Buddhism and Acceptance and Commitment Therapy

58

Buddhism and Acceptance and Commitment Therapy S t e v e n C. Hayes, University o f Nevada, R e n o

The philosophy, basic theory, applied theory, and technology of Acceptance and Commitment Therapy (ACT) are briefly described. Several issues relevant to Buddhist teachings--the ubiquity of human suffering, the role of attachment in suffering, mindfulness, wholesome actions, and self--are examined in relation to ACT. In each case there are clear paraUels. Given that a major focus in the development of ACT has been on the identification of basic behavioral processes that make sense of acceptance and defusion-based treatments, these parallels suggest that the basic account may also provide a scientific grounding within the behavioral tradition for a range of Buddhist concepts and practices.

HE PURPOSE of this paper is to relate Acceptance a n d C o m m i t m e n t Therapy (ACT; said as one word, "act," n o t A-C-T) to a Buddhist view of suffering a n d its amelioration. ACT was developed over the last 20 years from the c o n f l u e n c e of behavior analysis, the h u m a n potential movement, a n d experiential psychotherapies. That dev e l o p m e n t work refined the contextualistic philosophy u p o n which the therapy is based (e.g., Hayes & Brownstein, 1986; Hayes, Hayes, Reese, & Sarbin, 1993), developed a contextual theory of language and cognition (Hayes & Hayes, 1992; see Hayes, Barnes-Holmes, & Roche, 2001, for a book-length treatment), a n d generated a working account of relevant forms of psychopathology (e.g., Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), as well as developing ACT as a technological approach (Hayes, Strosahl, & Wilson, 1999). Each of these areas will be t o u c h e d u p o n in the present paper. The ACT work was always closely c o n n e c t e d to issues of spirituality (indeed, the first article on this work was on spirituality; Hayes, 1984) a n d the parallels between ACT a n d Buddhist t h i n k i n g are quite clear in some areas. However, there was n o conscious attempt to base ACT o n Buddhism per se, a n d my own training in Buddhism was limited. It is for that very reason that these parallels may cast an interesting light o n the c u r r e n t discussion. It is one thing to note how Buddhist philosophy a n d practices can be harnessed to the purposes of behavioral a n d cognitive therapy. It is a n o t h e r to note how the d e v e l o p m e n t of a behavioral clinical approach has e n d e d up dealing with themes that have d o m i n a t e d Buddhist t h o u g h t for thousands of years. Such an u n e x p e c t e d confluence strengthens the idea that both are engaging topics central to h u m a n suffering. Buddhism is a prescientific system a n d the processes it

T

Cognitive and Behavioral Practice 9, 58-66, 2002 1077-7229/02/58-6651.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

points to are n o t scientific concepts. Thus, while it may s o u n d sacrilegious, if Buddhist concepts a n d practice are pragmatically useful, it will fall to science, n o t Buddhism itself, to provide a scientifically valid a c c o u n t of why a n d when these concepts a n d practice are useful. The concepts a n d data u n d e r l y i n g ACT may be useful in that regard. Given this purpose, a fair a m o u n t of this article will focus o n ACT per se, so that a g r o u n d may be established from which to examine some Buddhist teachings. The following sections will consider the philosophy, theory, a n d technology of ACT. I will then consider the parallels between this work a n d Buddhism.

The P h i l o s o p h y U n d e r l y i n g ACT: Functional C o n t e x t u a l i s m What was originally "radical" a b o u t "radical behaviorism" is that scientific observations themselves were thought of as behavior. W h e n applying contingency t h i n k i n g to scientists themselves, Skinner (1945) saw that one could n o longer hold to the traditional methodological behavioral rejection of thoughts, feelings, a n d the like, because u n d e r some contingency conditions observing one's own feelings could be objective, while observing publicly accessible events might be subjective. It is a bit strange to call this view "radical behaviorism" because it overturns many of the major points that had previously defined behavioral thinking. Skinner's approach is made more accessible by t h i n k i n g of behavior analysis as a v~pe of contextualism, or pragmatism (Biglan & Hayes, 1996; Hayes, 1993). The core analytic u n i t of contextualism is the o n g o i n g act in context (Pepper, 1942), with a focus o n the whole event, a sensitivity to the role of context in u n d e r s t a n d i n g the nature a n d f u n c t i o n of an event, a n d a firm grasp o n a pragmatic truth criterion (Hayes, Hayes, & Reese, 1988). There are various kinds of contextualism, defined by their analytic goals (Hayes, 1993). Functional contextualism is that wing of

Buddhism and ACI" contextualism that adopts the p r e d i c t i o n a n d influence of events as the goal o f their analysis. A contextualist always asks, "In what c o n t e x t does that apply?" a n d looks for an answer that orients the analyst to effective action. Given the goals o f a functional contextualist, analysis should h e l p explain how to alter the problematic events, a n d for that reason, the account must eventually reach the m a n i p u l a b l e environment. Clients often take a quite different a p p r o a c h , focusing instead on w h e t h e r their i n t e r p r e t a t i o n s o f their own troubles are ontologically "true," w h e t h e r o r n o t these analyses are pragmatically useful.

