Psychological Flexibility for Therapists Under Pressure

This exclusive interview kicks off a series of resources on the topic of Psychological Flexibility from Dr. Elisabeth Morray, VP of Clinical at Alma.

Developed by Dr. Steven Hayes, the Founder of ACT, 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.

Dr. Elisabeth Morray (00:01)

I am so happy to be here with Dr. Steven Hayes, the founder of ACT and Process-Based Therapies, a prolific researcher and clinician educator, and the architect of Psychological Flexibility. Steve, thank you so much for being here.

Dr. Steven Hayes (00:19)

Well, it's awesome to be here with you, Elizabeth, and I've known you for years. I hope I took it's ok to call you by your first name.

Dr. Elisabeth Morray (00:26)

Please do, please do, yeah. I work with over twenty-six thousand therapists, and the conversations I hear today aren't primarily about interventions anymore. They're about documentation and audits, the benefits and risks of AI, reimbursement pressure, isolation, burnout, and at its core, uncertainty about the future of the profession. I think therapists are struggling with change, they doubt their own resilience, and they are wondering how they can continue to thrive in a system that doesn't always reward the clinical work that they're doing.

The reason I'm excited to speak with you today is that I think we have the opportunity to look at Psychological Flexibility, a skill that you've spent your career helping therapists teach to their clients, and maybe give therapists an opportunity to meet the moment with the spirit of Psychological Flexibility.

So before we dive into Psychological Flexibility, I'd like to start with getting a sense of whether what I'm experiencing in my work with clinicians is at all mirrored in the work that you're doing with clinicians who you are training and leading in your various roles.

Dr. Steven Hayes (01:42)

No, I see it everywhere. And, you know, our systems of care are asking practitioners to do more over and over and over again, to the point where things are really getting quite stressful at times to be in the helping professions. Psychological Flexibility is built on the idea of what are the smallest set of processes that do the most good for the most people. Last time I checked therapists are people.

And so, you know, if, we're not engaging in the kinds of self care that allow us to step into this chaotic world that is evolving and find a way to sort of live out what even brought us into the profession in the first place. to remember that we're serving others, but that we can't do that if we don't take care of ourselves.

And that includes the practical things, but it includes also just the psychological stance that we take on things.

Dr. Elisabeth Morray (02:35)

Curious to hear a little bit about what you see as some of the forces that do make it challenging for clinicians to show up in a way that kind of embodies what brought them into the work? What are the dynamics in this kind of chaotic clinical world that you've seen as being particularly problematic or disruptive to that clinical process?

Dr. Steven Hayes (02:57)

Well, some of us, I think we forget that this is unique or The system forgets that this is a unique human being we're dealing with. And this is a unique human being called a therapist. And that sense of connection, the therapeutic alliance, the importance of feeling seen in our uniqueness.

When the system is sort of saying no, the box that's checked here or the diagnosis that's given there, the number that implies this and this and this often, you know, driven you know, by systems that are not down at the level of the unique person sort of try to lure us into forgetting about our own uniqueness and the uniqueness of those we serve and how to connect in a way that supports and builds as part of a therapeutic alliance.

I think the single biggest thing that makes it hard, it isn't just that maybe people are wanting to cut on how much is being paid for a session. That's important in that we all have our bills to pay and so forth. That's really important.

But being required almost to think in terms of those numbers and categories only, instead of the uniqueness of the person in front of you and of the person that you are. What brought you into this field anyway? What do you want to accomplish with those moments or with another person?

And I think if we can find a way to connect with each other and connect with, well, with systems like what you're doing right now of trying to bring to the 26,000 people that are working with you that little breath of fresh air, or that window opening that allows us to maintain our humanity and the purposes that brought us into this field in the first place, right inside a really rapidly changing environment that sometimes turns it all into numbers and checkboxes and forms. That's secondary. It has to be dealt with. But it's secondary.

And, you know, some of the work that you've done of making those secondary things easier, just so that you can focus on the primary, I think is critical.

