The art and science of the clinical conversation: an interview with Matthieu Villatte
(la entrevista está disponible en español en este link)
Today’s interview is a little bit more personal than usual. I’ve met Matt a few years ago when he and Jennifer Villatte were part of the ACBS committee reviewing the scholarships applications for developing nations, and I was one of the applicants. Over the course of the years I’ve participated in some of his workshops and courses and I’ve come to appreciate a lot his unique approach to the clinical processes.
Matt is a Research Scientist and Clinical Trainer at the Evidence-Based Practice Institute of Seattle, WA in the United States. He obtained his doctoral degree in France, with an emphasis on Relational Frame Theory (a branch of contextual behavioral science studying language and cognition), and completed a post-doctoral fellowship at the University of Nevada, Reno under the mentorship of Steven Hayes, PhD. He is the co-author of the first manual published in French on Acceptance and Commitment Therapy and is associate editor of the Journal of Contextual Behavior Science. He is also is an ACT peer-reviewed trainer, as recognized by the ACBS.
But the main reason for this interview is his latest book, co-authored by Jennifer Villatte and Steven Hayes, Mastering the Clinical Conversation: Language as Intervention, one of the most innovative books I’ve read lately.
It is a strange book, it feels like an ACT book, but without address explicitly any ACT concept (for instance, they mention the word “defusion” exactly four times in the whole book, and in every case as a part of a list). Instead, the book explores how to use RFT to enhance clinical processes through conversation; no techniques, no exercises, just how to maintain a good, clinical, RFT-guided conversation. I know, it sounds like the nerd’s dream, but it is actually quite easy to read and surprisingly simple to follow.
So, I invited Matt to talk about the book, the relationship between ACT and RFT, and the road ahead for the CBS.
– Hi Matt, thanks for agreeing to this interview! Could you tell us a little bit about yourself, your academic background and the work you are doing right now?
Hi Fabian! So nice to talk to you. I am a PhD in psychology. I completed my academic education in France where I started doing research and training on relational frame theory and acceptance and commitment therapy. Later, I joined Steven Hayes’ lab in Reno, Nevada, for a post-doctoral fellowship. I also worked as an assistant professor at the university of Louisiana for a couple of years, and now I’m a research scientist and clinical trainer at the Evidence Based Practice Institute in Seattle. I focus a big part of my current time on the dissemination of contextual behavioral therapies.
–The psychology field in France is well known for the spread of psychodynamic traditions, not so much for its behavior analytic influence how did you first learn about CBS, RFT and ACT in that environment?
I was trained by one of the few behavioral psychologists in France, Esteve Freixa i Baque, who was actually from Spain. I just happened to be in a university where behavior analysis was taught, and where it was possible to pursue a PhD in this approach. During the first part of my education, I was trained as a traditional Skinnerian behaviorist, and it is when I started working on my dissertation that I got interested in RFT.
I wanted to study impairments in theory of mind in schizophrenia from a behavioral perspective, and I came across the early work of Louise McHugh and Yvonne Barnes-Holmes on deictic framing (perspective taking). That’s how I discovered RFT, and I decided to apply Louise and Yvonne’s work to schizophrenia and social anhedonia. Soon after I discovered RFT, I started my clinical training. I had heard about a clinical application of RFT called ACT, and I thought it might be interesting to dig further. With my colleague Jean-Louis Monestes, I started reading more about ACT, going to workshops in the UK, and to international ACBS conferences. ACBS is a very warm and welcoming community, so it was easy to make connections, and very quickly I started collaborations with people like Louise McHugh and Nic Hooper.
As you said, in France the field of psychotherapy is still dominated by psychoanalysis, but there is a growing community of CBT practitioners too. ACT has gained interest in both communities actually, perhaps because it is a behavioral and humanistic model. Some could say it is the best of both worlds!
– Since you mention it, France and Argentina have a similar academic background in psychology –this is, in both countries the influence of psychoanalysis has been huge. Would you say that influenced your work? If so, in what ways?
