Theories of Everything with Curt Jaimungal - Lilian Dindo: Mindfulness, Acceptance, Coping with Obsessive Thoughts, and ACT Therapy

Episode Date: September 17, 2025

YouTube link: https://youtu.be/L_hI7JNsbt0 Lilian Dindo is a Professor of Medicine at Baylor College, and we talk about ACT therapy. Patreon: https://patreon.com/curtjaimungal Crypto: https://tinyurl.com/cryptoTOE PayPal: https://tinyurl.com/paypalTOE Twitter: https://twitter.com/TOEwithCurt Discord Invite: https://discord.com/invite/kBcnfNVwqs iTunes: https://podcasts.apple.com/ca/podcast/better-left-unsaid-with-curt-jaimungal/id1521758802 Pandora: https://pdora.co/33b9lfP Spotify: https://open.spotify.com/show/4gL14b92xAErofYQA7bU4e Subreddit r/TheoriesOfEverything: https://reddit.com/r/theoriesofeverything Merch: https://tinyurl.com/TOEmerch LILIAN'S LINKS: -http://actfindyourpath.com -https://www.bcm.edu/people-search/lilian-dindo-20557 -https://www.bcm.edu/research/faculty-labs/act-on-health-lab -http://contextualscience.org LINKS MENTIONED: -Karl Friston episode: https://youtu.be/SWtFU1Lit3M -A H Almaas episode: https://youtu.be/6JlKf1QAvXA -Curt's Crash Course on Theoretical Physics: https://youtu.be/e8kyvdPP8os TIMESTAMPS: 00:00:00 Introduction 00:04:05 What is Acceptance and Commitment Therapy (ACT) therapy? 00:08:12 Suffering is a part of life 00:11:06 ACT is not just for therapy, but for general illness and rejection 00:14:24 Lilian's feeling anxiety in this interview *right now*, but ACT is helping 00:15:57 Dealing with panic attacks 00:18:22 "Anxiety" and "excitement" are physiologically indistinguishable 00:20:00 Implementing ACT (specific example) 00:26:15 Stop avoiding. The mind works by addition (not subtraction)! 00:30:00 Choosing courage vs. "mustering" courage 00:30:51 Coping vs. mollifying 00:33:45 Goal oriented vs. Value oriented 00:36:06 How to uncover your own values? 00:42:14 Do values imply a "should"? (specific example) 00:47:45 What separates those for whom therapy works for, from those who it doesn't? 00:54:57 Suicidal ideation / psychosis (there's hope with ACT) 00:57:14 Enhancing learning math / physics 00:59:50 Acceptance vs Acknowledgement 01:01:40 Physical vs Psychology (mind and body connection) 01:05:53 A visual example you can employ to abate anxiety 01:10:39 The role of belief / hope / faith / trust 01:11:08 "Thanking" the negative thought / emotion 01:11:50 People don't suffer with just ONE issue, but multiple Learn more about your ad choices. Visit megaphone.fm/adchoices

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Conditions apply. Visit your local Volvo retailer or go to explorevolvo.com. As with all podcasts, you can click on the timestamp in the description or over here you can see the timestamp to skip this intro. Lillian Dindo is a professor of psychiatry at the Baylor College School of Medicine and a researcher as well as popularizer of the psychotherapeutic technique or way of life, depending on how you look at it, called acceptance and commitment therapy, which we call act therapy. If you've watched the recent Carl Fristin episode, which is linked in the description, then you'll see that I consider that one to be the most important episode of all the theory. of everything podcasts. And that's in particular because it serves as a cautionary tale of what serious examinations into consciousness and reality-altering theories can cause in one's mind and

it's not pleasant. You may have heard me use the term abigenosis, which is what I think science will develop to, merging the inwardly experiential knowledges with the outwardly objective knowledge. Broadly speaking on the Toll podcast, one of the eventual goals is to take a syncretic approach to both the east and the west, which are ordinarily kept separate. What I like about Lily and Dindo is that the act therapy that she advocates for not only helped me during recent extreme psychological turmoil, but simultaneously it serves as a bridge between the philosophies of the East and the Practices of the West. Now if you're interested in the philosophies of the West and the practices of the East, then you can watch the recent

A.H. Elmas episode linked in the description as well. My name is Kurtzimungle and I'm a filmmaker slash podcaster slash person investigating theories of everything from a theoretical physics perspective, but as well as understanding the philosophies of consciousness and what role consciousness has to fundamental reality. Recently, there's been a video released on this channel called a crash course on theoretical physics, which was the longest time that I've spent on any single video on this channel. If you're interested in Salvatore Pius' ideas on quantum gravity or extra dimensions or what it means when a physicist, quote, quote, sets C to equal 1 to equal H-bar, then do consider watching that, as it's the lesson that I wish I had when I was going to university.

By the way, my background is in mathematical physics, and the math in this video was aimed at the high school level. There are plenty of myths in physics that are dispelled there as well, as well as general tips on learning mathematics and physics. Feel free to share that to someone who's interested in physics and mathematics. Thank you, and enjoy. Professor, one of the reasons I was and am excited to speak with you is because when one goes about this project of questioning what reality is and consciousness

and so on, which is essentially what concerns this channel, it can be destabilizing, there can be existential dread, and what I found that helped me was something called act therapy, an approach called act, and I was searching for more information about it a few months ago, and your name kept popping up over and over, and since then I think I've watched all of the material that has you online, so I'm super excited to speak with you about act, and why don't you start? off with what is act what does it stand for what is it and how did you become interested in it okay um so act is stands for acceptance and commitment therapy and act as a psychological treatment approach it evolved out of the behavioral analytic tradition and it focuses on teaching skills for living

effectively even in difficult circumstances so act actually is more than just a therapy. It's a framework for living well. And unlike a lot of treatment approaches or protocols that are tied to specific symptom presentations or disorders, Act is actually applicable to virtually all people, regardless of circumstances, culture, complaint. And I think part of the reason for that is the premise from which it begins. So act begins. with this fundamental understanding that pain, grief, loss, disappointment, fear, these are inevitable features of living a human life. And no one escapes it.