The way I see it the most is if I can get in a room with a group of clinicians and we're working on this, as we kind of sink into the humanity of what we're doing. It's like slipping into a hot bath or something where you go like, yeah, this is why I'm in this field. This is why these human beings called my clients are so important to me. It almost brings tears to our eyes when they connect with it.

And we so easily can be in systems that forget and are never really focused on what's most important and some of those things are the most important.

Dr. Elisabeth Morray (05:43)

I think that's actually something that I see quite a lot is this experiencing experience of questioning that therapists do around what they do, who they are, whether or not the work that they're doing and the services they're providing are valued. And I I wonder the way you think about when when one is sitting with those kinds of questions or that particular kind of almost existential uncertainty, right? Why am I here and why am I doing this work? What impact do you see that having on their behavior, on their identity, and on the kind of the way they show up in the therapy room when the those questions kind of enter the room with them?

Dr. Steven Hayes (06:30)

Well, if we can connect with our larger purpose, but also come in, then bring that into the present moment in a way that is, emotionally open and not cognitively entangled and judgmental, where we're consciously here, present with another human being doing something that deeply matters to them and to us and find ways to sort of humanize that and get that message out — in and out.

In, in the sense of I think of it this way: from it, toward it, and with it. The "it" that we're talking about there is a result of 50 years of research you can distill down every study that's ever been done about why therapy really works, why the alliance is really important, why the techniques we use land, How does change happen — and it is something you can say in a sentence And I can defend the science behind this. And not just on ACT. Yeah, there's 1500 randomized controlled trials on that, almost half of what mainstream CBT has — that's pretty great and way up there.

If you look at all of the science about all of the different forms of intervention in psychotherapy, I mean everything from yoga on up to analytic systems oriented, existential, humanistic, cognitive, behavioral, etc. here's the sentence:

Life's asking us and our clients to learn how to be more open, aware, and actively engaged in a meaningful life, while extending that to our relationships and our body.

That's kind of cool that we can say something that fundamental and that broad in one sentence. And I'm not singing an ACT uber alles song here. Any area that you're interested in, if you specify the processes that are really important, transference, mentalization, schemas, attachment. I mean, I'm using words that deliberately aren't ones that ACT people would use. Yeah, dig down into what they really mean and they fit the sentence I just said. So we've done something as a field that that sentence comes out of not just my work, it comes out of looking with a science eye at everything we know about how change happens.

And so we can take that distillation and then maybe use it to simplify and to focus. One of the things that's cool about this that I have to say, and here I'm entering into the randomized trial world, and there I'll just do the ACT side because I know it so well. The data show that whether you're a student in a social work program or a chief psychiatrist or an OT or PT or a nurse practitioner taking the time for us to be present with our values and to look at what distracts us over into fights with our own emotions or thoughts and come into that present moment.

While scaling that to our relationships in our body, you know, that yoga practice might really, really be important to you. That taking care of your nutrition might be really, really important or that time with your family so keeping that in balance as a provider helps you teach others how to find that balance in their lives as clients.

And you don't have to change what you like. You don't have to change your terms. You don't have to change what you know works or what really feels good to you. You have to just look anew at what's happening here therapeutically and allow some of the science to simplify it.

You're teaching people to be more open, aware, and actively engaged in a meaningful life. And you're tracking whether or not they're taking care of their relationships and taking care of their body and learning from their body.

That is something in the modern world that therapists are the ones who bring that knowledge into being. I mean, it is in our wisdom traditions, our religious traditions. It's out there. It's in our various health traditions and contemplative practice and all of that. But we are tagged as professionals to putting it into this structure that's typically called psychotherapy.

Psychotherapists are people too. And let's take the time to make sure that we are supported and lifted up and then working with great institutions like organizations like ALMA and so forth, find ways to navigate some of the challenges that are structural and that are built into our health care system as best we can. And who knows where we'll go and where the wheel is still in spin, but we're part of it. We're part of solving some of these problems and it starts with our ability to be our whole selves.

