By Tim Hyland
Illustration by Tim Pacific
Imagine for a moment a middle-aged man named Sam.
Sam suffers from anxiety. His worries and fears, rooted in a stressful job, are becoming crippling. He dreads going to the office each day. At night, his mind races. He can’t sleep. He finds that even the smallest hiccups at the office lead to days of worry—not just about being disciplined, but about being fired, and seeing his life fall apart as a result.
After more than a year of restless nights and difficult days, Sam finally hits his breaking point. He admits that he has a problem. He admits that he needs help.
So Sam goes into therapy. Over the course of several sessions, Sam’s therapist walks him through all of the mental steps he needs to take to conquer his anxiety. The therapist explores the root causes of Sam’s stress. He explores the complex thought processes that paralyze him. And in the end, he tries to convince Sam that almost all of the fears taking over his life are completely and utterly irrational.
And if Sam can simply control his thoughts and convince himself that the monster isn’t real—and monsters aren’t real, after all—he can make the anxiety go away for good.
For decades, most therapists would have agreed that the treatment proposed by Sam’s fictional therapist was the right approach. Through cognitive therapy, psychologists like Sam’s work to help their patients overcome any number of maladies—anxiety, addiction, eating disorders—by focusing their attention on their thoughts. Or, perhaps more accurately, the flaws in those thoughts.
The idea is simple: Identify the monster, and then destroy it.
“The idea with traditional cognitive therapy is that the thoughts you have will determine your emotional reaction,” says James Herbert, PhD, professor and head of the Department of Psychology in Drexel’s College of Arts and Sciences. “It’s all about the ‘mind talk’ you are constantly engaged in—becoming aware of it and picking it apart and trying to find any errors or flaws or distortions in it. The idea is that if you can correct those, and if you can control your emotional reaction to them, everything will be fine.”
It’s an approach that has been the standard in psychology for years, and even detractors admit that the existing body of research offers significant evidence that these approaches often do work.
Increasingly though, a new generation of therapists, including a number at Drexel, are raising tough questions about conventional cognitive therapy—and asking not only whether changing one’s thoughts is the key to long-term mental health success, but also whether it really makes sense for patients to do battle with those monsters at all.
Herbert is among the handful of Drexel researchers who believe that a new intervention, Acceptance and Commitment Therapy, or ACT, may ultimately change the way therapists approach treatment for patients battling everything from psychosis and anxiety to depression and even prejudice. Through ACT and other “mindfulness”-based approaches to therapy, psychologists such as Herbert attempt to treat their patients, not by asking them to disregard so-called “irrational” feelings and emotions, but rather by allowing them to recognize those negative thoughts and feelings as real—and then encouraging them to believe that they can make better decisions and live better lives regardless.
More simply, what sets Herbert and his colleagues apart from their more traditional counterparts is that they aren’t asking their patients to battle their monsters.
They aren’t pushing those patients to convince themselves those monsters don’t exist.
They’re simply telling their patients that, whether the monster is there or not, the reality is that the monster need not have any power at all over the patient’s life or well-being.
“Let’s say you have anxiety, and the monster represents that anxiety,” explains Herbert. “Now imagine we have this rope, and you and the monster grab the rope, and there is a huge pit in between the two of you. In traditional therapies, what you are trying to do is pull that monster into the pit. You’re trying to get rid of him. But the harder you pull, the harder he pulls, and in fact, most of the time you end up slipping ever closer to the chasm. So what do you do? Well, obviously, you drop the rope.
“Now, that doesn’t mean you get rid of the monster. The monster is still there. But what we’re saying is, you’re on your side of the chasm, and he’s on his, so the question is: Can he really influence you?”
This simple shift in perspective—not working to destroy the monster, but accepting that life can be lived even with the monster at the sidelines—is what sets ACT apart, and what makes it, in the mind of Herbert and others, an exciting step forward in the practice of psychology.
“The movie ‘A Beautiful Mind’ did a great job explaining this in some ways,” Herbert says. “In that movie, the main character was a schizophrenic and was engaged with these imaginary people in his mind. He was constantly fighting with them. But at the end, he basically said, ‘I am no longer going to engage with you.’ He didn’t get rid of them. He just chose not to engage with them. That’s exactly what we’re trying to get our patients to do.”
Adds Evan Forman, PhD, a Drexel associate professor who has led several promising studies on ACT: “There has been recognition that some of the ideas from [ACT and related treatments] do have merit and do have efficacy. These ideas have slowly been seeping into more traditional cognitive treatments, and even people who are carrying out traditional cognitive therapies are making use of these ideas. So I think there already has been a shift.”
Of course, it’s not a complete shift just yet. With the weight of years of evidence sitting with the backers of traditional cognitive therapy, there has been some resistance to this new line of thinking. To overcome that resistance and legitimate their new approach, proponents of ACT and similar therapies have had to put the work in—in the lab, and in the scientific literature.
They’ve had some pretty good success doing so, too.
