walk us forward on that in a way that applies to the individuals and couples and families that don't mean individuals, I mean the particular focus of our clinical work and I don't think it's way off in the distance. I think it's right here, right now

it's happening. It's going to look a little different from what we've done. Can I ask you? So there's this other school of thought to look at in between therapists, like, effect sizes, you know? Yeah. There's a recent book that we did an episode on, Better Practice or, you know, and talk about, like, you know, it's really about the therapist getting some feedback. Like there's the outcome ratings scale and then looking at them and how they personally are doing. in terms of like, you know, are they giving empathy?

And, you know, did the patient feel hurt and understood? Did the patient feel like they were working on things that they wanted to? So this kind of like outcome measure and then using the outcome measure to kind of coach yourself and being coached. And what I've seen in a lot of therapy schools is there's some therapists that just do better than other therapists, you know? Yeah. And so I'm curious. like how you see that in act. Have you ever looked at, you know,

one act therapist versus another is one doing better than the other? And then what are they doing differently? Do you have any thoughts on that type of? I do. And, you know, what this kind of common core process perspectives orient towards is the centrality of the relationship and so forth.

And I think that's very important, although there are apps and websites and things that have reliable effects. So it isn't just the social relationship. I mean, you can show that some change methods can be put in context that remove that and still have a big impact. But what I don't like is not being told exactly how to get there. Because a lot of these models work when you do correlational studies of therapist factors and ratings of it. I can tell you in the study of mediational outcomes.

The therapeutic alliance, for example, rarely functions as a mediator. And the only way that that can work is that it means we don't know in the arms of these randomized trials how to get better therapeutic alliances. If we did, and it's important, then it would function as a mediator. There's only five studies we can find where that was true. There's a vast literature on it that, it's correlational. It's not controlled and functional. But I don't want to blow up the importance of the topic because, some of the few studies that have shown this, some of them are act studies. And we've done things

like put in multiple mediator models, the therapeutic alliance or psychological flexibility changes of clients. And here's what happens. Therapestic alliance mediates outcomes. If you put in the psychological flexibility changes of the clients, it eliminates the variance due to the relationship. And now that's the thing that mediates outcomes. Here's why. If you understand it, you won't freak out. You really care about the therapeutic relationship. Here's why. The therapeutic alliance, the therapeutic relationship works because good therapy models acceptance, non-judgment, conscious attention in the now from another caring human being

where your values matter and we'll work together to get things done that you came to do. Those are the six flexibility processes. And you know that because if I asked you to pick somebody in your life who lifted you up powerfully, just pick up anybody who really was a powerful, empowering person in your life. And I asked you these questions. When you're with them, did you feel accepted for who you are? Were you constantly being judged, or was that somehow far away? Were they looking at their watch, or were they looking at you?

Are they with you? And did you have a sense when your eyes met that their two conscious human beings were together? Would they ride over your values without a second thought, or did what you care about matter? Or was it always one way or my way or the high? highway? Was it always up to them or did what you care about matter? And could you be together in ways that fit the opportunities of the situation? Right, right. I can give you the answer to your questions and I haven't heard you say anything. I know what you just said. You just gave me six yeses. Those are the six flexibility processes. So here's the deal. The reason why you're empowered by people is because they model flexibility processes because those are the processes that most empower people. So why can't we do that? We come in as a therapist accepting, not judgmental, conscious,

from this kind of core awareness of two human beings interacting consciously where their client's values and your values are in the room and that we can be together in ways that serve the goals and interests that we have. So what happens when you teach flexibility skills to therapists, is their working alliances go up. Their therapeutic alliances go up. Because they start putting it in other moments of interactions with their family, with their friends, with their clients, and with themselves.

Yep. And so I think it's important, but I don't want to be left. I actually do a thing when I'm doing workshops. I say, how many people in here think the therapeutic relationship is really important? 95% of the therapists quickly raised their hand. How many people in here think you do a pretty good, good a job of establishing effective therapeutic relationships. 95% of the therapists raised their hand.

