KELLIE NEWSOME: Every defeat, every heartbreak, every loss contains its own seed, its own lesson, wrote Malcolm X, and we'll flesh out the hidden lessons in a panic attack in part two of our interview with Steve Hayes. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.

KELLIE NEWSOME: And I'm Kellie Newsome, a psych NP and a dedicated reader of every issue.

CHRIS AIKEN: When we left Steve Hayes last week, he was prostrate on a shag carpet in the middle of the night, paralyzed by the worst panic attack of his life. He had tried everything, and this time his desperation led him to reach out for something completely irrational. He reached for more panic, and in moving into the panic instead of away from it, he found the seed of Acceptance and Commitment Therapy. What if you arrived at this kind of discovery without having gone through panic yourself? Tell me about that.

STEVE HAYES: No, and well, one suspicion that I would not, as I'm part of the evidence-based therapy wing. When I stepped out strongly with this, which I didn't do it for a long time because I wanted to know not just what, but why.

CHRIS AIKEN: Wasn't it 10 or 15 years of research before you really stepped out?

STEVE HAYES: 20? Yeah. From the night of the carpet moment to almost 20. So ACT is 45 years old, and I'm a hard-working man. I've published 700 articles and, you know, in some rankings, top 30 psychologist, top 10 clinical psychologist. Sorry for the self-praise, but I just, you know, I work hard, and I'm well known, but I just would not step forward until I understood why. And so I had to develop a theory of language and cognition and then actually test it, and we had to develop measures of the processes, and we had to do a whole bunch of single-case designs showing that it worked, and then figure out how to get it to move, and then, you know, finally step forward. And it landed at a particular moment, especially when I wrote the academic book and then the self-help book.

KELLIE NEWSOME: As that self-help book, Get Out of Your Mind and Into Your Life, climbed the Amazon charts, even beating Harry Potter for a week, it caught the attention of Time Magazine, which ran a feature article comparing ACT to CBT and pitting Steve Hayes against one of his mentors, Aaron “Tim” Beck, in an imaginary duel.

STEVE HAYES: It shook the foundations of evidence-based therapy because it was written up by the late John Cloud, a world-class reporter for Time Magazine, as a war between me and Tim Beck, as a war between me and CBT, which is not true. There was no war. I mean, the very first randomized trial was done with Tim's help near his Center for Cognitive Therapy in Philadelphia. I sent my first graduate student to him so that we could test his methods versus ours. And he's a wonderful man, and he said, Yeah, let's test it. He wouldn't let us do it right in his center. He found a thing down the block, but still, without his help, we wouldn't have had that. But the reporters wanted it to be a fight. They had a picture of me, and my motorcycle with red eyes that they didn't remove, and a picture of Tim with a bow tie, and underneath Tim were the words “the establishment.” It was something right out of some sort of motorcycle movie, or something, you know, I'm gonna come riding, you know.

CHRIS AIKEN: Around 600 BCE, Aesop, a Greek storyteller and enslaved person, set down the story of the crow and the pitcher. A thirsty crow came upon a pitcher with water at the bottom beyond the reach of its beak. After failing to push it over, the bird dropped pebbles one by one into the pitcher until the water rose to the top, allowing it to drink. Five hundred years later, Socrates put this more succinctly: necessity is the mother of invention. But inventions have to start somewhere. Steve Hayes may have been pushed to the brink of necessity by that panic attack, but when it struck him in 1980, the 30-year-old Hayes had already gathered a wealth of experience to build on. He had lived in a commune, dabbled in meditation, psychedelics, and environmental activism. Within the psychology profession, he was mentored by David Barlow, who helped develop the cognitive behavioral model of panic. Outside of the profession, Steve Hayes had taken part in the human potential movement, where a firestorm of unconventional ideas about psychology and human suffering were circulating in the 1970s. The panic attack provided the urgency, the opportunity, but chance favors the prepared mind. And I imagine that you heard this idea of moving toward the emotion, of radical acceptance, somewhere in these places.

STEVE HAYES: Yeah, yeah, yeah.

CHRIS AIKEN: Is it possible that you needed the urgency of being in that time of need for that really to solidify?

STEVE HAYES: I think so. And you know, our wisdom traditions, our cultural traditions, our painters, our writers, our great literature, people who tell the great stories, the movie makers, they're all onto this.

CHRIS AIKEN: Oh, what are they onto?

