Psychological Flexibility as The Therapist's Core Process

This article is the second in a series from Dr. Elisabeth Morray, VP of Clinical at Alma, following an in-depth conversation with Dr. Steven Hayes, the Founder of ACT and architect of Psychological Flexibility.

Psychological Flexibility is a concept and process at the very heart of acceptance and commitment therapy that can be uniquely and remarkably helpful in times we're living in for all individuals, but especially for therapists themselves.

To put it simply, Psychological Flexibility refers to the ability to remain emotionally open, fully present and focused on what matters most, even in the middle of conditions that challenge us.

The position I occupy as the clinical leader for Alma’s network of providers has allowed me to develop a deep understanding of the realities faced by behavioral health clinicians. Regardless of degree type, specialization, or location, we experience unrelenting demands on our time, attention, and emotional bandwidth.

We’re also facing significant uncertainty about the future of our field — what limitations on coverage and compensation might emerge in the healthcare space? What systemic protections for the vulnerable populations I treat can be trusted? What role will AI play in behavioral healthcare? How can I sustain myself and grow my business the way that I want to amidst all these challenges? In extreme cases, some of us are expressing a desire to leave the field altogether.

If we want to sustain ourselves and show up well for our clients, we need a different way of thinking and working that actually supports us as clinicians, even when other systems are breaking down.

For me, applying the lens of Psychological Flexibility to my work has created that model, and the goal of this series is to share why it’s so effective in this current moment — and how to integrate it into your personal and professional life.

The Waters in Which We Swim

There’s so much more to burnout than the size of our caseload. It’s what happens when the conditions required for good clinical work are systematically eroded. When the time you need to care for your clients and ensure that you’re showing up fully is overtaken by administrative paperwork and the constantly changing rules of compliance.

More recently, new pressures have taken hold. With telehealth, we’re more isolated as providers than we’ve ever been before. There’s rising anxiety about payer scrutiny and clawbacks. And we’re carrying the psychological load of practicing in a limiting sociopolitical context — one that now directly shapes what shows up in the room and how care can be delivered.

As clinicians, our jobs are to provide a steady, safe space into which our clients can bring their most vulnerable experiences, and trust that these experiences will be expertly and compassionately held, explored, and navigated. We know how exhausting it can be to do this well, day after day, client after client under even the best conditions.

Meeting this standard when the environments in which we live and practice outside of therapy space do not meet our basic needs, and often actually deplete our emotional and attentional resources is the challenge that many of us are now expected to overcome.

The Therapist Comes Into the Room, Too

The struggles that a therapist is having outside of the therapy room may, at times, find their way into that space. Our minds may wander our financial concerns during a session, and we realize that we missed the last two minutes of what our client was sharing. We find it harder to summon empathy for the person across from us who has a different set of political beliefs, perhaps possesses access to resources we long for, or even actively participates in a system that disenfranchises people who share our own identity.

As is the case for our clients, when we are having trouble adapting, our behavior tends to become more rigid. We may grapple with attention, decision-making, emotional availability, and risk tolerance. We may become more cautious, avoidant, reactive, or rigid in session, or become less engaged. Rather than risking the vulnerability that comes with emotional depth, we may instead rely on overly structured, less attuned ways of engaging, disengaging emotionally to preserve energy. This kind of rigidity is costly, not just for us, but also for clients.

It can be easy to blame yourself for these changes, to question whether you are lacking the motivation, discipline, and passion that brought you into the field in the first place. Traditional models of behavior change, which focus on the strengths, struggles, and “pathologies” of the individual, might direct us down this pathway of self-criticism and blame.

These approaches often ignore an important reality - our behaviors are deeply influenced by the environment around us. As our context changes, particularly when it is unstable or includes significant threat, our behavior must evolve if we are to stay aligned with our values and commitments.

In other words, we may need to update the “core processes” that support us, our work, and our clients. Fortunately, the field of behavioral science has given us some incredibly powerful tools to guide and support the kinds of changes that will allow us to flourish, even amidst the challenges of our current context.

Psychological Flexibility as an Alternative

Behavioral science has identified a core set of skills that allow people to adapt to challenging environments, and these are captured in the Psychological Flexibility model (Hayes et al, 2022). Rather than thinking of this model as a set of skills that we can impart upon our clients, we have an opportunity to embrace them ourselves, allowing us to show up for our own needs as well as for our clients’.

The term “Psychological Flexibility” refers to the ability to remain emotionally open, fully present, and focused on what matters most, even in the middle of conditions that challenge us.

Rather than minimizing the very real concerns that we experience in our current practice contexts, asking us to “detach”, or putting the responsibility for “coping better” on our shoulders, Psychological Flexibility supports greater freedom amidst these struggles. Freedom might look like the ability to stay engaged with clients while acknowledging real-world pressures, making decisions based on values rather than fear or reactivity, and allowing difficult internal experiences without letting them dictate our behavior.

The Psychological Flexibility Series

The future of good clinical work will not depend solely on how much knowledge we possess or how productive we can be. It will depend on whether we as therapists can remain psychologically flexible enough to evolve and adapt within a changing, and challenging, system. In the midst of chronic instability, a focus on Psychological Flexibility provides a powerful alternative to trying to control the uncontrollable. It does not ask us to have access to an endless supply of individual motivation and willpower. Instead, it gives us a framework for thinking about how we can set up an environment that better will resource and support our needs, while we do the same with our clients.

Psychological Flexibility skills allow us to remain present in moments that are painful, and to respond intentionally rather than react automatically. And perhaps most importantly, it gives us a framework for building professional lives that are sustainable, values-aligned, and deeply human even amidst uncertainty.

In the articles that follow in this series, I’ll explore core processes of Psychological Flexibility. These include present-moment awareness in environments designed to fragment attention; relating differently to fear, self-criticism, and professional uncertainty without becoming dominated by them; and connecting with values-based action when exhaustion, systems pressure, and disillusionment begin to pull us away from the kind of therapists we want to be.

My hope is that this series does more than introduce a set of ideas. I hope it offers a practical and compassionate framework for sustaining yourself in this work without losing the depth, humanity, and presence that meaningful psychotherapy requires.