And so the goal of act is not the elimination of these experiences or symptoms, but instead a wholehearted pursuit of living a valued life, valued life areas like relationships, meaningful work, education, personal growth, even in the presence of difficult emotional experiences and thoughts. So the emphasis on the heart of act is creating this life, a worthwhile life that you want both now and in the future. So act doesn't believe that people are broken or that they have illnesses, just that they're stuck in understandable patterns that aren't working for them based on their history, what they've been through. And so Act gives people the tools to deal with the opportunities and the difficulties

that life throws our way. And in a nutshell, it helps us accept things that are really difficult to control and teaches us to commit to doing the things that we deeply care about. So in a nutshell, that's what Act has, you know, is about. And I got into it when I was in graduate school and I had learned, you know, all these other models of therapy. And to be perfectly honest, I wasn't, for example, traditional cognitive behavioral therapy, interpersonal psychotherapy. And they were fine they were great you know but it didn't personally resonate with me you know it was like i'm the expert and i'm going to treat this person in front of me using this intervention and i remember

opening up you know starting to study act and opening up the book you know for for the class and there was this sentence in the first paragraph of the main act textbook and that The end of that paragraph said, the single most remarkable fact of human existence is how hard it is for human beings to be happy. That sounds extremely Eastern. Is this influenced by Eastern approaches? It's absolutely. So the other thing it says is suffering is a basic characteristic of human life. And it's absolutely influenced by Eastern philosophy. So it has, you know, there are six processes in act. And again, unlike other treatment approaches, it was built from the bottom up. And so there were lots of clinical science studies being done even before Act was presented

as a treatment model. And so it pulled from things that were found to be effective. And from the Eastern tradition, for example, we know that mindfulness is effective. And that this basic premise that suffering is, you know, a part of the human condition. And so act certainly has parts of the Eastern tradition, but it's not only that. Act is an exposure therapy, but it's not just an exposure therapy. Act as a behavioral activation therapy, but it's not just a behavioral activation therapy. It pulls in different processes that have been shown to work over time and puts them into a treatment package.

Is it fairly new? It is not fairly new. The first textbook description of Act came out in 1999. So Act as a package came out in 1999. But the developers of Act had been researching for about 20 years beforehand the different processes like, you know, thought suppression, you know. we know one of the most consistent findings in psychology, which is hard to find, is that thought suppression, even though it works really well in the short term, it actually leads to a rebound effect in the long term. So trying to push down thoughts, trying to distract from thoughts, trying to run away from thoughts, very effective in the short term.

But in the long term, actually has a rebound effect. So the developers of Act had been researching these processes for a few decades before they came out with the treatment model in 1999. Between 1999 and now, the research literature on Act has completely exploded. There are over 300 randomized controlled trials right now of Act. And in general, a recent meta-analysis of the meta-analys has shown that it's either equivalent, to other gold standard treatments or in some cases can be more effective and enduring. What are some of these understandable difficulties you mentioned earlier that people go through? So I imagine one may be obsessive thoughts. What are some other examples of illnesses or if one doesn't want to consider them illnesses or whatever you would like to call them?

What are some examples of distresses that people go through that act seems uniquely equipped to handle? I mean, again, back to just living a human life. I mean, everyone who's got a pulse is going to be rejected at some point. No matter how wonderful and intelligent and beautiful and successful you might be, you're still going to be rejected by people in your life, you know, and that's going to hurt. We're all going to have an illness in our life. we're all going to face a medical illness that's going to challenge us. We are all going to face heartbreak, the loss of people we love.

In anything that you care about, there's the flip side that it comes with pain. If you have a child, you know that you love that child deeply. You care for that child, but with that love comes intense anxiety about their well-being and their health and their future, right? And so in act, they have this saying, in your pain, you find your values. And in your values, you find your pain. And that means that anything you care about, if you care about a friend and you care about a friendship and you're betrayed, right?

And so the natural thing, like, let's take that for an example. You have a friend, really good, close friend. and you were betrayed or you felt rejected. The easy thing to do would be to withdraw, not talk about it, withdraw, shut them out of your life, right? And you can also avoid future friendships, for example, because you feel like you've been rejected and you've been, you know, you don't trust. And so it applies to any of life's difficulties, you know, going to grad school, you have to be going to any action. actually, you know, educational program, it's not easy. You have to face criticism. You have to face difficult challenges. How do you face those challenges? Do you withdraw or do you face them? So when you

ask me, like, what are the challenges? I think there's really far reaching. It's anything in life that is going to hurt sometimes. And also opportunities, you know, when someone says to me, like you just said to me, will you come do this interview? It would really be much easier and less anxiety provoking to say, no, thank you, right? Much easier. But over time, if I keep doing that, number one, I never learn how to cope with my anxiety. Number two, my anxiety starts actually seeping into other areas because I never learned how to cope with it. And number three, my world's getting smaller because I'm not doing something I care about. This latter part sounds like the exposure therapy aspect,

but if you were to avoid it, well, that's going to make it worse than if you were to encounter it voluntarily, slowly, incrementally on your terms, then it increases your resilience. So are you feeling anxiety right now? I'm definitely feeling anxiety right now. My heart, like, so what is anxiety, right? And if you disentangle anxiety, what is it? Any emotion has three components.