STEVE HAYES: They're all onto the challenge people have to be on a hero's journey. You know every big story. Who? Me? Little old me? And it's scary. I don't wanna do it. Yeah. And then with the help of your mates, sometimes Gandalf, sometimes the rest, sometimes with a different sense of self, of transformational experience. You know, I'm not afraid, and Yoda says, You will be. You know, the hero's journey. You face your demons. You find this other sense of self, often with the help of others, and then you see a valued path, and you step forward. And when you do that with your history, with your feeling small, with your being inadequate, sometimes the ring gets thrown into the crack of doom. You know, the golden fleece gets pulled down off, and you can come back and give it to the community. But the reason that we like those stories is this is our story, this is your story. You have challenges. Every single listener has challenges, big challenges. It's hard to be human, and finding that strength of this more spiritual sense of self, which is often in the great stories, help from others, carrying your past with you, don't try to eliminate it, turns out often it becomes key in the moment, or something you thought was a weakness is a strength. Focus on your values. What's really important? Get your feet moving, even though it's hard. You slog up the side of the mountain, you know, with the all-seeing eye going, or Voldemort crossing the bridge, or whatever the thing is, and you just keep walking. And sometimes great things happen, but it doesn't mean you're finished. It means another round can begin. Well, what I just said is the ACT model. So, my point being that the reason why this resonates so with human beings around the world is not because it's so special; it's precisely because it isn't. It's just that we're using science to dial into the processes that are underneath our great cultural wisdom in a way that, in the modern era, it gets to be heard. Because you can't go into the healthcare system, for example, just telling stories out of your wisdom tradition. People don't want that. They want science. Okay, well, let's do it that way then, and let's see, but let's be humble about it.

CHRIS AIKEN: So, did you feel a sense of risk changing the field like this, coming in as a young psychologist with so many new ideas?

STEVE HAYES: Huge, huge risk. And also, let's be honest, I mean, I still was a panic-disordered person in recovery. I didn't want to run out to the front of the parade. I wanted to run from behind. 

CHRIS AIKEN: Was it difficult at all coming public as a professional with panic disorder?

STEVE HAYES: A little early on, but I soon found that there was almost too much credibility that came from it. And I've told my story. I decided to really get out there and tell it when I decided I wanted to write a popular book called A Liberated Mind, and I needed a Big Five publisher. I'd written a whole bunch of books, I've written 47 in my life or edited, but that was a big step for me. And so I arranged and figured out a way to get a TEDx talk, and told the story and so forth. But in clinical work, like if I was doing a workshop, boy, talking about my own anxiety history was gold with people who were treating anxiety or who themselves were anxious. I mean, one of the first things a client will ask you is, have you ever had a panic attack? And I can say, yes, many, many, many, many, many. In fact, it took me like 15 years or something. My last panic attack, maybe more than that, was 10 years after I was really into ACT. They didn't go boom down to zero; they slid down.

CHRIS AIKEN: I want to insert a caveat here about panic attacks and panic disorder. I have had a panic attack. It came on out of nowhere once when I stayed up too late and started to think too much about the sensations in my body. But when I share this fact with patients, I don't talk about it with the sympathetic camaraderie that Steve does. To me, panic attacks and panic disorder are night and day. Around one in 4 people have had panic attacks, or 23%, but let's break down what happens to them. About 66% will go on to have more than one panic attack, recurrent, but very few will develop full panic disorder. Only one in 25, or 4% of the population, have panic disorder. Panic attacks are not even recognized as a disorder in the DSM. They are normal but annoying events, a false alarm, a test of the emergency physiologic system. Panic disorder is a phobia of panic attacks, and once you get a phobia of them, your baseline anxiety goes up, and the attacks become more frequent. Patients don't understand this intuitively. They see panic attacks as the enemy, but focusing on getting rid of all panic attacks is a bit like telling a patient with a spider phobia to go out and buy more bug spray. We've all seen spiders cross our path, and usually it's unpleasant, but there is a big difference between unpleasant and phobic. Here's how it looks. I once saw a patient who had not left the house for a whole week. What happened? I asked. Well, I thought there was a snake outside, but after a week, I looked closer, and I realized it was a garden hose. Phobias are a state of mind far beyond everyday anxiety. So much worse when the source of that phobia is always with you. It's not a snake or a bridge, it's your own body. That is panic disorder.

STEVE HAYES: My first really big workshop was done at the University of Washington in 1986. I've got the things right here. It was recorded. 

CHRIS AIKEN: Wow.

STEVE HAYES: It shows me giving this in front of the late Neil Jacobson, a huge person in behavioral couples therapy. You know, with these huge monster scientists. And I think I counted them, I watched the session, and I had at least four panic attacks in the workshop. You could tell by watching. Because I stop, I stumble, I can't talk. I look towards the screen. I pretend that I've got something to ponder, you know, and I'm just trying to find enough balance that I can make sound come out of my mouth.