The Basic Theory Underlying ACT: Relational Frame Theory T h e theory of language a n d cognition u p o n which ACT is based is called Relational F r a m e T h e o r y (RFT; Hayes et al., 2001). T h e core c o n c e p t i o n in RFT is that h u m a n s learn to relate events mutually a n d in combination, that this relational response is b r o u g h t u n d e r the control of arbitrary contextual cues, a n d that the stimulus functions of events are m o d i f i e d by the functions o f o t h e r events related to them. C o n s i d e r a child who has l e a r n e d to relate events as "opposite." Suppose the child is told, "A is the opposite of B a n d B is the opposite of C; A can be used to buy candy; which do you want, B or C?" T h e relations a m o n g these events are arbitrarily specified. T h e relation is b o t h mutual (-if A is the opposite o f B, t h e n B is the opposite of A) a n d c o m b i n a t o r i a l (the relation between A a n d C must be one o f sameness, because an opposite of an opposite is the same). Further, the child will probably be able to select C over B, based o n the specified functions o f A (i.e., buying candy) a n d the relation o f B a n d C to A (since C is derived to be the same as A you can p r o b a b l y also use it to buy candy, while B is the opposite o f A, so presumably you cannot). Scores o f studies have b e e n d o n e in the basic literature on such p e r f o r m a n c e s (see Hayes et al., 2001, for a review). Relations of this kind e m e r g e in infancy (Lipkens, Hayes, & Hayes, 1993) a n d a p p e a r to be absent in n o n h u m a n s . Derived stimulus relations are what p e r m i t h u m a n verbal behavior to be useful, because they enable functions of the natural e n v i r o n m e n t to be altered by what o n e says. Unfortunately, they also greatly increase h u m a n contact with painful events. W h e n a h u m a n b e i n g tells a story of a painful event in the past, some of the negative functions of the original event will be a t t a c h e d to the telling. Even very positive e n v i r o n m e n t s can lead to pain t h r o u g h relational means, as when a great success rem i n d s one o f past failures. U n a b l e to avoid pain simply by avoiding external circumstances, h u m a n beings begin to try to avoid negative private experiences directly, a process we call "experien-

59

tial avoidance." For example, h u m a n s will "try to forget about" past traumas, or will try n o t to feel anxious in situations that lead to anxiety. All of these processes substantially increase the h u m a n capacity for suffering.

The Theory of Psychopathology Underlying ACT: FEAR T h e acronym FEAR expresses four of the key concepts in an ACT a p p r o a c h to p s y c h o p a t h o l o g y - - f u s i o n , evaluation, avoidance, a n d reason giving (Hayes et al., 1999). Cognitive fusion refers to the d o m i n a t i o n o f derived functions over direct ones. As behavior b e c o m e s m o r e verbally regulated, it also tends to b e c o m e m o r e insensitive to direct experience. People can begin to "live inside their heads." T h e mischief that cognitive fusion p r o d u c e s is increased by verbal evaluation. Verbal comparative relations are useful in h u m a n behavior because they allow c o n c e p t u a l i z e d consequences to be weighed, a n d thus facilitate h u m a n p r o b l e m solving a n d planning. This same process, however, also permits the c o m p a r i s o n o f experie n c e d to feared o r wished-for events, greatly amplifying the capacity for h u m a n suffering. F o r example, a very successful person can believe himself to be a "failure" because the o u t c o m e s p r o d u c e d are less than an i m a g i n e d ideal. A p e r s o n can imagine wonderful o u t c o m e s a n d be dissatisfied if only g o o d o u t c o m e s are achieved. Experiential avoidance occurs when a p e r s o n is unwilling to r e m a i n in contact with a particular private experience (e.g., bodily sensations, emotions, thought, m e m o ries, behavioral predisposition) a n d takes steps to alter the form, frequency, o r situational sensitivity of these events, even when d o i n g so causes psychological h a r m (Hayes et al., 1996). Unfortunately, the m o r e negative private events are avoided, the m o r e they t e n d to occur. Deliberate (i.e., verbally guided) attempts to avoid private events r e m i n d the p e r s o n of the events to be avoided (thus evoking t h e m ) , deflect the p e r s o n from effective o r i e n t a t i o n to the c u r r e n t e n v i r o n m e n t , a n d often t e n d to elicit the very e m o t i o n b e i n g avoided. Finally, reason giving draws the p e r s o n into useless attempts to u n d e r s t a n d a n d explain as a m e t h o d o f controlling the outcome. Often the "good reasons" offered only increase experiential avoidance and, f u r t h e r m o r e , provide a verbal f o r m u l a that increases resistance to c h a n g e for fear of "being wrong." Reason givers tend, as a result, to be difficult to treat (Addis &Jacobson, 1996) a n d m o r e likely to engage in useless worry in response to negative m o o d s (Addis & Carpenter, 1999), despite the fact that such worry a n d self-analysis has m i n i m a l i n s t r u m e n t a l benefit (Borkovec, Hazlett-Stevens, & Diaz, 1999). While a careful analysis is b e y o n d the scope o f the p r e s e n t article, most forms o f psychopathology seem to

Hayes involve specific forms o f FEAR. Such p r o b l e m s as substance abuse, social withdrawal, a g o r a p h o b i c avoidance, ruminative worry, obsessive-compulsive behaviors, a n d so on all seem to have clear c o m p o n e n t s o f experiential avoidance a n d cognitive fusion for many suffering with t h e m (see Hayes et al., 1996, for data in several o f these areas).

The Applied Technology: ACT F r o m an ACT perspective, psychological health is the process of increasingly living life in accord with chosen values, while simultaneously m a i n t a i n i n g a nondefensive contact with historically p r o d u c e d private reactions (thoughts, feelings, memories, bodily sensations). Defined in this way, psychological h e a l t h is available to anyone, No history is so terrible that it is impossible to do a bett e r j o b of noticing what one's history produces in the private domain, while placing one foot in front of the o t h e r in a valued direction in the behavioral domain. T h e acronym "ACT" refers to the key steps involved: Accept, Choose, and Take action (cf. Emery & Campbell, 1986). ACT interventions are designed: • to r e d u c e cognitive fusion t h r o u g h the use of exercises a n d paradoxical a n d process-oriented language in therapy; • to u n d e r m i n e experiential avoidance by confronting the costs o f that avoidance a n d the conflict it p r o d u c e s with client values; • to teach acceptance a n d willingness as an alternative c o p i n g response, a n d to practice deliberate defused e x p o s u r e to t r o u b l e s o m e thoughts, feelings, bodily sensations, and the like; • to h e l p the client maintain contact with a transcend e n t sense o f self that makes acceptance a n d cognitive defusion less fearsome, t h r o u g h the use o f exercises a n d practices; • to clarify life values; a n d • to behave in accord with chosen values t h r o u g h behavioral c o m m i t m e n t strategies. T h e r e are several stages to ACT. T h e first is called "creative hopelessness." If it is the case that h u m a n suffering emerges in part from natural a n d ubiquitous h u m a n verbal processes a n d is e x a c e r b a t e d by cognitive fusion a n d experiential avoidance, as is suggested from RFT, then clients n e e d to face the possibility that what they have b e e n seeing as a possible solution to their p r o b l e m s is actually part o f the p r o b l e m . In essence, d o i n g what seems rational a n d n o r m a l is nevertheless pathological. Clients are asked to consider the possibility that perhaps they are having psychological pain in part because trying to get rid of pain is painful. This is a difficult insight, because the alternative is n o t