To be honest, I think psychoanalysis first influenced my work as a counter example of what I wanted to do. Up until late in my PhD years, I was really rejecting psychoanalysis entirely. What mattered to me was that we used evidence based practices that where well connected to experimental research. In addition, psychoanalysts still tended to reject CBT quite strongly in France, so it was hard to have a nuanced perspective on psychoanalysis. You pretty much had to choose a side between psychoanalysis and CBT.
More recently, since I moved to the US 6 years ago, I learned about psychodynamic approaches that are more pragmatic and open than what I knew about psychoanalysis in France. In fact, it took me a while to understand why my American CBT colleagues didn’t seem quite as bothered by psychoanalysis as I was! Well, they had never seen a kid with autism being treated by a silent psychoanalyst or by being packed in wet sheets, whereas for me, it was a very common and disturbing experience.
As I learned more about psychodynamic approaches, and got trained in functional analytic psychotherapy in particular, I started to see the value of therapeutic techniques that are often not explicitly trained in CBT, such as less directive conversations, reflective listening, and an interest in the client’s history. Believe it or not, it is actually through my more recent work in clinical RFT that I have become more interested in psychodynamic approaches and to some extent, even psychoanalysis. In particular, the way RFT makes sense of symbolism helps ground techniques like free association or dream analysis into sound behavioral principles. Now, I’m not saying I would use Freudian theories per se, by I think there is something really effective in the way psychodynamic therapists help clients explore their own experience and make sense of that experience.
– Let’s talk about the book you wrote with Jennifer and Steven. And I have to say, for a nerd like me, the book is a treasure, because you write about the core processes of RFT as they unfold in the therapy room. Now, why do you wanted to write that specific book?
Thanks for your kind words! It took us some time to finish this book, so it is really nice to get such positive feedback since it has been released. The idea of this book started when Jennifer and I met in 2009. Our first discussions were about the links between ACT and RFT, and we were both excited by the possibility of better grounding ACT into behavioral principles of language and cognition. At that time, it was pretty common to hear in the ACT community that “you don’t need to know RFT to do ACT”. We were not sure if knowing RFT was necessary, but we thought it could be useful. We thought what we needed to do was sit and explore what we could do with what we had learned about RFT in the past couple of decades. When ACT was developed, RFT was still in its early years, but decades after, RFT research had significantly grown, and we thought perhaps we could approach its clinical applications in a different way.
So, originally, the goal of the book was to show how to use RFT principles to do psychotherapy, without using middle terms from psychotherapy models. It was like going back to the roots of behavior therapy, but including principles of language and cognition. At some point, the focus became a bit more specific, that is, about the use language in therapy. Given that RFT is a functional theory of language, we thought it should tell us something about how to use this tool effectively.
– You wrote “we have bent over backwards to avoid writing this book as an ACT book” (p.358), and the book indeed feels like a direct bridge from RFT to the clinical work, bypassing the ACT terms we all are most familiar with (such as defusion), almost entirely. Why was this an important goal for you, what are the upsides of doing that?
As I was saying, originally, the book was more tightly connected to ACT than it ended up being. At first, I thought we would do a kind of RFT-based ACT book. And in a way, readers can still see it this way, I guess. But as we dropped ACT terms and started thinking more broadly about clinical work in general, allowing ourselves to explore a wide variety of clinical traditions, we realized that a number of techniques made perfect sense from an RFT perspective, while they were not included in ACT, explicitly at least.
Of course, because ACT is a very flexible model, you can probably virtually include any technique that works. But if we look at what is traditionally emphasized in ACT manuals and trainings, there is definitely a lot of techniques that are left out, like exploring a client’s history to make sense or their current actions, analyzing reasons of a behaviors, or changing cognitions. Again, many ACT therapists probably actually use these techniques, but they are generally not explicitly included in ACT. So, our goal was not to move away from ACT but to free ourselves from the ACT framework in order to think as broadly and inclusively as possible. We wanted clinicians using cognitive therapy, hypnosis, psychoanalysis, or humanistic therapies to recognize their own work in our approach. We wanted to provide a coherent and integrative framework in which it is possible to use techniques from any model.