It has the physical experience. So right now, like, my heart's definitely racing a little bit more than maybe the norm. I can feel my throat like a little bit constricted, you know. I feel a little bit shaky. So those are the physical sensations, right? Then there's the thoughts. Now, right now, I'm focused on you. So, you know, there aren't a lot of thoughts going on. But in general, like the thoughts are, like before I came in, oh, my God, am I going to know how to answer this? Is, oh, I have to blow this. I'm going to sound stupid, right? I mean, it's, these are the thoughts. And then the third piece is the behavioral like urge that you have that comes with an emotion. You know, that's a component of the emotion. And when it's anxiety, the behavioral urge is to run, right? It's to say,

not going to do this because if I run in the short term, my anxiety goes down. Right. So what I've learned to do, and I've had panic attacks, by the way, and I learned and I, you know, I've run away many times. But what I've learned to do is when I notice my anxiety, well, let me ask you this, Kurt. Let's say that I notice my heart racing and my three, stroke constricting. And I start saying to myself, this is terrible. You cannot do this. This is terrible. This is the worst thing. This is awful. Why am I like this? Why after 20 years do I still get this way? It's so ridiculous. Get with it. What do you think will happen to my anxiety? It won't go away. It may increase. And especially if you leave in that situation once,

it'll make it much more likely for you to leave again. And so avoidance will increase as well. Both, yes. So actually, if I respond to the physical sensations with rejection and why, and this is awful, then it actually increases the anxiety. So now when I notice my heart racing and my throat constricting, I say, okay, your heart's racing. Okay, your throat's constricting. And this is important, like this is important for me to do. So, you know, I can be with this. That's the value part. Exactly. You connect it.

The values piece is what makes it worthwhile. Like, why would I put myself in this situation? Well, I'll put myself in this situation because it matters to me, because this is something I care about, you know. So it provides the motivation. It provides the why for why I should do this. Values are the purpose behind why you might do things that are uncomfortable. are difficult. So there's number one, you know, just noticing my, okay, like my heart's racing. Okay. That's okay. You know, my throat's, okay. My throat's constricting. That happens when I go

running. That happens in many situations. But sometimes I interpret it as dangerous and sometimes I interpret it as pleasant. But the physical sensation itself is the same. And so it's like now I can say, okay, I'm okay. I can have this anxiety and still commit to doing this because it matters to me. Is it exactly physiologically the same? So I hear there's plenty that people will say excitement and anxiety are two sides of the same coin except it depends on the interpretation you place on it. One is positive? But I don't know. Is that actually true? If one was to examine all of the biomarkers, could one in a blinded study determine dispassionately, this actually this person is going through an anxious emotion, whereas this one's going through an excited emotion?

crazily, yes, they're the same. There's this, and you might want to cut this off from the video. Sure, sure. You might want to cut this off. But anyway, there's a study by some famous sex therapists, and they did a biomarker study, actually, where they hooked up people who were, you know, like blood, electrodermal response, heart rate, few other biomarkers.

And they found that the biomarkers were exactly the same or similar enough, I guess, so that's statistically significant, that people having an orgasm were indistinguishable from people having a panic attack, right? Well, that's extremely interesting. Right. And so, you know, the heart racing, broke and stricting. like feeling like whoa right like they were indistinguishable on the electrodermal response and on the heart rate and another biomarkers so so yeah in a lot of

ways they're not distinguishable actually okay now in a meta manner we've gotten to the why of act that is why should people who are listening slash watching to this care about act so the value of act let's get into the what of act what is act can you break it down step by step how does someone go through the process of act how does the person go through the process of act well it depends it depends which um way you do it right so which treatment delivery format you're doing and so it could be one-on-one therapy it could be workshops it could be online you know okay i'll give you an example for me i was dealing with the obsessive thoughts that came from rumination of what the heck is reality and then questioning my own. And then I started to use

one of the analogies. What's great about act is that it has these visual analogies. So one of them is thoughts as if they're passengers on a bus and you're the driver of the bus. And if you were to simply quiet the thoughts or tell them to shut up or go away or be distressed about them and place an undue amount of attention to them, then they become a bit louder, much like an obstreperous audience member would become more agitated the more that you speak to them perhaps what you should do is simply acknowledge their existence say oh i see that you're there which is why by the way i want to get to is acknowledgment a better term than acceptance but we can get to that later that's a very good question because accepting to me seems to take those thoughts on

and say oh no your reality should be questioned and perhaps so-and-so is not true so anyway i that's a very important question and i hope we get to it we'll get to it's written down and And so then I would view those thoughts as visually as passengers on a bus, and I would say, okay, well, I'm going to direct this bus where my values are. And initially, I missed out on the values portion, so it wasn't as effective until I, because then where am I going with the bus? That, to me, is where the values come in. And why should I even go there? So initially, I missed out on the value step. Later, when I added that, it became more effective for me.

Okay, so that's how it worked for me. And I think initially, before that, I was doing something that didn't work, which you mentioned earlier, a thought suppression. I did, I had a rubber band on. Anytime I would have these thoughts that would give me anxiety, I would do this self-administered adverse therapy, which I thought worked for thoughts. And it apparently doesn't. It rebounds later. Maybe initially works, but so I stopped that and found Act and then I saw some success. So that's my personal case with Act.

So given that, that's what I mean. Can you take us through an example of how someone listening may employ this in their own life? And perhaps how one should apply it in their own life is too broad. And maybe you just want to take a specific example and say, you understand the question. So I'll start broad and maybe go a little more narrow. But tell me if this is the wrong direction. So I'll share the kind of key features, right? First of all, a rich and meaningful life and act is about what you want, not what you don't want.

It's about going for something that you value and care about rather than escaping from or avoiding experiences that you don't want. Okay. And so, for example, patients will come in or people will come in and they'll say, I don't want to feel anxious anymore. I don't want to feel pain anymore. I don't want to feel sadness or guilt anymore. people are quick and automatically will tell you all the things that they don't want. And our medical field and in general, our society is like, okay, well, let's figure out how you cannot feel this way, right?

Let's figure out how you cannot feel this way, think this way, et cetera. Act will say, well, okay, if you weren't in pain, what would you be doing instead? if this pain we're not getting in the way of living as it is right now, what would you be doing? If you weren't so anxious, what would you be doing, right? If you weren't so guilt-ridden, what would you be doing? You're trying to get away from symptom focus to what do you want to be doing in your life if those things were not there. So that's the first thing. Then there's the issue of how to manage emotions and thoughts.