Dr. Elisabeth Morray (11:22)

I think there's a lot of talk in the field about the idea of self-care and that therapists should do things outside of the therapy room in order to resource themselves. And I think those things are obviously important. and I think one of the things that I've so appreciated about your work is that it actually applies to what you are doing when you are sitting in that chair across from another human being.

Dr. Steven Hayes (11:47)
Yeah.

Dr. Elisabeth Morray (11:47)

And that Psychological Flexibility is something that is embodied in the therapist. And so, as much as we might think about the kinds of interventions we are experimenting with with our client to see if we can get their behavior to move and shift and become more flexible, I think we have the opportunity to do that same kind of experimentation with our own behavior.

And I'm curious, like if we kind of drill down to the nitty-gritty, you're sitting across from another human being and you yourself are encountering painful, tight, difficult, you know, whatever, internal experiences. What are some ways that Psychological Flexibility might influence what what you are doing as a therapist in that those moments where it is hard and where you are struggling?

Dr. Steven Hayes (12:37)

Well, those are those words I said: from it, toward it and with it. The toward is that, you you're trying to work on these processes in the end game of your client. But if it's coming from it, well, you're modeling behavior when you're doing it. And the with it means that the interchange, the betweenness with your clients also need to have that quality.

So let's take something like self doubt. You know, something shows up. Am I going to be adequate to this? Or, Can I go there with this person? Okay. you could think of that as, I need to get rid of all that self doubt so that I can be confident. And when I'm confident, then I'll be able to be competent at being able to move this person, too.

Well, wait a minute, slow this thing down. Confidence comes from Latin "con" with "fides" means faith. The actual behavior is to be true to yourself, to have faith in your own self. What does that mean? It might mean, could I use the fact that I know something about self doubt? If I can take it from here… [ed. note: places hand in front of face] to over here [ed. note: moves hand so that face is revealed].

You might think, I'm waiting for my life as a successful therapist to start after I get rid of all the self doubt. That's the least confident thing you could do in your professional life, it has no faith in yourself. You're not going to get the emotion of confidence if you do the behavior of non-confidence. Well, the behavior of confidence is to start with yourself and your caring work as a whole person called a clinician. So what can I do with self-doubt? Well, I could notice that's where my mind goes. I could notice that it's trying to help me, not hurt me. And that sometimes when I notice that I study more, I do some things that actually heal that. But I also notice that if I allow it to get here, my client disappears.

The client's in the same exact position. It is not your enemy to know something about what it's like to be human so that you can extend it to that human being in front of you.

Now, therefore, my self-doubt might not be, am I good enough as a therapist or can I step up to this really challenging multi-problem patient, oh my goodness, I've got a meeting I have to go to and I have a presentation I have to make and I, you know, I have a form I haven't filled out yet and I'm behind in my notes and I…, you know, okay, okay. That's important. We can get to that. But can we get to the client by moving it here?

And so some methods, you know, like for example, I'll give you two. These are classic ACT methods. Let's say, suppose the self doubt -— I'm just centering on that as an example — is maybe I'm not good enough. As a therapist, in this moment to help this person, just settle down. Maybe I'm not good. All right.
What would it what would happen if it's like this? If you said those words to yourself in the voice of your least favorite politician? How about if you sang them? I'm not good enough. I'm not good enough. We actually do these kind of crazy things in ACT work, by the way.

And now just to humanize it, just so that you know I'm not making fun of our minds. We don't deserve ridicule. We're just human beings. We've got both sides, you know? We argue in our heads. We started doing it when we were four years old. Goofy with horns on one shoulder, goofy with halos on the other. You know, even little kids understand that. I sometimes like, okay, I'm not good enough. I say to a group of clinicians, when is the first time you ever had a thought like that? And man, it's elementary school. It's sometimes early elementary school.

And I'll sometimes ask the person, it's kind of like an IFS thing to do, Okay, bring yourself into the room as a child and have it say to you what you say to yourself when you get pulled away from that moment with your client into self doubt, like I'm not good enough. Like to actually picture yourself at that age and what you looked like and have those words said in a way that you could almost hear it in the little girl, little boy voice.