I think a big advantage of approaching clinical work form the perspective of RFT principles is that barriers between models tend to fall. As I was saying earlier, I have myself become much more open since I started approaching clinical work from the perspective of RFT. In my clinical trainings, I generally use examples from a great variety of therapy models to illustrate RFT principles. Some are not even evidence based yet, but conceptually at least, they make a lot of sense. So why not explore them further?
– What do you think ACT therapists could gain in terms of clinical fluency from learning the RFT principles? Could you give us and example?
There are lots of areas where ACT therapists can benefit from knowing clinical RFT. For example, the Chapter 6 of our book is focused on the self and is closely related to the concepts of self as context in ACT. The Chapter 7 about meaning and motivation is close to the concepts of values and actions in ACT. In many ways, the Chapter 5 on activating and shaping behavior change is about defusion and acceptance. So in a way, our book remains fairly close to the ACT model organized in three pillars (open, aware, engaged). We also wrote a whole chapter on metaphors and another one on experiential exercises, which are two key areas of ACT. But our bottom up approach brings something different than ACT books.
First, we dismantle concepts like self as context or values into more precise principles that are actionable in therapy session. So, what we bring is a level of precision that allows therapist to better recognize opportunities for intervention, and to use the right processes moment by moment inside a fluid conversation. Perhaps one of the key contributions we are making in this book is how to use different types of framing to create a symbolic context that supports the client’s progress.
We were not the first to think of doing that actually. Carmen Luciano and Yvonne Barnes-Holmes and their students conducted a couple of studies in which they tested different types of framing and their impact on clinical outcomes. The point is not to analyze every bit of framing included in our language. That would be impossible, and certainly not practical. What we propose instead is to target the key types of framing that can alter the symbolic context in a significant way, and thereby, change the client’s response. For example, leading a client to connect her actions with meaningful purposes through hierarchical framing can be as simple as asking, “What would doing this action be about? Why would that be important?” It is not the topography but the function of our language that matters, and knowing RFT helps you identify and target useful functions at each moment of the clinical conversation.
So, ACT therapists who learn clinical RFT will likely no drop anything they like doing in session, but they will be able to gain precision in their language. Paradoxically, I have found that the more you know about RFT, and the less technical your language becomes in session. I think this is because you gain a deeper understanding of the function of your language, and so you can use any kind of symbol to create the right context. Sometimes, a silence or a silly joke can be incredibly powerful, for example.
– The book claims that RFT could enrich any clinical practice, regardless of the theoretical orientation of the therapist. What is your experience working with non-RFT/ACT therapists?
Since we started doing clinical RFT training, we trained hundreds of participants who generally had a background in ACT. This is not surprising because RFT is more known in the ACT community. But a significant portion of our participants comes from a different tradition. Some from other 3rd wave approaches, like DBT, FAP, or different mindfulness based therapies. Some have a traditional CBT background. Some are psychodynamic therapists. And others are hypnotherapists. We have also trained practitioners in a variety of settings and with different jobs. One time, I trained the whole staff of a hospital, which included nurses, psychiatrists, psychologists, and social workers. The training was the same for everybody and it worked because we talked about core principles that apply to any situation and any therapeutic style.
Clinical RFT doesn’t tell you how you should speak or sit in the therapy room. It tells you how to assess the effect of your intervention and how to choose what works best in a given situation. If you are a talkative therapist, you can still hit the same targets as another therapist who is more reserved. The interactions in the therapy room won’t look the same, but functionally, you can obtain the same results. The integrative nature of clinical RFT is something that therapists find extremely attractive. I think there is a growing interest in the possibility of moving beyond packages and models. Therapists want to do what works best for their clients, but they want to have the freedom and flexibility to do their job with their own style, and to use what their clients prefer. Clinical RFT allows you to stay connected to the science and to be natural and flexible at the same time.