And our society has trained us to kind of think or to respond to emotions and thoughts that we don't like by pushing them away. Right. If I tell my friend, I feel really anxious. What's the first thing they're going to say, Kurt? About what? If I tell a friend, I'm like, I go to a friend and say. No, no, no. Sorry.

They may say, what are you anxious? about? Okay, they might say, what are you anxious about? And I'll say, I'm really anxious about giving this talk. Then what will they say? Oh, don't worry about it. You'll do fine. You go, girl. Yep, exactly. Don't feel anxious. You're fine, right? Don't worry about it. You're fine. It's like, so all the implicit messages we get is don't feel that way, right? Or if, or if I'm saying I feel really sad right now, don't feel sad. It's going to be fine. Right. Right. We are taught even all the advertisements about antidepressants, anxiolyics, are you anxious? Are you sad? This can take it away. Right? This can take it away. So we've been programmed to think it's not okay to feel this way. And so the problem is that both emotions and thoughts, things inside our body that people cannot see. are mostly involuntary.

These are mostly conditioned or programmed responses to certain circumstances in our life. And the idea in act is to simply notice them for what they are and not struggle against them. So let me give you two examples. Number one, if I say, and I'm going to give you a very benign one, Mary had a little lamp. When? Red, white, and?

I don't know this part. Blue. Blue. One, two. Three. That's programmed. If I tell you, Kurt, do not say lamb after Mary had a little. Could you not think lamb? Could you do that?

I mean, I can't, I don't know. I imagine no. I imagine the answer is no. Okay, Mary had a little, think of something else. Panda. Okay, I'll come back to that. You will always, always have lamb in your head. Because our brain does not work by subtraction.

Our brain works by addition. So trying to undo something is impossible, actually. If I told you right now, a good friend of yours just got into a accident? What would that trigger for you? I'd feel anxious and worried. Could you undo that? I don't know. Some of the Buddhists say that with enough mindfulness training, one can get to a point where stimuluses no longer provoke you, at least not to the same degree. I've seen some video online of a monk self-alighting. So setting one self-alighted calmly and then just dying. I don't know. how the extreme amount of discipline so absolutely it's true what you learn is how to respond to these

things in new ways it's not that they stop showing up they still show up but when they show up and you're not as consumed by it your attention is not so narrowly focused on it it doesn't have as of an impact on you, right? So if I'm, so I see this, for example, in a lot of my pain patients or my chronic medical condition patients, like their life has been so fixated on the medical condition, on the pain, on, you know, getting things, you know, getting the right meds, getting this, getting that, that they've lost track of the rest of their life and they're depressed. they're not focused on their family as much.

They're not focused on their career as much. They're not focused on things that bring them joy. It's like they're narrowly fixated on one aspect of their life, which is the condition or the illness or the medical problem. And I'm saying step back and recognize that there is more to you than that. But if this is the only part you're going to fixate on, of course it's going to like consume you. And paradoxically, Kurt, the more you open up your life and do things like these patients with

medical conditions, when they stop fixating just on the medical condition and start doing other things again, paradoxically, the pain goes down. It's the same thing with anxiety. When you start engaging in life more and you allow the anxiety to be there without it being kind of the thing that drives whether you do something or not. Paradoxically, the anxiety goes down. A question that occurred to me is when you were mentioning that you were feeling anxiety. And by the way, I'm extremely nervous generally when I'm doing these interviews as well. And also being interviewed for sure. I'm extreme. Oh, my God. I don't, I generally say no to people interviewing me. So I don't have as much courage as you. Perhaps I should muster some.

What occurred to me was, does this technique help you? Can I say something? Sure, sure. perhaps you will choose to muster some you don't have to do anything right it's even that subtle comment about perhaps i should you don't have to do anything do you choose to is there something about it that matters to you in that it's a very different experience to say i have to do this versus I'm choosing this willingly, even if it's going to elicit anxiety in me. That's great. That may help me in the future or I may choose to allow that to help me in the future. I don't know what's the right response to that. But regardless, where I was getting at was, does this technique simply allow you to cope or does it ameliorate the anxiety?

Because those are two different issues. Yeah, absolutely. They are. And that's the paradox of this. Although act does not aim to reduce symptoms, it's asking you to willingly sit with. So that's the term I use instead of acceptance, because I'll tell you why. If I'm willing to have the anxiety, that's instead of acceptance. If I'm willing to have the anxiety in service of something. that matters to me, right? That's the goal. The goal is me being willing to experience

something difficult because it's in service of something that matters. But when I do that, repeatedly, paradoxically, my anxiety goes down. It's not the goal. The goal is not to reduce my anxiety. The goal is for me to live a life that's meaningful and rich. But what's paradoxical and what all the research is showing is that when you do that, actually anxiety goes down. And I'll give you examples from my studies because, so I'm funded by the National Institutes of Health and the VA Department, the Veterans Affairs Department. And NIH and the VA for a long time has focused on symptom reduction, right? So when I apply for grants, I say...

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treatment, I don't say that ever. Not once do I say, okay, you know, you guys met criteria for depression, which they all do, to be in the study, for example. And my goal is for you not to meet criteria. I never say anything about that. It's a political decision. It's a funding decision that I put it as the outcome. But paradoxically, the intervention, even though I never talk about reducing anxiety and depression, I talk about helping them live a rich and meaningful life and to let them explore their emotions and not be afraid of them. But most of my studies, I have found significant reductions in depression and in anxiety and improvements in meaning and purpose. Is that too complicated?