obvious. Superficially, the literal alternative would be to "stop trying to get rid o f psychological pain," b u t if o n e did so in o r d e r to feel better, one would be d o i n g so to rid o f psychological pain, a n d thus the struggle would n o t have stopped. The Chinese handcuff m e t a p h o r (Hayes et al., 1999) is c o m m o n l y used early on in ACT to p o i n t to the problem: T h e situation h e r e is s o m e t h i n g like those "Chinese handcuffs" we played with as kids. Have you ever seen them? It is a tube o f woven straw a b o u t as big as your index finger. You push both i n d e x fingers in, o n e into each end, a n d as you pull t h e m back out the straw catches a n d tightens. T h e h a r d e r you pull, the smaller the tube gets a n d the s t r o n g e r it holds your finger. You'd have to pull your fingers o u t o f their sockets to get t h e m o u t by pulling t h e m out once they've b e e n caught. Maybe this situation is s o m e t h i n g like that. Maybe these tubes are like life itself. T h e r e is no healthy way to get out o f life, a n d any a t t e m p t to do so j u s t restricts the r o o m you have to move. With this little tube, the only way to get some r o o m is to push your fingers in, which makes the tube bigger. T h a t may be h a r d at first to d o because everything your m i n d tells you to d o casts the issue in terms o f "in a n d out" n o t "tight a n d loose." But your e x p e r i e n c e is telling you that if the issue is "in a n d out," then things will be tight. Maybe you n e e d to c o m e at this situation from a whole different angle than what y o u r m i n d tells you to do with your own psychological experiences. (p. 105). T h e purposes o f the creative hopelessness phase o f -ACT are to u n d e r m i n e reason giving, block experiential avoidance, a n d to disconnect language from its normal, literal functions. In the next phase o f ACT, what is n o t working is given a bit m o r e form: T h e core p r o b l e m is often the conscious, deliberate a t t e m p t to control private events. T h e following m e t a p h o r is m e a n t to c a p t u r e the useless quality o f experiential avoidance as a c o p i n g strategy: Let's imagine you were h o o k e d up to the world's most sensitive polygraph a n d in such a way that both o f us could clearly see its readings a n d thereby immediately know how anxious o r relaxed you were. Now suppose I p r e s e n t e d you with the following task--all you have to do is r e m a i n relaxed. Furt h e r m o r e , to increase your motivation on the task, I take out a l o a d e d revolvex, p o i n t it to your head, a n d tell you I will pull the trigger if you fail at the task by b e c o m i n g anxious. W h a t will h a p p e n ? In o t h e r exercises a n d t h o u g h t experiments, clients will be asked to deliberately try n o t to think thoughts, or

Buddhism and ACT

to examine a n d score their own efforts to control private events t h r o u g h o u t the day. Willingness, defusion, a n d acceptance is t h e n briefly presented as an alternative focus for therapy, a n d exercises a n d metaphors are used to help the client see this alternative. It is n o t yet pursued, however, because a safe place needs to be carved out that will allow the client to o p e n u p to previously avoided private events without being overwhelmed. T h a t safe place is consciousness itself. T h e observer exercise (a variant of the "self-identification exercise" developed by Assagioli, 1971, pp. 211-217) is designed to begin to establish a sense of self that exists in the present a n d provides a context for cognitive defusion. This is a key exercise in ACT. We will briefly summarize it here. T h e client sits with eyes closed. After some time centering the client, the therapist continues: "I want you to r e m e m b e r something that h a p p e n e d last summer. Raise your finger when you have an image in mind. Good. Now just r e m e m b e r all the things that were h a p p e n i n g then. R e m e m b e r the s i g h t s . . , the s o u n d s . . , your feelings . . . . A n d as you do that, see if you can notice that you were there then noticing what you were noticing. See if you can catch the person b e h i n d your eyes who saw, a n d heard, a n d felt. You were there then, a n d you are here now. I ' m n o t asking you to believe this. I ' m n o t making a logic point. I am just asking you to note the experience of b e i n g aware a n d see if it isn't true that in some deep sense the 'you' that is here now was there then. The person aware of what you are aware of is here now a n d was there then." After several more cycles of such guidance, toward various memories at different ages, the therapist continues: "You have b e e n you your whole life. Everywhere you've been, you've b e e n there noticing. This is what I m e a n by the 'observer you.' A n d from that perspective or p o i n t of view, I want you to look at some areas of living. Let's start with your body. Notice how your body is constantly changing. Sometimes it is sick a n d sometimes it is well. It may be rested or tired. It may be strong or weak. You were once a tiny baby, b u t your body grew. You may have even had parts of your body removed, like in an operation. Your cells have died a n d literally almost every cell in your body was n o t there as a teenager, or even last summer. Your bodily sensations come a n d go. Even as we have spoken they have changed. So if all this is c h a n g i n g a n d yet the 'you' that you call 'you' has b e e n there your whole life, that must m e a n that while you have a body, as a matter of experience a n d n o t of belief, you do n o t

experience yourself to be just your body. So just notice your body now for a few m o m e n t s , a n d as you do this, every so often notice you are the o n e noticing." [Give the client time to do this.] The exercise t h e n goes o n in a similar way to e x a m i n e roles, emotions, behavioral predispositions, thoughts, a n d memories. It concludes: "So as a matter of experience a n d n o t of belief, you are n o t j u s t your b o d y . . , your r o l e s . . , your emot i o n s . . , your thoughts. These things are the content of your life, while you are the a r e n a . . . the c o n t e x t . . , the space in which they unfold. As you see that, notice that the things you've b e e n struggling with, a n d trying to change, are n o t you anyway. No matter how this war goes, you will be there, u n c h a n g e d . See if you can take advantage of this c o n n e c t i o n to let go just a little bit, secure in the knowledge that you have b e e n you t h r o u g h it all, a n d that you n e e d n o t have such an investment in all this psychological c o n t e n t as a measure of your life. Just notice the experiences in all the d o m a i n s that show up, a n d as you do, notice that you are still here, b e i n g aware of what you are aware o f . . .