What would you want to do if that could happen? Almost universally, people would want to hug the kid, put him on their lap, say something reassuring. But when you're brushing your teeth in the morning, you can say the most harsh things to yourself about your upcoming work day that are, I'm not good enough [ed. note: spoken in an adult voice], instead of, I'm not good enough [ed. note: spoken in a very small child’s voice]. We know this thing that started long ago.

And your clients they're looking to you for that. None of us are the world's expert on it. And one step at a time we can each get better at it and I think that's what a life journey is about. If you look at people who are older and you ask them what they've learned, they start saying things like, don't sweat the small stuff.

Why do they say that? Because that's called wisdom. Life will teach you this lesson, but if you can learn it quicker, and that's what our clients are facing, they need to learn some of life's lessons quicker. And they're sometimes doing things that are the exact opposite. You know, like a common thing would be self doubt, fear. I'm just going to suppress it. I'm going to ignore it. I'm going to argue against it. I'm going to try to medicate it completely away. I'm going to try to, you know, rationalize it.

You know, you can't run away from yourself. You know, no matter how fast you run, your history is coming with you. If you got a client in front of you who's trying to run away, you know you're going to have to help them to slow down, stop, and look. That's the same thing true with us. That means we don't have to pretend. We don't have to ignore. And we can be uplifted by the process of uplifting others.

By distilling down with the stuff that's really important, and it's in all of our therapy traditions. I hope a few things I've said here might get you curious about some of the things in ACT, but the bigger thing is to allow what life is trying to teach us all to do so.

Dr. Elisabeth Morray (18:36)

I want to take a moment and kind of riff on the theme of I'm not good enough and use that as an opportunity to talk about this question that many therapists have around what is good enough and do our ways of measuring good enough actually reflect the spirit of the work that I think you just captured so beautifully.

is that actually captured in PHQ9 and GAD7s and the typical kind of metrics that we are expected to use to, demonstrate our own worth and our own value through our clients' kind of progression in a very one-dimensional linear fashion. And so I'm curious: what are your thoughts in terms of the idea of good enough therapy and a good enough therapist?

If you were designing a system that could capture that in ways that would feel meaningful and useful, what would that system look like?

Dr. Steven Hayes (19:45)

Well, if I was designing it, I would design it in a way in which every voice matters and what people really yearn for and want in that support from helping professions could be the focus of what they do. We've gradually socialized, and I'm old enough to have seen some of these changes, socialized the world into thinking that no, you have a mental disorder if you're asking for help. Which one do you have?

Oh, wait a minute, you're talking about a whole person. And have you not seen in therapy that if the relationships are not working well, things are not working well. Conversely, you're working with somebody on anxiety, and now they have a new love relationship. And it's really in that limerence phase and suddenly therapy doesn't seem as important. Have you seen that? Yes, you've seen that.

Dr. Elisabeth Morray (20:35)

Yes, a time or two.

Dr. Steven Hayes (20:37)

Why? Because we're whole human beings. If we have an accident, we got chronic pain, that's an issue. If we've got a cancer diagnosis, that's an issue. If we have ringing in our ears, that's an issue. But we've taken the whole person, sliced and diced them, and then had this idea. And it wasn't an evil idea. It was a good idea. At least it was meant for good purposes. Is that if we could categorize the things people say and what we see, we could guess that underneath all this is a disorder, latent disease. Eventually we'll figure out it's a real disease. And the difference between the syndrome and the disorder and disease, when you know where did it come from and why, how it develops over time and why, and how you can intervene on it, then you have a disease. And it doesn't have to be a germ, it could be a social disease, that's okay.

The concept of disease is a wonderful functional thing. Yeah, but read the DSM-5 work group or the DSM-6. I just spent wonderful time with Jonathan Alpert at Albert Einstein School of Medicine and on stage, a wonderful man who's second in line to the DSM-6. And he will say, and It's right there in the beginning: this book is not known to tell you how to best do treatment. And it's not known how to answer the question of why. In other words, it's not a disease. These are syndromes.