No, no. So first, there are quite a few thoughts that occur. So one is we mentioned the Eastern approach. This, to me, sounds like the merging of the Western approach of bearing one's cross. So it doesn't matter that you're going to feel the suffering. You do it anyway because there's a higher value. And then the other thought that occurs to me is that it's extremely interesting how often that happens in different aspects of life, where if your aim is to reduce something,

something, or to attain something, you don't get it. But if you take a route where you're not supposed to care about what you want, you end up getting it. So, for example, in relationships, if you desperately want that person, you try to please them, you end up not doing so. And if you are in business and you try to get money, often it doesn't work out. You have to be passionate about the product. And so it's just interesting how that work. You don't get what you want by trying to get what you want. Well, I think what you're describing is the difference between being goal-oriented versus value-oriented, right? Let's say my goal is to get into medical school.

And I'm like, I need to get into medical school no matter what, you know, pressure from family, whatever it is. Like, that's a goal. I can check it off the list, right? But what's the value behind that? Is it to help people? is it to you know is it a selflessness thing what is the value behind getting into medical school and if you if you focus on that then let's say you don't get into medical school right then you say

well what was the value behind that was the value behind that helping people are there other ways that i can help people there are many other ways that you can help people right you can go to school, you can go to nursing school, you can join a nonprofit that focuses on these things. And so when you're focused, when your values are clear, then you're more about the process. You're more about the experience versus if you're goal-oriented, you just want to get there and check it off the list. But then you check it off the list and you're like, well, what's next? Let me say in other words, and let me know if this is correct so that I make sure that we're on the same page.

Goal versus values is akin to when sometimes people say you shouldn't be objective oriented versus process oriented. Is it akin to that or is that different? It's kind of similar. Yeah, it's kind of similar. Okay, so that's a great question right there. Are you coming up with them or are you realizing them? So are you making them? Are you uncovering what was there?

Anyway, that's a sub question. That doesn't sound like an easy process. So how can you help someone through that process? What tips do you have for people to realize their own values? In the example you gave, a potential was that I want to help people. That's why I want to go to medical school. But it also may just be, I want the status, but I think I want to help people. Or I want the money, but I think I want to help people.

Or actually this was instilled in me as a child, and it's actually not my own value. I don't even care. But that takes to me, that sounds like that I may take months or even years of therapy. So how does one streamline that approach to get to one's values? That's a really good question. And I actually struggled with this for a long time, actually. Like, you know, it seemed like such a broad question to me. Like, what are your values?

Well, it's tough, right? And I remember, like, having this aha moment, you know. And, well, there are many ways to get to it. But I had this aha moment, which broke down values into, like, how do I want to be in this moment? How do I want to be like, okay, I'm with you right now, Kurt. So I check in with myself and I say, what do I want to be? How do I want to be in this moment with this person, you know? So it makes it a little bit more concrete to me, you know. But it's also that, but it also needs to be a little bit more broad. And I'll give you a very personal example from my

life like um so i'm you know i'm a working mother and balancing my career with being the kind of mother i want to be can be very challenging you know and so for example i go to work let's say from eight to five and as i get up off my desk um kurt and i'm walking out the door right Right. There's a lot of anxiety because my colleagues are still there. I still have a lot of things on my to-do list, right? I have a lot of things on my to-do list. My career is very important to me. And so when I get up at 5 p.m. to leave and all my colleagues are still there and my boss is still there. And I still have a lot of things on my checklist. I'm anxious. And I connect with... the value of what I want to be as a mom. And I want to be a mom that's available for a certain number of hours every night with few exceptions because that matters to me. So I carry the anxiety I have about my career, but what helps me walk out the door

is kind of knowing that my son is on the other side, right? So sometimes it's just a matter of like, you know, filling out questionnaires or like just, you know, people asking you certain questions about what are your priorities in life, right? But I see a lot of people just on automatic pilot, right? On automatic pilot doing things like they always have staying at work, long hours, barely seeing their parents, you know, their children. And they say, they say, like, for example, the patient. that, like, works double shifts, then goes to the bar, takes out a picture of his children and shows the people at the bar, like, here's my child, I love my child so, so much, goes home, hung over, and when the kid comes to talk to him, pushes him away, like, no, no, not now. I'm hung over.

We can talk about what matters, right? I can say my son matters. I can say, My parents matter to me. My sister matters to me. But if I don't put it into an action, it means nothing. It doesn't mean anything. And so let me give you another example. Sure. Kurt, if I asked you, if I said there's a building on fire outside and I want you to run into it,

what would you say to me? No, no. Thank you. You would say no? Thanks for the offer. Yeah, yeah. What if I said to you a loved one you have is in that building? Yeah.

What would you say then? Yeah, which loved one, but I understand. Yeah. So if it's my wife, I'll go in in a second. Okay. It shifted from an automatic no to an automatic yes because there was the why. The question is, why would I go in there? What would be the purpose?

And the purpose is your partner. Right. And so when you're, is it going to be easy? Is it going to be non-threatening? It's going to be awfully hard and it's going to be life threatening, right? Right, right. And yet you are willing to experience the fear, the dread, the anxiety that it's going to take to get into that building because there's something there that matters to you. So that's the acceptable.

acceptance is not just saying, oh, okay, I accept, I accept, you know what I feel here. It's that I'm willing to feel what there is as I move towards something that scares me. Earlier, we had a little discussion about should versus values. And you were saying, Kurt, well, we didn't explicitly have this discussion, but you said, perhaps you shouldn't think in terms of should. I know that's paradoxical, but you understand what I mean, that in terms of thinking of choice, it's better. And I'm unclear how values don't imply a should. So if you have a high value, to me, a should comes in because it's you're doing what's right. Now, it's what you're saying

that the value is somehow internal and the should is somehow external and it should come from should. It should come from you or I, it's a bit difficult for me to say without using the word should. So hopefully you understand the question. I mean, it could be just an issue of linguistics, right like it could be just the terminology we're using but values are freely chosen from from an act perspective values are freely chosen it's not what our parents tell us we should want it's not what i feel society wants me to say right in the definition of values it is freely chosen and one indication that someone is not living a life that's consistent with kind of what they want is there's a lack of vitality.