[Leave a brief period of silence.] These kinds of exercises help the client find a trans c e n d e n t part of themselves (namely, a sense of fromhereness or pure consciousness) that is n o t t h r e a t e n e d by difficult psychological content. W h e n that c o n n e c t i o n is made, clients are ready more assertively to expose themselves to their own emotions, thoughts, memories, a n d so on. Many techniques are used to encourage defusion a n d willingness: physicalizing painful experiences (e.g., "What color is it? What shape is it?"), practicing language conventions that increase the distance between thoughts a n d their referents (e.g., the c o n v e n t i o n of n a m i n g all reactions by kind, such as "I am having the t h o u g h t that I ' m going to lose control; a n d I am having the evaluation that this would be bad"), or p r a c t i c i n g d e f u s i o n exercises (e.g., saying a word over a n d over u n t i l all m e a n i n g is lost). Perhaps 100 such t e c h n i q u e s have b e e n i n c o r p o r a t e d i n t o ACT protocols, t h o u g h t most clients are exposed only to a few dozen. The acceptance of previously avoided private events is n o t a goal in its own right in ACT. Rather, these coping strategies are taught so that they can be p u t in the service of moving behaviorally in valued directions. ACT encompasses a detailed m e t h o d of values clarification. Values are verbally constructed, globally desired life directions. Goals are the outcomes that are achieved while h e a d i n g in a valued direction. So defined, values u n f o l d as an ongoing process, they are n o t ever achievable in a static

61

62

Hayes

sense. For example, one can value b e i n g an honest, loving person, b u t that is n o t a concrete o u t c o m e that one can have as an object. No matter how long a value has b e e n pursued, there is more to do if the value is retained; that is n o t true with goals. If s o m e o n e said, "Well, I ' m an honest person now," a n d stopped b e i n g honest, the value would have changed. A concrete goal is different. If someone said, "Well, I have my Ph.D. now," a n d stopped working for the Ph.D., the goal would merely have been

achieved. In ACT, client values are elaborated in several major domains (relationships, work, citizenship, health, and so on) a n d concrete actions that would instantiate these values are identified. W h e n actions are identified, usually barriers to accomplishing these actions immediately emerge. Often these barriers are more private events. The strategies of acceptance, willingness, a n d defusion are then practices with these barriers, and concrete behavioral c o m m i t m e n t exercises are arranged. At this point, ACT looks more like traditional behavior therapy, b u t the earlier work continues to inform behavior change efforts. The core question in ACT is this: Based on a distinction between you a n d the things you've b e e n struggling with a n d trying to change, are you willing to experience those things, fully a n d without defense, as they are, a n d n o t as they say they are and do what takes you in a valued direction in the c u r r e n t situation? If the client can answer yes to this question, then life itself opens up just a bit. If the answer is no, then, psychologically speaking, the client becomes a bit smaller. While an e x a m i n a t i o n of the impact of ACT is beyond the scope of this paper, recent studies have reconfirmed its impact in r a n d o m i z e d controlled trials with various clinical populations (e.g., Bach, 2000; Bond & Bunce, 2000). Effectiveness research has also shown that training in ACT produces generally more effective clinicians (Strosahl, Hayes, Bergan, & Romano, 1998).

ACT a n d B u d d h i s t C o n c e p t s a n d Practices In considering how ACT connects with Buddhist philosophy a n d practices, I will limit my c o m m e n t s to the following issues (each of which has b e e n touched u p o n by Kumar, 2002, in the present volume) : the ubiquity of hum a n suffering, the role of attachment, mindfulness, valued action, a n d issues of self.

The Ubiquity of Human Suffering and Its Source in Attachment T h e Four Noble Truths begin with the idea that hum a n suffering is ubiquitous. In the first sermon delivered by the B u d d h a after e n l i g h t e n m e n t (the Dhammacakka Sutta, or Wheel of Dhamma Discourse), he said, "Birth is suf-

fering, death is suffering, sorrow, a n d l a m e n t a t i o n , pain, grief, a n d despair are suffering, association with the unloved or u n p l e a s a n t c o n d i t i o n is suffering, separation from the beloved or pleasant c o n d i t i o n is suffering, n o t to get what one wants is suffering" (as cited in D h a m m a , 1997, pp. 17-18). The list given is obviously m e a n t to be a partial one, a n d it is obviously ubiquitous. K u m a r (present volume) says it this way: "suffering is an inalienable part of existence, inflamed by any attempt to contain it." The source of suffering is a t t a c h m e n t or craving. T h e Buddha said it this way: "This is the Noble Truth of the origin of suffering: It is craving which produces rebirth, b o u n d up with pleasure a n d greed. It finds delight in this a n d that, in other words, craving for sense pleasures, craving for existence or b e c o m i n g a n d craving for nonexistence or self-annihilation" (Dhammacakka Sutta, as cited in Dhainma, 1997, p. 18). K u m a r (2002) states that, acc o r d i n g to Buddhism, "Suffering is g e n e r a t e d by the m e n t a l t e n d e n c y toward essentialism" based o n "experie n c i n g thoughts, emotions, behaviors, or self as discrete a n d u n c h a n g i n g . " A n o t h e r m o d e r n Buddhist scholar says it this way: The real cause of suffering is the reaction of the m i n d . . . . The reaction is repeated m o m e n t after m o m e n t , intensifying with each repetition, a n d developing into craving or aversion. This is what in his first s e r m o n the Buddha called tanha, literally "thirst": the mental habit of insatiable l o n g i n g for what is not, which implies an equal a n d irremediable dissatisfaction with what is. (Hart, 1987, p. 38) In ACT, suffering is also considered to be an inalienable part of h u m a n existence. A specific process is posited as the source of the ubiquity of h u m a n suffering: the bidirectionality of h u m a n language. Pain is unavoidable for all complex liwing creatures, due to the exigencies of living, but h u m a n beings enormously amplify their own pain through language. Because verbal relations are arbitrarily applicable, any situation can "remind" h u m a n s of past hurts of all kinds. In nonverbal organisms, only forreally similar situations will perform this function. Indeed, because events can be related verbally in an infinite n u m b e r of ways, even situations that have the opposite functions of previous pain can evoke this pain. For example, a person who has experienced a painful death in the family may recall that death when seeing a hearse, b u t may also recall it on a spectacular spring day, or when seeing a flower, or when seeing a child play with great innocence a n d joy.Just as a person playing a word-association game can say "hot" when given the clue "cold," so too can a person seeing events that are joyful a n d frill of life be rem i n d e d of painful deaths. Similar effects occur clinically: relaxation-induced anxiety, suicide increases d u r i n g holi-