I say, how many people in here think you live in therapeutic Lake Wobogon where all the therapists are above average? And then the people titter because half the therapists are below average. Hello, it's a mathematical requirement. And guess what? Those are the ones that aren't having good outcomes, but they're in the workshop raising their hands. unless only, you know, really cool therapists come and do trainings with me,

which maybe could be true, but I don't think of that's that true. You know, so give me a way out of unknowingly being in the group that cares about the alliance, cares about the relationship, and is accidentally fostering dependence, you know, accidentally, you know, rescuing clients. I mean, you can care and be bad at something. And you probably know clinicians who are like that. You wouldn't want to send your clients to them, but boy, do they have a bleeding heart, man,

they just care about the alliance, blah, blah, blah. But you know, they're never coming off their client list. They're going to be on there forever. I bet you know a clinician like that. I do. And you don't want to send your friends and family to them. so I like the spirit of it and I think it's actually true but I want to be able to train clinicians so they get they get in the really high group and out of the group yeah I think here's what

I'm hearing from you therapeutic alliance of course is important but after I've read all these studies on the importance of it it's not clear what actually you can do to increase it and the studies that are attempting to increase it it don't always work out well. Yeah. And so what you're saying is, hey, here are some things that are probably going to mediate that impact. And, you know, I feel it from you. I mean, I feel from this conversation, like I feel like your attention, your connection, your, you know, your non-judgmentalness. It's evident to me. And so, you know, yeah, let's, let's target these six things. Let's see where you're weekend and let's see what we can improve.

And then adding in feedback informed stuff, of course, that's great. But if you just have that, well, then variation selection is what you're hoping for. But variation might not include the kind of variation you really need as a person to be a therapist who really move that client. Let's use Western science to say, what are the processes? And those processes are embodied by the therapist. We know this, you know, the psychological flexibility literature shows that kids, for example, if there's some sort of school shooting or something horrible, the kids who develop PTSD are the

ones who have parents are inflexible because it's being modeled to them. The same thing with therapy. So, yeah, let's work on ourselves. Let's put it into the space and the betweenness with our clients. And let's work with our clients. but don't forget that we're modeling in the therapeutic alliance processes, and let's make sure that they're good ones, and not just things like getting people to come back because they're dependent on you,

or getting people to try things because they believe in you. I mean, a lot of those things can blow up. Yep. How about believing in themselves? Let's, I want to hear from my medical students here, if they have any questions or thoughts as we kind of wrap up here, Maddie, do you have any thoughts, Matt? I liked the example of an imposter syndrome.

I think I have those kinds of feelings every once in a while. And I'm grateful to be exposed to all this stuff. And it just really fostered an interest of diving deeper into these different types of therapies. So thanks for coming on. Well, and thank you for modeling that openness by sharing that. By the way, imposter syndrome big time. In my head, not so much, I have to admit, as all where I get it, kind of drops away. I guess I just don't care anymore, but it's not that it's not there.

I can certainly find it. But yeah, and that just indicates that you're human and you care, I think. It kind of comes with the territory. Am I good enough? I don't know. Let's find out. Maddie, what about you? Here you go.

I probably have too many questions. But one I have is, because I know you talked about a little bit before, how you can use act like more in a social context to promote change. So I was just wondering what would that look like if it worked the way you wanted it to? Because there's so many things going on today where we could all use a little bit more acceptance and openness, like with Black Lives Matter and all the LGBT. Absolutely. Well, and there's about four or five randomized trials of act, forced stigma and prejudice of all kinds, maybe more than that. actually, if I expand it out, because some of it, if you look just at racial prejudice, I think there's two or three, but then you look at, you know, the sexual minorities or gender issues.

And what we found, actually, if you just take that issue of prejudice as an example, that it's predicted by failure to take the perspective of the other person, failure to connect with the emotional responses that come when you do, and unwillingness to sit with it when it's hard, those three things will predict the objectification and dehumanization of others in every area we've measured, whether it's, you know, you have a weight issue or a substance use issue, a mental health issue, gender, religious minorities, sexual minorities, racial minorities, language differences. In every area we've looked, there's this core, and it's predicted by these flexibility processes. And if you can change them, it alleviates it. So we've put it into things like the World Health Organization recently did a randomized trial of act with South Sudanese

refugees who are in Uganda with a self-help program that consisted, because most of these folks are not literate, of a cartoon book and an audio tape. It was published in Lancet. global health, a pretty high-level medical journal. And if you go to the World Health Organization's site right now, they didn't have anything for the stress of COVID, and they put up the Axel Help program. If you're stressed about COVID, you can go, and who will tell you, you can download the cartoon book and the audio tape. Because it's been, why? Because they showed, even in that kind of a challenged world where people had escaped from violence with nothing but their children and the clothing on their back and they're sitting in

dirt that you could get effect sizes as large as you get for self-help in the developed Western world. That was the benchmark they set for success. So now they're saying, well, geez, that broad, you know, COVID is really stressful to you, try this. That's probably helpful. So we've put it into interventions, the one that if I can just mention that is a social transformation change is an intervention we call pro-social, which takes act and then mixes it in with Eleanor Ostrom's Nobel Prize winning core design principles. Lynn Ostrom, she's dead now, but I spent time with her. My colleague David Sloan Wilson, who's an evolutionary biologist, showed that indigenous peoples can protect their forests, lakes, rivers, and streams, but only if they

organize their groups in an evolutionarily sensible way. And we're looking around the world at the failure of command and control economies or bottom-up invisible hand economies. They're both failures. But there's a middle path, which is the way humans actually work. The model of human beings that are in either command and control or invisible hand is a lie. We are not inherently greedy, and we don't like being told what to do. But we do like working with our mates.