CHRIS AIKEN: Steve could tell that he was having panic attacks on that video because he knows his coping strategies well, but it's a fair guess that his audience had no idea he was panicking. This is a useful pearl when you work with panic disorder because these clients live in abject fear that they will have an embarrassing panic attack in public. It's part of the definition of agoraphobia, a fear of having an embarrassing, debilitating symptom in public, like panic, vomiting, or falling. So when you see a patient with a phobia of vomiting, that's usually agoraphobia. Now, sure, a speaker may have to pause when they have panic attacks, but the audience will likely interpret that pause as thoughtfulness, not fear. Patients with panic disorder are gonna tell you that they are totally unable to function during a panic attack, that they have to leave the meeting, hang up the phone, or go home sick. But this has more to do with the exaggerated fears of panic disorder than with reality. Contrary to popular belief, anxiety does not make people perform worse on cognitive tests. Neither state nor trait anxiety has a significant effect on executive function, memory, learning accuracy, or attention.

KELLIE NEWSOME: CBT challenges the anxious thoughts behind panic attacks, but changing those catastrophic misinterpretations is not what brings about recovery. Instead, it is self-efficacy, which sounds like what happened here as Steve Hayes turned a terrifying ordeal into a triumphant one. Instead of a story of panicking on stage, it's a story of overcoming a daunting hurdle.

STEVE HAYES: I have to tell you that that was not something that made me feel smaller. It made me feel like, Yes!, because if you can step forward in front of these monsters as a little assistant professor and still speak about something you deeply care about in the midst of a panic attack, you know, well, then I can understand how hard it is, and I can be there with a client who says, I just can't. I can't, I can't. I say, I get it. My mindset said the same thing. Here's how. Let's go out and do some exposure work together. Let's go find anxiety, and we'll, you know, we'll get into the mall and go in and order a hamburger at the clothing store. We'll do public humiliation. We'll lie on the floor and say, help, help. We're having a panic attack, and I'll lie right next to him. I did the craziest stuff in the early days of just learning to come and get me. If clients get that spirit, it's really hard to have a panic attack when you want one. Talk to people who have panic disorder. It's almost impossible. I want a panic attack. Can't have one.

CHRIS AIKEN: Okay, I gotta admit, I got a little confused at this point in the interview, so let's slow it down. Steve isn't talking here about classic exposure therapy, where you bring on a panic attack in CBT by, say, breathing into a paper bag or spinning in a swivel chair. The idea behind those maneuvers is slowly, through graduated exposure, the patient becomes acclimatized to the panic sensations. What Hayes is describing is something we see in Acceptance and Commitment Therapy: assignments that are supposed to change the client's relationship to anxiety. The idea is that panic attacks come from an adversarial relationship with anxiety, where anxiety is the enemy. And if we flip that switch and genuinely embrace anxiety the way you do when you line up to get on a roller coaster, if we genuinely want those panic attacks to come on, then the panic attacks won't happen. When we say no to panic attacks, they come barging in. But when we say yes, they go away. Sounds interesting, but is it really that simple?

STEVE HAYES: Not always. I don't wanna give it as a formula. Please don't follow this at home. You know, like, Oh, I don't know how to fix panic attacks. I'll just say no. Next thing you know, you're lying to yourself. No, no, no. Oh, it doesn't work. Work with what if it no pulls the trigger? But saying yes instead of no has to be authentic. It has to really be. I give up, I am not gonna measure the success of my life by whether or not I have a panic attack. If you don't mean it, your mind will know it. So it's tricky, really tricky to do deliberately. To say yes deliberately to doing things that are hellacious, make you feel insane, like you can't function. You actually have memories of not being able to function in that initial thing, and I raised my hand to say something to these full professors. They finally turned to me, and here's what they heard: nothing. I couldn't make sound come out of my mouth.

CHRIS AIKEN: Oh, okay, I thought our connection was bad. 

KELLIE NEWSOME: Join us next week for an update on pramipexole in depression. And then we will reconnect with Steve Hayes about a popular movement that inspired many of today's psychotherapies before it veered off in an unsavory direction and turned into a cult. This month, The Carlat Psychotherapy Report has tutorials on psychotherapy for borderline personality disorder, anorexia, and bipolar. It's one of our six newsletters; the others focus on geriatric, child, addiction, and hospital psychiatry, and the general Carlat Psychiatry Report. Get $30 off your first-year subscription with the promo code PODCAST.