Like you don't sense vitality in what someone is doing, right? It feels more like it's being imposed, that it's like, I have to do this, right? Or I don't want to be doing this. Or you're just not, you're not vitalized, right? So back to my example with work, sometimes I feel like giving personal examples helps. If it's too much, tell me. But like, no, the more personal the better. You know, every time I get really frustrated with my job, with my work, with my career,

I step back and I ask, do I choose this? No one's forcing me to do this work. I don't have to do this work. Do I choose this work? And that helps me a lot with the full recognition that I choose a package, that I can't just choose the things I like and throw away the things I don't like because everything we have in our life is a package of, you know, the things you like and then the things that you have to do because, you know, it's part of the broader package. So maybe that's kind of what you're talking

about with the should. Like, okay, doing this work, I really have to write certain notes. And I have to, like, do all this bureaucratic stuff. That said, do I choose a package, that this as a package is something I care about, that working with these patients, doing this research, makes this other tough stuff worthwhile? Interesting. One of the reasons I was bringing that up is because I know there's a heavy emphasis on internal locus of control. It's called internal locus of control, I believe. And then that to me sounds like to get philosophical, like the humanist movement. And then that stands in contrast to

religious movements, especially of the West, where the West is more about there's some commandments you should follow, you need to follow. But then to many people, their religion is what they value. So their value comes with the shoulds in that case. And then it's one to say, well, if you're Christian or if you're Muslim or Jewish because those are the Western traditions, if you're those, then perhaps you need to abandon your religion in order to properly apply act therapy so that you have the internal locus of control. It comes from you. It doesn't come from God. You choose it. No, I don't think so. That was what was lurking underneath. I don't think so. I think if you choose a spiritual, like a spiritual tradition, you're choosing that. You're choosing the package.

It's like stepping. Yeah, again, like you're talking. You're talking. again about a very concrete thing that's like more goal like that okay so i'm going to church check right that's a goal i'm going to go to church check and goals can be very valuable to like tell you if you're on the right path towards something you value right but the broader value if someone is you know maybe religious now some of them are of course some people are doing it out of compliance right Right. Absolutely. And then other people absolutely are doing it because spirituality as a broader domain is valuable. And the specific goal, if you want, or package that they choose is a Christian or Jewish or Muslim, right? Like the broader thing is that they are a spiritual person and that the goal they have is to fulfill certain obligations within that spiritual tradition. It's like me, I love what I work, what I do. And as part of that, I have to, I actually have to do certain things.

Like check, you know, I have to do certain trainings. I have to fill certain CMEs, so on, so forth. Some bureaucratic. It's the values part that's, that you don't have to, that you, that's chosen. The goals are the kind of the posts along the way that you can say, okay, check, did that. I know I'm on the right track. I understand, yeah. What separates people for who this works for quickly or plenty from those who it takes a longer time to work for or works less for?

Is it their temperament? Is it their attitude? Is it the application of a certain technique? The amount that they stick with it, for example? Yeah. That's a really good question. And I think it's hard because for decades in our field, we have been trying to do these. matching studies, right, where, okay, we're going to match this kind of person with this

kind of therapy, you know, like this person would do better with this therapy, this person would do better with this therapy. And despite millions of dollars being, you know, committed to this kind of research, we don't really have a good answer to that question, not just for act, but for really a lot of the therapies. Like, we have not been able to figure out what's the thing that, you know, matches people. Like, why would this work for someone? That said, in the meta-analysis of the meta-analysis of act studies and some of the comparison studies, what we know or what we found is that people who have suffered longer

tend to do better in act, right? And people who have complex difficulties tend to do better with act. Why do you think that is? It's a good question. So my thought on this, and I don't know that there's any data behind this, but in act, there's a very key concept called creative hopelessness, okay? And the idea behind creative hopelessness is, okay, like, let's say you have anxiety, right? And I ask the person who has anxiety, how long have you had this?

And they'll say 15 years. What have you tried? Well, I've tried alcohol. I've tried drugs. I've tried medications. I've tried avoiding. I've tried deep breathing. I've tried it all.

Okay. And how has that worked? hasn't worked in terms of reducing the anxiety. Okay. And how has it worked in terms of like where you are with your life and how big your life is? And they'll say, well, maybe it's really kind of gotten smaller my life. So what we do with creative hopelessness is explore with the person, how long they've had the problem, all the techniques they've used.

and if they've gotten anywhere with these techniques in the long term. And what the result is is the patient being like, oh my gosh, I've been doing this for years and years and years. And I'm worse off than when I started. This, it's called creative hopelessness because there's a hopelessness to it. But in that moment, it gives you the opportunity to say, okay, I think I need to try something different. this has not worked it's like it's like up in front of your face that it has not been working you know you've laid it out and that everything you've been doing has not been working and so the creative part is that there's this pivotal moment it can be a pivotal moment where and i've seen it happen

countless times i see it in my you know my participants my client's eyes like there's a pivotal moment that's like, oh my gosh, this is not working. So I need to try something else, right? This sometimes requires a long time of suffering, right? So that's why sometimes I think it resonates because for some people, they've tried, for example, distraction and it's worked temporarily, and they've only had it for a few months, and they're good to go. So, you know, it's fine.

But for people who've had it for a while, this resonates there's this pivotal moment where they're like ah okay okay it sounds like they've tried plenty and then they're thinking well i need to try something new but that something new could be almost any of the therapies that are tried and you said that act seems to work better for these people who have tried plenty already so what is it because if it's this pivotal moment then would that pivotal moment not apply to any of the other therapies that they could try that are new any new therapies? I mean, again, act is, it tends to be equivalent to other gold standard. Ah, right, right, right. So it's not, I'm not saying it's better and I'm not, I'm not sure it's

conclusive that it's better for these people. But act is one of, it is the only therapy, actually, like scientifically based one that's been examined with, you know, randomized control trials, that has such a heavy focus on the values. And it's, it's, it's, And it's also built on all these, you know, basic science studies showing that like thought suppression doesn't work, distraction doesn't work, they come in the rebound effect. But again, the values piece is what provides the motivation to do the hard work, right? So the woman who has had panic attacks for 10 years and barely leaves her house anymore, okay? and has been to treatment and they've tried to reduce the panic attacks, works for a bit, not too long, and she's not leaving her house very much anymore.