Buddhism and ACT days, depression p r o d u c e d by joyful events, o r panic prod u c e d by noticing the c u r r e n t absence o f anxiety. T h e bidirectionality o f h u m a n language also increases suffering by providing a language for self-knowledge, thus providing an invitation to experiential avoidance. Emotions provide a g o o d example. In nonverbal organisms, events that p r o d u c e aversive reactions are avoided. In verbal organisms, the reactions themselves b e c o m e targets o f avoidance. H u m a n language allows loose sets o f bodily sensations, contextual features, a n d behavioral predispositions to be verbally constructed into "emotional states." We may learn to call one loose set "depression" a n d a n o t h e r "anxiety." T h e aversiveness o f these verbally organized events is in turn amplified by verbal evaluation (e.g., anxiety is "bad" a n d s o m e t h i n g that "people who are t o g e t h e r d o n ' t have"), a n d by constructing verbal futures linked to these e m o t i o n s that are aversive (e.g., "If I have a panic attack h e r e I would make a c o m p l e t e fool of myself'). These verbal constructions considerably increase the aversiveness o f the e m o t i o n a l event itself. H u m a n suffering is f u r t h e r increased by h u m a n language because o f the verbal evaluation systems d e s c r i b e d earlier. H u m a n s constantly c o m p a r e the c u r r e n t situation to verbally constructed futures, which increases the d o m i n a n c e of verbal sources o f behavioral control (e.g., "I would be able to live if only I could get free of this anxiety"). F u r t h e r m o r e , h u m a n s can verbally construct outcomes that have never b e e n experienced. These processes can be painful even when they are literally accurate. For example, everyone "knows" they will die, a n d e d u c a t e d persons "know" that the universe will e i t h e r e x p a n d infinitely a n d b u r n out or will be drawn back t o g e t h e r into an infinitely dense pea. In e i t h e r case, they know that all of h u m a n a c h i e v e m e n t is finite. Finally, having e n o r m o u s l y increased the h u m a n exposure to pain, h u m a n language suggests solution strategies that work j u s t fine in the external world b u t are often p o i s o n o u s when a p p l i e d to c o n d i t i o n e d private events. These include particularly ineffective t h o u g h t a n d emotional suppression or avoidance strategies, which increase the frequency o f events b e i n g avoided, f u r t h e r define the situation as an aversive one, a n d decrease attention to the c u r r e n t d e m a n d s o f the natural environm e n t a n d thus decrease instrumental effectiveness. T h e Buddhist c o n c e p t o f craving a n d a t t a c h m e n t draws its m e a n i n g from lay language. T h e B u d d h a considered the source of a t t a c h m e n t to be multilayered, a n d he saw his own e n l i g h t e n m e n t as a kind o f p e e l i n g o f that o n i o n based on his direct experience. H e discriminated m a n y steps in the W h e e l o f Suffering, each based on the next: likes a n d dislikes, sensations, contact with events t h r o u g h the senses a n d the mind, the illusion o f m i n d a n d matter, consciousness, reaction, a n d ignorance.

T h e theory u n d e r l y i n g ACT provides a process that may h e l p explain the B u d d h a ' s insights. For e x a m p l e , c o n s i d e r the idea that a t t a c h m e n t comes from likes a n d dislikes, which in turn c o m e from sensations. C o n s i d e r the definition o f a t t a c h m e n t q u o t e d earlier o f "longing for what is n o t here." F r o m an RFT perspective, this longing has to d o with verbal knowledge o f certain events, verbal relations a b o u t the past, present, a n d future, a n d with "frames o f comparison" allowing events to be evaluated against o n e a n o t h e r (Hayes et al., 2001). To p u t this process in a simple form, c o n s i d e r the sentence "I want X." T h e word "want" comes from the O l d Norse term rant, m e a n i n g literally "missing." T h e simple verbal act o f wanting s o m e t h i n g thus requires (a) noticing verbally (in the RFT sense o f that term) what is present, (b) noticing verbally what is n o t present, thereby contacting this event t h r o u g h derived relations, a n d (c) c o m p a r i n g the two. If these verbal functions d o m i n a t e , the p e r s o n will b e c o m e "attached" to a verbally constructed future in which what is n o t p r e s e n t is present. Scientifically, what is p r e s e n t all along is the process o f verbal construction. D o m i n a t i o n by a verbal future that minimizes contact with the p r e s e n t (attachment) comes from a verbal c o m p a r i s o n o f verbally known a n d evaluated experiences a n d sensations. T h e B u d d h a ' s insight remains, b u t a scientifically known process helps fill in the picture. Acceptance and Mindfulness For a Buddhist, "the first step toward e m e r g i n g from such suffering is to accept the reality o f it, n o t as a philosophical c o n c e p t o r an article of faith, b u t as a fact o f existence" (Hart, 1987, p. 38). T h e second is seeing its source in craving a n d attachment. T h e B u d d h a d e s c r i b e d the cessation o f suffering in his T h i r d N o b l e Truth as "giving up, r e n o u n c i n g , relinquishing, d e t a c h i n g f r o m craving" (Dhammacakka Sutta, as cited in D h a m m a , 1997, p. 18). Giving u p a craving is n o t a d e l i b e r a t e c h a n g e in the craving. It is a p r o f o u n d type o f c h a n g e at a n o t h e r level. It is a c h a n g e in the a g e n d a o f craving itself, n o t immediately a c h a n g e in the form o r frequency o f a craving. "Letting go of a craving is n o t rejecting it b u t allowing it to be itself' (Batchelor, 1997, p. 9). ACT takes a similar view, b u t a specific set o f psychological processes is posited as the source of transfornladon. Just as self-struggle comes from cognitive fusion, acceptance is a natural result o f cognitive defusion. Cognitive behavior therapists have decades o f research showing that psychopathology tends to be associated with certain kinds o f thoughts. Usually this leads to concrete efforts to c h a n g e the c o n t e n t of thoughts, b u t the contextualistic qualities o f ACT o p e n a different solution: C h a n g e the c o n t e x t in which thoughts r e d u c e effective action. All verbal relations, like all behavior in a contextualistic system, are situated. F u r t h e r m o r e , the i m p a c t o f