“People who are working in ACT have gone to great lengths to link these interventions with basic scientific work, to keep it very grounded scientifically,” Herbert says. “The basic concepts are solidly grounded in research ranging from small studies to huge clinical trials. It’s not just a fad. We at Drexel have been part of that movement. We are by no means the only ones, but I would say there are at most a half dozen places that are really known for their work in this area, and we are definitely one of those.”
Indeed, thanks to the efforts of Hebert, Forman and others, Drexel has been recognized as the home of several studies that have added to the growing body of evidence demonstrating that ACT holds great promise in the treatment of a variety of psychological conditions.
In one recent study, for instance, Herbert and a Drexel team tested ACT therapy on a group of students who complained of high anxiety related to their college exams. After the students took their midterm exams, researchers split the subjects into two groups, with one group undergoing traditional cognitive therapy and the other counseled through ACT-focused methodologies. The idea was simple: find out which therapy, if any, could generate better results.
“The first group got a brief cognitive therapy intervention, in which they were taught to recognize and work through their anxiety-related thoughts,” Herbert says. “Then we had the ACT group, and they were taught to notice those negative thoughts—thoughts such as ‘I’m going to fail’—and even embrace them as real, but simply to notice them without trying to change them, and instead focus their efforts on taking the tests.”
The results were impressive. The group that underwent traditional therapy showed no change—either positive or negative—in their final exam grades over their midterm performances. The ACT group, however, showed “significant improvement,” Herbert says. “And these were all kids with significant test anxiety.”
Forman, meanwhile, has been working with Meghan Butryn, PhD, a research assistant professor in psychology, to study how ACT and similar therapies can help obese individuals better control their food cravings. ACT proponents believe this is one area in which the method might hold some of its greatest potential. “Obesity is essentially at epidemic levels at this point, as there are more people overweight than not overweight in this country and many other Western countries as well,” Forman says. “The question is what to do about that.”
Over the years, Forman notes, cognitive therapies have actually proven to be quite successful in helping food-addicted patients better manage their diets and even lose weight— at least in the short term. In the long run, however, those approaches haven’t achieved the desired results, with successful dieters often putting weight back on and slipping into old habits. Forman and others believe that ACT could overcome some of the hurdles traditional approaches cannot, because ACT approaches the problem from a different point of view.
“People generally know what they want to do,” Forman says. “They understand that if there’s food around that isn’t good for them, they should avoid it. But it’s not a question of not ‘understanding’ it. It’s the desire to eat that ends up propelling their actions. They don’t like the way it feels when they try to resist the temptation. So we thought if we could train people to better put up with that feeling of deprivation, we might have more success.”
Overweight individuals, Forman and Butryn surmised, were unlikely to ever get rid of their craving—their monster—so instead of attempting to make that happen, the researchers focused on getting people to become more comfortable with those cravings, and to look beyond them by asking themselves what they really care about most: the food in front of them, or a long, happy, healthy life.
“We thought if we could instead get people to get in touch with what they really cared about, they might make better choices,” Forman says. “These approaches are supposed to offer just that skill. ACT helps them get in touch with their deeply held values—the things they care about most in life.”
Indeed, in a study published in the journal Eating Behaviors last year, Forman and Butryn’s hypothesis—that ACT could be employed to help compulsive eaters control their cravings—was proven true. For the work, Forman and Butryn split a group of 48 women—all of whom admitted to eating sweets at least five days a week—into two groups. One group received traditional counseling, with the other undergoing ACT treatment. The women were then asked to carry with them for a period of 72 hours a container of sweets—but were also asked to resist their temptations to eat them.
When the results were in, the researchers found that, when compared to the traditional therapy group, the individuals in the ACT group saw “reduced cravings and consumption of sweets.”
“If you take a group of people who respond very strongly to food, or people who say they feel very strong food cravings, they just do much better [in resisting those cravings] with acceptance-based treatment, which is what we predicted,” Forman says. “We saw a very big impact.”
“It’s not hard to get the weight off,” Herbert adds. “It’s maintenance that is tough, and we see that people tend to regain all the weight they’ve lost [in traditional therapies] plus a few pounds. What we’ve found is that people are able to keep the weight off with ACT, however. They have a much better rate of keeping the weight off by incorporating those principles into their weight-loss strategies.”
In other words, the results so far are promising. The evidence supporting ACT is growing ever larger, and even though Herbert and Forman admit that traditional therapies might continue to be effective in many situations, they believe that ACT could represent a revolutionary change in the way clinicians look at mental health. There is even some evidence, Herbert notes, that these therapies could be used to help people overcome prejudice.
The possibilities, it seems, are limitless.
“What we’re trying to teach people is that it’s often an arbitrary result of one’s history that you have these thoughts, and that you don’t necessarily need to figure out the meaning behind your thinking in order to move forward in your life,” Herbert says. “The cognitive therapists would say, ‘You need to change the content of your thoughts,’ but we say, ‘Try to develop a different relationship with your thoughts. Recognize them, but get on with your life.’ It just opens up a new approach for a lot of different conditions.”