Her daughter is graduating, and this requires her to go sit in a building with or in an auditorium with hundreds of people, like the most stressful thing for someone like this. What would motivate her to do this work, Kurt? as her daughter is on the stage and she looks up into the seats and she sees that her mother is there, right? You make the values front and center for the mom. Do you want your daughter to see you there? Would you be willing to experience that feeling of overwhelming fear? anxiety if it means that your daughter for the rest of her life will say my mom was there. So values make it worthwhile and it's a really important aspect. And so like a lot of the

traditional CBT have now incorporated values into their treatment models because we're finding it's such a powerful piece, right? But values have always been the heart of act. have you found any studies that demonstrate whether act works for suicidal ideation or other I think you call them distressors before or but I'm not sure other because we don't want to call them illnesses but other and nor do we want to call them disorders per se but issues other issues maybe psychosis schizophrenia derealization or so what's really interesting is like I said there's over 300 randomized controlled trials on act. And they range from mental health conditions like depression, anxiety, psychosis,

to Cotillomania. There's a huge range of mental health conditions. It's been effective in a huge range of medical conditions, diabetes, multiple sclerosis, cancer, heart failure, a lot of those, HIV, and in terms of, the outcomes are different, right? It's like getting back into care or cancer-related anxiety or... Oh, okay. Just to be clear, you're not saying employ act in order to induce your cancer to a state

of remission. No, it's like for things related to it like cancer-related anxiety. Or for in the heart failure patients, it's improving behaviors that would improve actually your health condition, right? migraines, it's been helpful for migraines because migraine is a very similar condition, right? The more you struggle that you're getting headaches, the more you're going to get headaches. And the more you avoid life because of fear of getting headaches, the more sensitive you become to things that trigger headaches. And also, it's been used in a range of life things like chess performance, stigma, prejudice.

um rowing so enhancing sports rowing enhancing sports rowing enhancing sports performance for example um how about learning in general so like for example in this channel learning math and physics i don't know if i've seen a study on that that doesn't mean it doesn't exist um could you imagine how it could be used to enhance learning or would it just be if some anxiety was holding you back from learning we addressed that and then the learning i think so i think so i think it would be more like, how do you become more present focused when you're studying? How do you, you know, not let anxiety and difficult thoughts get in the way because you can overthink. You can worry so much that it gets in the way of how you do. So you would address that

part of it, you know. Like in the medical conditions, we address treatment adherence with our diabetic patients, for example, because patients don't want to think about their condition, they won't take their medications because the medications remind them of how sick they are, right? It's an avoidance strategy. And so you're telling them to face this thing that's scary to them because actually in the long term, it will help them with their condition, right? So there's a lot of treatment adherence things that act works on because a lot of difficulty with treatment adherence is due to avoidance.

It's uncomfortable. It's inconvenient. It's anxiety provoking. Act has also been used in workplace stress and burnout among medical professionals. But you asked, oh, I know what you asked me about, does it work for psychosis? Which reminded me, and now I'm jumping back. So Act is listed as an empirically supported treatment by the American Psychological Association and other important boards for five conditions, for depression,

anxiety, OCD, psychosis, and chronic pain. Now, it's been tested in dozens of other conditions, but to reach the scientific rigor to be listed, you have to have a certain number of clinical trials and they have to be from independent labs. And, you know, so there has, it's a very rigorous thing to get listed on that. But imagine it's actually listed as an empirically supported treatment for psychosis.

And so, yes, it works for that more in terms of not reducing symptoms per se, but learning to live with them more effectively and productively. In the first study of psychosis, act reduced re-hospitalization. And getting back to the question of, is acknowledgement a better term than acceptance? Because acceptance has the connotation that you should accept the thought, like go with it, believe it even. So it's not what it should be called. It's what works, right? It's what works. That said, I don't use the term acceptance in my work. You know, it's scientifically it works, you know, when we're writing about it. But in the like day-to-day interactions with my patients or with my clients, I don't use the term acceptance because it's a very loaded actually, actually term.

Like they take it as like just suck it up and accept it, you know? And that's definitely not the intended message. Acknowledge is a much better term, I think. The thing that acknowledge doesn't get into, I think, although it might, I just haven't thought about it enough, but acknowledge is a really good one. I think what willingness does as an extra step is connects it to the value because are you willing to feel this way or to have these thoughts in service of something important to you? Would you be willing to experience fear and anxiety if it means you'll be at your daughter's graduation?

Would you be willing to experience all the difficulties of graduate school if it means that you'll get to do what you want to do at the end, right? So the willingness piece for me connects it to the other side, which is a critical one. But certainly, acknowledge is much more, I think, compassionate than accept. One of the questions I have, and it's more of a philosophical one, is determining whether an issue is a psychological problem or a physical one. So, for example, for me, for a series of weeks, I was waking up soon after going to sleep,

terrorized by something, by a dream, and feeling horror as they woke up. And then it turns out, as soon as I started sleeping on my side, all of that went away, and it's because I have a mild sleep apnea that I didn't know about. And this is common in people who have sleep apnea, your mouth, your throat, closes and so you wake yourself up and because it triggers a certain reflex you wake up in fear and you think or I thought that I need to go to see Sigmund Freud or Carl Jung to resolve childhood issues that are coming up in my dreams but it all went away when I slept on my side so that was a physical problem that I thought was a psychological one so how does one