631

Hayes thoughts, like all relations between psychological events, is also contextually situated. T h e p r o b l e m with negative o r irrational thoughts, from a contextual p o i n t o f view, is n o t the form of the t h o u g h t b u t its excessive literal quality. C h a n g i n g the literal quality by literal intervention (e.g., t h r o u g h cognitive disputation) is fraught with difficulty because the process contradicts the outcome. Conversely, c h a n g i n g the context in which thoughts are taken literally changes its literal quality., even if the t h o u g h t continues. C o n s i d e r the thought, "I must be perfect." In n o r m a l cognitive behavioral approaches, this t h o u g h t would be targeted, disputed, tested, a n d c h a n g e d t h r o u g h direct means. A wide variety o f contextual alternatives exist, all of which are c o m p o n e n t s of ACT. For example, the t h o u g h t could be watched dispassionately, as one watches thoughts while meditating. T h e t h o u g h t would be rep e a t e d ou.t loud rapidly for a few h u n d r e d times, until only its s o u n d remains. T h e t h o u g h t could be given a size, shape, colol, speed, form, texture, a n d so on, thus treating it as o n e treats obsmwations of external objects. T h e person could thank their m i n d for such an interesting t h o u g h t to watch. T h e person could e x a m i n e the bodily sensations, emotions, memories, a n d behavioral predispositions that e m e r g e in association with the thought, a n d could take time e x p e r i e n c i n g these events as aspects of an unfolding, c h a n g i n g process of living. T h e person could label their own cognitive processes (e.g., "Now I am having that t h o u g h t that I must be perfect"). T h e person could think the t h o u g h t very, very slowly, so that each word takes minutes to s o u n d out. These various p r o c e d u r e s are designed to reduce the literality of the t h o u g h t - - w e a k e n i n g the t e n d e n c y to treat a t h o u g h t as if it is what it refers t o - - b u t without targeting the form o f the t h o u g h t itself. Instead, these methods alter the c o n t e x t in which thoughts of a given form are troublesome. While these m e t h o d s were n o t consciously drawn from Buddhist practice, they have clear parallels there. In Buddhist traditions, Right Mindflflness, part of the Eighttold Path, includes many practical m e t h o d s of acceptance a n d delusion. For example, "If one experiences any feelings in the body, w h e t h e r gross or subtle, one should be aware of t h e m in the p r e s e n t m o m e n t . . , if there is liking o r disliking, desire, angm, or doubt, these should be taken as m e d i t a t i o n objects" (Dhamma, 1997, p. 39). Zazen, following the breath, a n d the like all seem designed to reduce the d o m i n a t i o n o f the literal m e a n i n g o f events. Similarly, Zen koans are p r e s e n t e d as verbal puzzles, but their essence is n o t that at all. W h a t underlies koans is what is there when the puzzle is no more. As was p o i n t e d o u t by the Zen master Chung-feng, "It c a n n o t be understood by logic; it c a n n o t be transmitted in words; it cannot be e x p l a i n e d in writing; it c a n n o t be m e a s u r e d by

reason" (as q u o t e d in Kapleau, 1989, p. 77). T h e dual qualities of openness to e x p e r i e n c e in the m o m e n t a n d r e d u c t i o n of the literal d i m e n s i o n when it interferes with that openness seem characteristic of virtually all Buddhist practices o f e n l i g h t e n m e n t . T h e techniques o f cognitive delusion r e d u c e the behax4oral i m p a c t of thoughts, at least in ACT. B o n d a n d Bunce (2000), for example, f o u n d that positive behavioral a n d psychological o u t c o m e s in ACT were p r o d u c e d by increases in the acceptance o f previously avoided private events. Similarl}; Bach (2000) f o u n d that severely mentally ill patients with hallucinations or delusions treated with ACT showed a 48% reduction in rehospitalization over 4 m o n t h s c o m p a r e d to t r e a t m e n t as usual, a n d that this o u t c o m e was p r o d u c e d by a significantly greater decrease in the believability, but not the frequency, o f psychotic symptoms. Valued Action

Buddhism is sometimes called a religion, b u t it is, at its essence, without d o g m a or belief (Batchelor, 1997). Even the Four Noble Truths are n o t so m u c h beliefs as orientations to action: seeing suffering, letting go o f attachment, a n d cultivating wholesome deeds. T h e b o t t o m line in Buddhism is n o t belief, b u t living a n d doing. T h e Eightfold Path is intensely behavioral. As a behavior therapy; ACT takes the same stance. Acceptance and cognitive defilsion is n o t an e n d in itself b u t a means to successful living. W h a t requires acceptance a n d delusion will be d e t e r m i n e d by history a n d purpose. T h e goal is not to feel all one's feelings, b u t to feel all those that occur in the context of living a valued life. For example, if raising a family brings a person in contact with painful material, the task is to observe that pain a n d to raise one's family. This seems entirely c o m p a t i b l e with Buddhism. S. N. Goenka, a m o d e r n Buddhist teachm, says it this way: "This is holy indifference: n e i t h e r inaction n o r reaction, but real, positive action with a b a l a n c e d mind" (Hart, 1987, p. 54). Self