We're the social primates. That's how we evolved. And if you can build a different culture around that. And so the book is called Pro Social. It's entering into small groups and organizations around the world. There's a large group of trainers. And so it's that spirit of let's put psychological flexibility where it's needed. We can put it in our diversity training.

We're going to do it anyway with your hiring committee. You have to do your diversity training. We've shown that we can actually move some of these stigmatizing processes even with implicit measures. But let's put it also in softening some of these conflicts between peoples and finding a way to go into the refugee camps or to deal with some of these, you know, what do we do with immigration? What are we going to do with what climate change is going to do? And a vast number of people are going to have to move or die. And you look forward. We have a train wreck coming if we can't figure out how to work together with others. And think about this as one group called human beings in one world, the planet itself,

and find a way to support each other and rising to these challenges. So psychological flexibility will be part of it and we're kind of out at the edge trying to figure out how to put it into this more communitarian and social level of intervention. That's good. You can check out the World Health Organization

publication as a start. We did, if I, excuse me, I've gone on, but we took pro-social and we put it, for example, in Sierra Leone with the Ebola, crisis. We did act plus pro-social and where we put it was in the city of Bo, which had an act clinic. It was one of only two clinics in the entire country. One psychiatrist, one psychologist and a six and a half million people, Sierra Leone. And we were able to deflect that Ebola outbreak at the height of the thing two summers ago, better than any other district

in Sierra Leone. And what did they come up with? Can I have time just to tell a quick story, two-minute story? You can keep talking, yeah, we're loving it. We're loving it. It's good. What we did was we went in, we did these act workshops using a thing called the Matrix, which orientes you a really quick way of, what do you want to move towards,

what happens inside you, move away, What does that look like on the outside if you move away? What would it look like on the outside if you move towards? This matrix training combined with Lynn Oström's design principles. And in a group, literally I have a picture of it, 500 people under a concrete roof in a village somebody proposed. Here's what we should do. Remember, these are folks who don't even understand the germ theory of disease.

They hacked health workers into pieces. machetes because they thought that people come in with moon suits for bringing the infection. Oh, no. You remember these stories. This is Sierra Leone. And somebody said, well, they have these rituals. You have to pray over, kiss, and watch the bodies of the dead in order to pass them on to the next life properly, right? And here they have people saying, no, we have to take people who are sick and carry them away.

And if they already died, put them in plastic bags and burn them. Well, that's a sacrilege. And what they came up with, I have a blog I wrote called Kiss the Banana Trunks. It was this idea of they would cut down banana trunks because there were banana trees everywhere in Sierra Leone. And they would wash through the rituals, wrap it in a clean sheet and bury it. And that ritual spread through the Bow District. And I have a picture in this blog of a woman carrying three wrapped banana trunks. That's her husband and her two children.

And she's walking to bury them, having prayed over them. There's a picture of the church where they did the rituals, and there was a mound of about 30 banana trunks, each neatly wrapped in a white sheep. So, you know, the West would never come up with that. Their idea was doctors with guns. They got the doctors who cared and the military with them, and they would hold guns of people and say,

give me your sick relatives, we'll shoot you. And yeah, it stopped the infection, but you in Sierra Leone, you know, in the areas where they did that, domestic violence is like two or three times high what it was before. You know, they ripped the culture in shreds. What the people who came up with a banana ritual called it

was a reparation ceremony because it was a ceremony of repair for the damage that they were doing to their culture. and to their love, to their traditions. So I don't know. I mean, let's not sell human beings short. Could we give them tools they can use and processes that matter and get in there

and step up to these challenges of racism and poverty and immigration? And if we don't, and climate change and all the rest, if we don't, I don't know how we're going to have a world that's livable for our children. or our children's children. All right. I want to give Matt a chance here to ask a question. I just want to thank you very much for your time, Dr. Hayes. It's been fascinating hearing you speak.

Enjoyed your articles talking about some of the similarities between Buddhism and Act, as well as spirituality in general, and maybe building off of your answer to Maddie's question. I'm wondering if there are any specific sticking points you've found in integrating Act into more of a Western worldview Are there certain points that people are very resistant on when they see some of the similarities applied to a Western point of view? Well, Act resonates with all the wisdom traditions, not just Buddhism. I mean, every single major spiritual registration has a mystical wing, and they all mess around with literal analytical judgmental language.

