Constructing a liberated and modern mind: six pathways from pathology to euthymia
Authors: Steven C. Hayes
Journal: World Psychiatry (2020)

Traditional psychiatric nosology has been largely based on the idea that human psychological suffering reflects a latent disease1. As Fava and Guidi note in their paper2, this conception has interfered with a more balanced and positive approach. It is not just that the focus on psychological distress has overwhelmed needed attention to positive experience. It is also that the latent disease model underlying syndromal diagnoses provides minimal clinical guidance regarding the nature of psychological health. It is obvious that human thriving is not merely the absence of distress. However, without a more adequate approach, clinicians are not given guidance about how to pivot their attention from pathology toward psychological prosperity in a more meaningful and coherent way. If a process-based diagnostic approach is adopted, however, clear pathways arise from pathology to euthymia. More so than eudaimonic detachment, euthymia denotes the balanced satisfaction of human needs and yearnings. Just as distressing human emotions reflect the frustration of core yearnings, positive human emotions and well-being reflect their accomplishment. For that reason, we may be able to use the core human yearnings reflected inside pathological processes to provide a kind of roadmap for the creating of euthymia itself. In an extended evolutionary approach to process-based diagnosis, processes of change link to variation, selection, retention, and context sensitivity in at least six psychological dimensions: affect, cognition, attention, self, motivation, and overt behavior3. As a set, these psychological dimensions are then nested in between social/cultural and genetic/physiological levels of analysis. The psychological flexibility model (PFM) that underlies acceptance and commitment therapy (ACT) contains six known pathological processes of change that are paired with six known positive processes of psychological growth4, 5. These six pairs line up with the six dimensions just listed. In the area of affect, the negative change process of experiential avoidance pairs with the positive process of experiential acceptance; in the cognitive area, cognitive fusion and entanglement pairs with cognitive defusion; in attentional areas, rigid attention to the past and future, via rumination and worry, pairs with flexible, fluid and voluntary attention to the now; in the area of self, defense of a conceptualized self is paired with a perspective taking sense of self and ongoing self-awareness; in the motivational area, unhealthy forms of compliance, self-gratification, or aversive and avoidant rule-based demands are paired with chosen values; in the overt behavioral area, perfectionism, impulsivity or procrastination are paired with committed and step-by-step acquisition of broader patterns of values-based action. What is not usually noticed in these pairings inside the PFM is that they are connected by deep human yearnings6. Consider those focused on by self-determination theory, one of the best empirically supported approaches to human needs: belonging, autonomy and competence7. Entanglement with a conceptualized self can be thought of as the mental mismanagement of a yearning to belong, in which people attempt to gain group membership and social connection or support by presentation of a persona that is especially able or especially needy. Over time, the mental attachment to specialness undermines belonging by fostering narcissistic pretense and avoidant/self-aggrandizing forms of "self-esteem" , or coercive presentations of pathos. Either of these forms of adjustment lowers healthy connection and eventually drives others away. Perspective taking and shared awareness, conversely, are known to foster genuine connection, attachment and belonging. In a similar way, the yearning for autonomy or self-directed meaning is mismanaged by compliance, self-gratification and rule-based demands, but is satisfied by chosen values; while the yearning for competence is mismanaged by perfectionism, impulsivity or procrastination but is satisfied by the committed construction of larger and larger patterns of values-based action. In all of these pairs, the deep yearning underneath pathological processes of change is not the problem – pathology is just the wrong solution to the correct human challenge. What draws people into pathology is the one-two punch of short-term and more certain contingencies dominating over longer-term and more probabilistic ones, and an excessive reliance on the evolutionarily recent adaptation of symbolic thinking and problem solving. Those general features are managed in ACT by the three remaining pairs of change processes in the PFM. By learning cognitive defusion skills, the yearning for understanding and coherence, that becomes increasingly central as symbolic language is acquired, can be met in a more generally useful way. Instead of trying to achieve literal coherence, in which all thoughts line up neatly in a coherent and consistent row, the person learns to step back from symbolic thinking processes and allow them to impact life choices based on functional coherence – the wise understanding that comes from allowing useful thoughts to guide behavior based on their history of workability over the longer term, while respectfully declining the mind's invitation to comply with the rest. Similarly, instead of trying to satisfy an inborn yearning to feel by always "feeling good" – that is, by feeling only those events that are cognitively evaluated as "good" or "desirable" (which ultimately leads to a reduced capacity to feel at all) – a more defused approach is taken to those evaluations, allowing emotions to be explored and felt more openly and without needless defense. These acceptance skills satisfy the yearning to feel, and allow the helpful knowledge that emotions contain to be used, leading to more capacity for joy, appreciation, love, and well-being. Finally, the yearning to be oriented can focus less on the ruminated past or mentally constructed future, and more on a deeper connection with what is actually present, inside and out. Pathological change processes can thus be thought of as mismanaged yearnings. This mismanagement is caused by an evolutionary mismatch between half a billion-year-old learning processes or even more ancient genetic, epigenetic, perceptual, sensory and neurobiological systems, and the dominance of symbolic reasoning and problem solving that is 200 to a thousand times more recent, but that has been put on steroids in the modern technological era8. By focusing on what lies beneath pathology, however, a roadmap to euthymia is revealed. The flexibility, consistency and resilience that define euthymia are fostered by healthy management of yearnings for belonging, coherence, feeling, orientation, self-directed meaning, and competence, in turn fostering wise psychological management of social/cultural and physical/biological health challenges. From the viewpoint of processes of change, psychopathology itself contains much the same lesson in its evidence for sources of mismanagement of these very same yearnings and challenges. Flexibility is based in part on the increased and conscious context sensitivity afforded by perspective taking and voluntary attentional control; consistency is fostered by the greater motivational dominance of values, and the acquisition of committed action skills; resilience is fostered by greater emotional and cognitive openness and their ability to incorporate both "negative" and "positive" experiences into a life worth living. Considered as a set, these PFM skills foster euthymia, because they allow us to do a better job of evolving on purpose, supported by healthy psychosocial forms of variation, selection, retention, and context sensitivity. People in distress are not broken. The mismanagement of healthy yearnings lights a path toward euthymia, if we learn how to notice the presence of these yearnings inside pathology and pivot in the direction of their healthy satisfaction.