Issues of self provide a n o t h e r relevant p o i n t o f connection. T h r e e kinds o f self are considered in ACT: the conceptualized self, self as an o n g o i n g process o f knowing, and the t r a n s c e n d e n t self. ACT seeks to u n d e r m i n e the conceptualized s e l f - - t h a t is, an a t t a c h m e n t to a literal c o n c e p t i o n of who we a r e - - o n the same grounds that it seeks to u n d e r m i n e a t t a c h m e n t to any specific thought: that such a t t a c h m e n t is unnecessary a n d unhelpful. A phrase used in ACT that characterized its posture toward the conceptualized self is, "Kill yourself every day." Self as an o n g o i n g process of knowing is a fluid, dynamic process of knowing one's own flow of experiences. E n h a n c i n g self-as-process is implicitly a goal o f various

Buddhism and ACT

forms of therapy, particularly in humanistic a n d experiential camps. This kind of self supports o n g o i n g verbal (or "conscious") contact with events, such as feeling feelings, or sensing sensations. That, in turn, can be clinically useful in r e d u c i n g excessive rule control a n d e n h a n c i n g contact with the effects of actions. This seems very m u c h in line with Buddhist thinking. The self as discrete a n d u n c h a n g i n g is problematic. It is a form of attachment. The self as a process is what o n e fosters through mindfulness. T h e r e may be a p o i n t of divergence in the third area: a t r a n s c e n d e n t self. ACT relies o n this sense of self to support clients in exposing themselves to feared private events. The t r a n s c e n d e n t self, or self as context, is theorized to result from deictic verbal relations, such as h e r e / now, I/you, or n o w / t h e n (Barnes & Roche, 1997; Hayes, 1984), a n d may be defined as knowing from a locus or perspective. A n o t h e r term might be consciousness per se, as distinct from consciousness something. Some experimental support for this c o n c e p t i o n has recently b e e n shown in very y o u n g children: Teaching children deictic verbal relations results in a notable increase in perspective t a k i n g - - i n c l u d i n g the ability to take a n o t h e r person's perspective into account (Barnes-Holmes, BarnesHolmes, & Cullinan, 2001). Consciousness is n o t thing-like for the person b e i n g conscious. O n e can be conscious of the limits of everything except one's own consciousness. Self as context is present everywhere we have ever been, so far as we know, by definition. This means that one's own experience of a t r a n s c e n d e n t sense of self is that it has n o limits: It is n o t a thing. Things are n o t things unless they have limits. In o n e i m p o r t a n t sense of the term, self, thus, is n o t h i n g (a word that was originally written as "no thing."). So far, this sounds very m u c h in line with Buddhist thought, a n d perhaps forms the psychological basis of the Eastern concept of spirituality, a n d of God, as "everything/nothing." There may be a p o i n t of divergence, however, because while the person is alive, a sense of perspective is n o t known by that person to change once it emerges (in the preschool period). Indeed, in ACT this sense of self as context is argued to be critical therapeutically because it means that there is at least one stable, u n c h a n g e a b l e , imm u t a b l e fact a b o u t oneself that has b e e n experienced directly a n d is n o t just a belief or a hope or an idea. In the context of therapy, this kind of stability a n d constancy helps a client c o n f r o n t extreme psychological pain a n d trauma, knowing in some deep way that n o matter what comes up, the client's deepest sense of b e i n g is n o t threatened. I am n o t sure whether this concept diverges from Buddhist teachings. Speaking of an i m m u t a b l e self from the p o i n t of view of a knower seems to conflict with Kumar's (2002) statement that "self as . . . u n c h a n g i n g deviates

65

from the natural process of change i n h e r e n t in all existence." Most Buddhist texts do n o t speak of self as context, though an observing self seems to be the implicit b a c k g r o u n d of all knowing. In all likelihood, it is the fear of reification of self concepts that is at the basis of the relative silence o n this issue since, after all, "everything that arises a n d passes away is n o t self' (Snelling, 1998, p. 31). This topic is subtle a n d h a r d to talk a b o u t d u e to the reflective issues involved. It is a particularly difficult issue to frame within a written manuscript. Nevertheless, I will try. By a t r a n s c e n d e n t self I do n o t m e a n the belief in such a self or the belief in immutability, b u t the experience of from-here-now a n d the essential continuity it provides for all verbally known events from the p o i n t of view of the knower. T h e claim is simply that all verbal knowing is known "from here now." That experience is an i m p o r t a n t sense of the word " I " - - n a m e l y , that in o n e i m p o r t a n t sense 'T' am from-here-now. This sense of perspective is i m m u t a b l e from the p o i n t of view of the knowing person. It is n o t i m m u t a b l e in the sense that it assumes a form that c a n n o t or does n o t change. It is i m m u t a b l e in the sense that it has n o form at all. It has n o limits that can be known by the knower, by definition. In that sense, it is n o t a thing, a n d only things can change. No thing cannot. It is possible to imagine that a person can experience events from somewhere else, some when else. Some spiritual traditions make such claims (e.g., claims of time travel, multiple planes of existence, or of b e i n g in two places at once), b u t even then, the "somewhere else" would then be "here" a n d the "some when else" would then be "now" from the p o i n t of view of the person d o i n g the experiencing. If that was n o t true, I see n o way that the experience could be "known" by the person, since knowing as a process is now.

Conclusion Buddhist concepts a n d practices have proven their hum a n value over the millennia, b u t the question for cognitive behavior therapists is this: What additional value can be obtained by considering these practices from the p o i n t of view of cognitive behavioral psychology? Importing Buddhist practices into the technical armamentarium of cognitive behavior therapy is fine, b u t it is n o t a very ambitious step. These concepts a n d practices are thousands of years o l d - - t h e y are already d o i n g good in the culture. Buddhism includes traditions of faith, ritual, practice, a n d c o m m u n i t y that are designed to support mindfulness a n d wholesome actions, a n d short of becoming a religion, n o system of psychotherapy will include all of these elements. A real step forward in empirical clinical practice could come, however, by considering these concepts a n d prac-

Hayes

t i c e s in s c i e n t i f i c t e r m s . T h a t m i g h t l e a d to s o m e t h i n g new. S c i e n t i f i c p s y c h o l o g y is still a n a d o l e s c e n t . W e d o n o t k n o w h o w m u c h c a n b e d o n e by a p p r o a c h i n g a n c i e n t s o u r c e s o f w i s d o m f r o m t h e p o i n t o f xqew o f s c i e n t i f i c knowing. In each area examined, there are clear parallels between ACT and Buddhism. These parallels suggest that there can be a common core of understanding about the nature of human suffering within the religious and scientific d o m a i n s . T h e y a l s o s u g g e s t t h a t i s s u e s o f a c c e p t a n c e , c o g n i t i v e f u s i o n a n d d e f u s i o n , self, a n d v a l u e d a c t i o n m a y b e w o r t h e x p l o r i n g as o n e way t h a t b e h a v i o r t h e r a pists might consider Buddhist concepts and practices f r o m t h e p o i n t o f view o f m o d e r n b e h a v i o r a l psychology'.