– More often than not, ACT trainers give some form of the advice “While doing ACT, talk less, do more”. Given that your book is focused exclusively on conversation, what would you say about it?
This is a great question! In traditional ACT training, experiential work is often opposed to using language. This is based on lab studies showing that language can create strong insensitivities to important elements of the context. But the research Hayes and his colleagues did on this topic in the 80’s was not about language in general. It was about rules and instructions. Rules and instructions are not the only way we use language. Rules are descriptions of contingencies, which is what we use in psycho-education. With language, we can also encourage clients to observe these contingencies. For example, when we ask a client to observe how she is feeling in this moment, we are using language. And she is using language too when she is describing what she is feeling. So, language and experience are not opposed, but using descriptions of contingencies can lead to insensitivity to this experience if these descriptions are not used carefully.
I would say that clinical RFT encourages you not to talk less, but to tell less, and not necessarily to do more, but to evoke more, that is, to create the context in which the client will make his own observations and draw his own conclusions. It is also important to understand that from an RFT perspective, language is much broader than the words we say. It is about symbolic relations. So, even when ACT therapists encourage their clients to do more, they actually probably almost always use language. For example, doing an exercise like the Chinese handcuffs is loaded with symbolism. If it were not, doing this exercise wouldn’t have any impact on clients’ lives. They wouldn’t learn anything from putting their fingers in a tube. They need to draw a symbolic connection between what happens in this exercise, and what they do in a more clinically relevant situation. Our book is all about being experiential. It is about using language experientially.
So, ACT therapists won’t find any contradiction with their work, I believe, but they might learn how to be experiential without using exercises, through natural conversations with their clients. And they will learn to choose, build, and deliver experiential exercises without disrupting the therapeutic relationship.
– What do you think are the biggest challenges CBS and ACT are facing today? What would you like to see happening in ACT? What would you hate to see?
The first development phase of ACT has been focused on research and has led to more than one hundred RCTs. The second phase has been more focused on dissemination. There are ACT books on everything and ACT trainings all over the world. Of course, research didn’t stop during this second phase. In fact, most RCTs were conducted during this second phase. But I would like to see a higher level of precision in ACT research.
In particular, and not surprisingly I suppose, I would like to see more RFT in ACT RCTs. I would like researchers to test interventions more directly based on clinical RFT. It can be called ACT if that is necessary for grant funding or other reasons, but test ACT is not what interests me most. I would actually prefer if we moved toward clinical RFT or clinical CBS in our clinical research. This way, we could include techniques coming form different models, like CFT, DBT, hypnosis, FAP, and so on. If ACT is a clinical application of CBS-RFT, then I think it is time to go back to the roots. ACT is not enough based on RFT at the moment. It is conceptually and broadly based on RFT, but experimentally, we don’t have much data. We need more research to develop clinical interventions from the bottom up. So far, most ACT interventions came from the clinic, and then were tested in RCTS that don’t really tell us how these interventions work at the level of RFT principles. Something is missing between middle terms like defusion and values and the more basic behavioral principles. If we want to be consistent with our mission (I am thinking in particular of the paper written by Hayes et al in 2012 in the Journal of Contextual Behavioral Science, which presents the CBS strategy), then we need to fill this gap. I really hope clinical researchers are going to do more clinical RFT research in the future, to improve ACT of course, but more important, to improve clinical work in general.
– Where are you going now? What is the next direction for your work?
At the moment, I am focused on getting our work on clinical RFT more visible. I developed with my co-authors a website (languageasintervention.com) with a lot of free resources to learn clinical RFT, which follow the chapters of the book step-by-step. I will be doing a lot of trainings in different countries in the coming year.
The release of our book was a big milestone, and more contributions are coming from other clinical RFT researchers and trainers. I hope our book will stimulate new people to do training and research in clinical RFT. I have started some research projects to test interventions based on clinical RFT with a few colleagues in the US and in Ireland, for example. But there is really not enough research in this area. We need more labs involved. I will be at the next world conference of the Association of Contextual Behavioral Science, where I hope we can explore new ways to develop clinical RFT research.