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the lack of it being the cause of the problem? Let me know if that was clear because I can restate that. Well, the question is a hard one and I won't answer it directly. What I will say is that mental health and physical health issues are intertwined and play a very strong bidirectional effect on each other. So, for example, people who have, when you do longitudinal studies, people who have depression are at much higher risk for cardiovascular disease and migraine and a range of physical health problems. And the reverse is true. Patients with migraine and cardiovascular disease, MS, are at much higher risk for mental health difficulties like depression and anxiety. So it's, they're very bidirectional and longitudinal studies have shown

this and people have spent a lot of time trying to figure out which comes first and it differs for different people. I think the important thing to know is that they do influence each other, you know. I'm not sometimes targeting both is the best strategy, like let's take migraines, right? Stress, so migraines are. triggered by many things. It's triggered by certain foods. It's triggered by certain changes in elevation. But it's one of the main triggers of migraines is stress, right? So if you address the stress, you might minimize the number of migraines. That doesn't mean that migraines are not a true neurological condition because it is. The brains of patients with migraines,

even outside of a migraine episode, their brains are different from people who don't have migraines, right? And so would that person benefit from both a preventive or acute migraine medication and stress relieving strategies? Probably. Absolutely, actually. Same thing applies for cardiovascular disease, right? People who have depression are two times more likely

to die from cardiovascular disease than people without depression, right? Is that the cause? It's hard to say, right? But does it impact it? Absolutely. So maybe that's a different way to answer your question. Sure. And can we end on the visual, just one more visual exercise?

One more visual. Well, there are many, but one like the bus driver, for example, that's very similar to the bus driver, but I do individual. with my patients. It's called the lifeline, you know, and I get, and it's a physical one in the sense that I stand next to them. And then I say something like, what is something that you really care about, that you haven't been doing, you know? And so maybe someone will say to me, like, I want to go out more with friends, but I'm too anxious. And then I'll really get at, I'll say, well, tell me why that matters to you. You know, why, why do you even care about that? Well, because, you know,

I want to have friends and it's important and I really care about people. And so I'll put a sticky note on a door, which is a little bit far away from us, you know. And I'll say, what's one step that you can take? What's one small thing you can do that can move you closer to this? And they might say something like ask someone on a date or they might say something like say yes to an invitation, right? And I'll say, great, and I'll put that sticky on the door next to the value. Like, want to have more social interactions. I want to ask someone on a date. So then I say, okay, let's think about walking towards that. Let's imagine that you're about to go ask someone on a date. tell me what what shows up for you like what thoughts pop up like you're not good enough or

you're going to look stupid you're you know not lovable enough like what shows up so i guide them but they start like telling me some thoughts and they say okay and what shows up in your body as you think about going to ask someone on a date and they'll say oh like anxiety like my heart's racing you know and so i'll stick sticky notes on their body that has all these things like heart racing she's going to reject you you're going to look like a loser this is terrible i can't handle it right but when you write it out and it's like outside your head and you're putting it on a sticky note on their body first of all you're you're kind of disentangling a little bit the monster that comes as a flood and then i asked the person to start

walking with me towards that sticky note that says what they want to be doing, right? And as they are walking, I start yelling out all these things at them. You're going to blow it. You're going to be rejected. It's going to be terrible. You're going to panic. And as I do that, I turn them around so that they stop walking towards their value and start walking away from all. And then I say, how does it feel to walk away from that thing that matters to you? They'll say it's a relief. Because I stop, I stop yelling at them as well. Like, their mind stops yelling at them. They've dodged a bullet. And I'll say, okay, that's right. You've dodged a bullet. But what about that thing that matters to you, that thing that you really want to do?

And he'll be like, well, it's still far away, right? And I keep doing this. and like walking and then turning him around walking and like yelling these things that are on the sticky note and turning him around until the last time or the final round what i'll do is i will walk with him all the way to the sticky note have him grab the sticky note even though the thoughts are still there right he was willing to walk towards that thing that mattered despite all these difficult thoughts and emotions that showed up. And then I'll say, what does it feel like to actually get there? And they'll always say like that feels like more rewarding. Like I didn't let the fear win. I didn't let my mind win. I didn't let my emotions win.

I let the thing that matters win. I like that. so the reward the reward trumps the relief correct interesting because of time constraints the last three questions were answered over email and so i'll read them aloud here question number one how much of a role does belief slash hope play enact that is to say when a patient believes quote unquote that the treatment will work or hopes that the treatment will work or trusts that the treatment will work then i imagine it would increase its efficacy lillian states the placebo effect is a real thing. Hope is an important aspect of change. It helps if a person has trust in the provider

and in the treatment for sure. Question number two. What about finding a purpose slash thanking the negative thought? Understanding where it came from and its reason and realizing it's not needed but was trying to be helpful in its own way. For example, saying to oneself, yes, I see you anxiety, and I understand how you're trying to protect me when I was younger. That's how you came about. But I'm still going to ask that guy out on a date anyhow. Lillian answers, yes, this is something we would do in act for sure. Our mind is often trying to protect us. So thanking it and telling it where the thought originated and that the context is now

different and that the thought is no longer helpful is an act consistent move. The last question, question number three. Generally, in studies, one excludes people with comorbidities because it complicates the issues. However, it seems like fewer and fewer people are those who just have an isolated condition. That is to say, greater and greater numbers of people suffer from multiple issues rather than just one. Thus, these studies don't necessarily reflect treatment strategies that work for the majority of people. How does one overcome this flaw? That is, not reflecting a patient's true set of symptoms in the way studies are designed. Lillian answers, most of my work has been with people who have

comorbidities. Increasingly, people are looking at samples that generalize more to the larger population. Professor, thank you so much. I think that's a great note to end on. I think that's extremely inspirational. Great. I'm glad. It was really nice to be here. Thank you for inviting me. I appreciate it. I appreciate you coming out, and thank you so much. Pleasure. Take care. The podcast is now finished. If you'd like to support conversations like this, then do consider going to patreon.com slash c-U-R-T-J-A-I-M-U-N-G-A-L. That is Kurt J-Mungal. It's support from the patrons and from the sponsors that allow me to do this full-time.

Every dollar helps tremendously. Thank you.