References Addis, M. E., & Carpenter, K. M. (1999). Wh); why, why?: Reason-giving and rumination as predictors of response to activation- and insight-oriented treatment rationales.Journal of Clinical Psyehology, 55, 881-894. Addis, M. E., &Jacobson, N. S. (1996). Reasons tot depression and the process and outcome of cognitive-behavioral psychotherapies. Journal of Consulting and Clinical P~ycholo~¢, 64, 1417-1424. Assagioli, R. ( 1971 ). 77~eact of will. New York: Viking. Bach, E (2000). 77~euse qf Accepmnce and Commitment Therapy to pT~Jent the *ehospilalization ~f psychotie patients: A randomized continUed trial. Unpublished doctoral dissertation, Universig, of Nevada, Reno. Barnes, D., & Roche, B. (1997). A behaviot:analytic approach to behavioral reflexivity. The Psychological Record. 4Z 543-572. Barnes-Holmes, Y, Barnes-Holmes, D., & Cullinan, V. (2001). Education. In S. C. Hayes, D. Barnes-Holmes, & B. Roche (Eds.), Rdational fmme theoo,: A post-Skinmv'ian account t f human language and cognition (pp. 181-195). New York: Plenum Press. Batchelor, S. (1997). Buddhism without bdi~: A contemporaU guide to awakening. New York: Riverhead Books. Biglan, A., & Hayes, S. C. (1996). Should the behavioral sciences become more pragmatic? The case for fimctional contexmalism in research on human behavior. Applied and P,eventive PD.chology: Current Scientific PerspeetiveL 5, 47-57. Bond, E W., & Bunce, D. (2000). Mediators of change in emotionfocused and problem-fi-mused worksite stress management interventions../ournal oj Occupational Health Psychology, 5, 156-163. Borkovec, T. D., Hazlett-Stevens, H., & Diaz, M. L. (1999). The role of positive beliefs about worlT in generalized anxiety disorder and its treatment. Clinical PD'cholo~ and Psychotheral~); 6, 126-138. Dhamma, R. (1997). The.first distou~:w of the Buddha. Boston: Wisdonl Publications. ElneCr', G., & Campbell,J. (1986). Rapid relicfJ}om emotional dist~vss. New York: Rawson.

Hart, ~ \ (1987). The art of living: Vipassana meditation as taught by S. N. Goenka. San Francisco: Harper. Hayes, S. C. (1984). Making sense of spirituali~ Behaviorism, 12, 99110. Hayes, S. C. (1993). Analytic goals and the ~-arieties of scientific contextualism. In S. C. Hayes, L.J. Hayes, H. W. Reese, & T. R. Sarbin (Eds.), Varieties of scientific contextualism (pp. 11-27). Reno, NV: Context Press. Hayes, S. C., Barnes-Hohnes, D., & Roche, B. (Eds.). (2001). tCdational fiame theory: A post-Skinnerian account of human langazage and cognition. New York: Academic Press. Hayes, S. C., & Brownstein, A.]. (1986). Mentalisin, behaviol:beha~4or relations and a behavior analytic view of the purposes of science. 77te Behavior Analyst, 9, 175-190. Hayes, S. C., & Hayes, L.J. (1992). Verbal relations and the evolution of behavior analysis. A meriean Psychologist, 4 Z 1383-1395. Hayes, S. C., Hayes, L. J , & Reese, H. W. (1988). Finding the philosophical core: A review of Stephen C. Pepper's WorM Hypotheses. .]ournal c~ the Experinwntal Analysis of Behavior," 50, 97-111. Hayes, S. C., Hayes, L.J., Reese, H. W., & Sarbin, T. R. (Eds.). (1993). Varieties ofscienliji~ contextualism. Reno, NAt: Context Press. Hayes, S. C., Strosahl, F,L,& Wilson, K. G. (1999). Acceptance and Commitment Therap'y: An expe,iential approach to behavior change. New York: Guilford Press. Hayes, S. C., Wilson, K. G., Giftbrd, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment.Journal of Consulting and Clinical Psychology, 64, 1152-1168. Kapleau, E (1989). The threepiUars c?/'Z,n: Teaching, practice, and enlightenment. New York: Anchor. Lipkens, G., Hayes, S. C., & Hayes, L.J. (1993). Longitudinal study of derived stinmlus relations in an infant.Journal of Experimental Child Pw:holo~,, 56, 201-239. PeppeL S. C. (1942). World hypotheses: A stucly in evidence. Berkeley: University of California Press. Skinnm, B. E (1945/1972). The operational analysis of psychological terms. Reprinted in Cumulative reeord: A selection of papers. New York: Appleton-Centtu~Crofts. (Originally published in Psychological Rwiew in 1945) Snelling, J. (1998). Buddhist traditions of meditation. In J. Smith (Ed.), Breath sweeps the mind: A first guide to meditation practice. New ~]~rk: Riverhead Books. Strosahl, FL D., Hayes, S. C., Bergan,J., & Romano, R (1998). Assessing the field effectiveness of Acceptance and Commitment Therapy: An example of the manipulated training research method. Behavior Thera[o', 29, 35-64. I would like to thank Amasamy, s.J., for his helptul comments on the manuscript. Address correspondence to Steven C. Hayes, Ph.D., Department of Psychology, University of Nevada, Reno, NV 89557-0062; e-mail: hayes@ scs.unl2edn. Received: .]anua U 10, 2000 Accepted: FebruaO"20, 2001