They all do, whether it's silence. I mean, Christian monks, they're doing silence, whether it's repeated prayer. You know, say on the rosary, you know, ejaculations, et cetera, the Catholic tradition I was raised in. So I think the B word has actually been a problem because while it's true in the East, some of these processes are there and as, you know, an ex-hipy. I knew about some of those things, more from the Hindu wing, actually, because my individual history of just people I happen to run into. although I ran into people like Joseph Sasaki Roshi, the now dead, famous, and master and so forth as a 20-year-old in California.

But I think it's actually narrowed the impact because you don't want to walk into South Carolina and start to talk about Buddhism. I mean, nothing bad about South Carolina, but I lived in the Carolinas, and you'll be shown in the door very quickly because the ministers have explained how dangerous this is.

And so let's find a way to be more universal in how we discuss these things. And it's fine to learn from wisdom traditions and read Buddhist texts if you want to. But that's not where Act came from. And I think we can put it into Western science. And not as that, you can put it into cultural wings that are not evident.

I'll give you an example. We do act-based safety training with people like boiler makers. You know, they have to go down inside these big machines and so forth and wear hard hats. And if a tool gets dropped from above, you know, they might die. And so safety matters, but they're pretty tough, you know. And the idea of wearing a safety belt and putting, ah, come on here. Okay, so we, here's what mindfulness is.

And the work that we're doing was the act for boilermakers, situational awareness. And everything you want to talk about with mindfulness, you can talk about in that language. And we've got, I've got pictures of boiler makers who had printed themselves the little act hexagon and glued it in the front of their hard hats. And why? Because here's the values-based thing. I want to be there to watch my kids graduation. You know, it's not about some grand hoity-to-y thing. You know, I want, but can we put things into normal people's lives?

Yeah, we can. And let's find a way to language about that in a way that fits the culture or the traditions. So culture adaptation doesn't just mean, you know, a collectivist culture. You have to talk about things in a collectivist way. No, it might mean talking to a person who doesn't have a high school education. When we're doing mindfulness work with them, we have images. and quotes from cage fighters who, by the way, do meditation.

You know, or shock jocks. Who's that famous shock jock who's a meditator? I'm blocking all his name. Howard Stern. You know, he's a meditator. If I'm going in and I'm talking to folks, I would, you know, real like blue-collar folks, I don't want to be putting up the Dolly freaking llama.

I'll show him a cage fighter and Howard Stern. Yeah, yeah. So let's, you know, I don't think we need all this full woo-woo wrap-around. I'm not meaning that in a disrespectful way. I hope I'm not heard to mean that we want to kind of say anything disrespectful about our spiritual wisdom of traditions. I'm just saying the essence is more important than the form. Yep.

And get it into people's their hearts, their heads, and their hands. whatever language does that I'm down to that hey this has been this has been really good can I have you back Dr. Hayes for another part too we'll do we'll do some more like I think the little examples really bring home

these points and this has been truly wonderful I've been blessed by it I think my listeners will have been grateful to have heard your wisdom and your experience. And I think some of the things that you were doing, you were doing very quickly. And so we'll write that out and slow it down for the written portion.

And if you re-listen to it, you could probably get it again and sort of let it sink in. And it's been a pleasure. And we'll have that. If I could just say, if people find there's something in here that resonates, of course, they can go to my website. You'll probably put it up there. It's just my name.com,

Steven C.H. dot com. And I'll send them a little seven mini lesson for free. I don't spam people. It's a one click out out, but I do send my newsletters. But also the act community has a tradition of giving away and really kind of making barriers low. So if you're interested, you'll find just out on the web a lot of resources that are there. The society that I, the association for contextual behavioral science, which has a really good, by the way, a psychiatry, special interest group is, you know, we charge values-based dues, pay what you think it's worth based on your ability to pay, as long as it's $12 because we give all that to Elsevier for the journal,

which then comes for free. So there's really low barriers to get in there and learn these things and to see the tapes. And so if it's something that resonates, follow it. I've watched what happens. If something connects and people follow it, they get good, they learn how. And I don't think Neil is the only one. It becomes useful very fast. Yeah, 100%. I'll have all your links on my website and in the show notes. I'll put some of those up as well.

And yeah, it's been a pleasure. And, you know, if any of you want to get some free CME, I'll put that up on my website in the free see me section on psychiatrypodcast.com. And I will be more than happy to collaborate with you in the future. And it's been a real pleasure. Thanks, David. Thanks, Neil, and thanks to your students.