Now, here's the part that I think as therapists we need to think about. OK, the system of care has settled on this, and we're using it. But it's still in spin. After all, The National Institute on Mental Health went through a whole phase with RDoC, research domain criteria, trying to back out of the DSM. If people don't know that, they need to know that.

Academic psychiatry put this into the world, and I'm part of the psychology group that said, let's give it a try, the DSM-6. to now. But you have honest critics, know, Alan Francis, who helped do the DSM-5, you know, being very critical. But I'm talking to Jonathan here, the second in line for DSM-6, and he said, yeah, that's right. We don't really know.

OK, so let's do this: In addition to the checkbox and the things you have to fill out, can we not forget that we've got a whole human being here in front of you? And here's the wonderful thing that I think people need to know. The thing I just said of learning how to be more open, aware, and actively engaged, scaling out to relationships and your body, applies to all of these problems.

I'll give you an example. I have ringing in my ears. I'm an old punk rocker. And then I love trance. Don't love punk rock and then trance and then lived to be 77 years old because you have constant ringing in your ears. Guarantee it. These kids walking around with things in their ears, you know, I'm going like god just wait till you're my age, son.

Clinicians need to know about one out of four of your clients have constant ringing in their ears. A significant portion of them, it's the most distressing thing in their life. Almost nobody listening to me is asking their clients about it nor are their clients telling them because obviously this is a physical problem that only an audiologist can help. No, it's not true. It's just like chronic pain It's there are other things like that or dealing with a cancer diagnosis. When you learn how to onboard your thoughts and feelings; come into the present moment in a way that's flexible, fluid and voluntary; focus on what's important and build habits around that. If you do that, then you're able to shift how you perceive the ringing, for example, where it's just one of many, many, things.

I'm not hearing any ringing in my ears until I start talking about it. Because it was one of many, many things that I've learned. I learned by getting it completely wrong and spending three years freaking out about ringing in my ears before it occurred to me to apply my own life's work to it. And then it was handled in about two days.

And we've now done randomized trials on it. have measures of it. I'm just using this as an example. If you can distill down to the wisdom you actually can create the good form of psychotherapy. If you focus on the processes that are most important, and I gave you the list, find your own way and your own approach and methods to talk about that. You have ways of talking about being more emotionally and cognitively open.

If you do it your way. If you'd be interested in ACT, I'd love it. But do it your way. Those processes will apply to that relationship breakup. It will apply to that cancer disorder. Now, you're going to know some, you may need to do referral, you may need to think through some things. I don't mean you're an expert in everything. But this core of empowering people to be their whole selves and step forward.

That's what our real job is. And I think sometimes with the PHQ-9s and the rest... if I can say something a little critical, the PHQ-9 was written by a marketer. It only came out recently because the person who signed his name to it wasn't actually the person who developed it. That's a fact.

And when you read the items, you can see they're plausible, reasonable, but they're also narrow. And it would kind of make sense that they're narrowing down to just one way of thinking about the whole person.

And let's not forget the whole human being called you and the whole human being you're dealing with called your client. If you do that in a way that brings the best of science to it, and the best of clinical traditions to it, the best of yourself when you're in the flow, you all know what it's like, to be in therapy where you're in the flow. Stop and look back, and I bet you, in those moments, you are feeling more open, aware, and actively engaged in a process that matters.

So in a way, this is simplifying. In a way, it's making it a little more complex because the system fights you. And frankly, your mind fights you because sometimes it just wants to turn you into a problem to be solved. And your clients the same thing.

Okay, so push a reset button and let's support each other as clinicians, as providers, as the kind of work that you're doing at Alma. Let's support each other in dealing with a kind of chaotic world and learning how to be there for the well-being of the clients that we serve. That's the bottom line.

Dr. Elisabeth Morray (26:50)

I find myself listening to that metaphor of or the reality for you, but the metaphor for me of the ringing in your ears. And what would it mean to be a therapist where the ringing in your ears of a chaotic, difficult system were to be there and yet you could still step forward as a whole person.

And that, to me, really captures what we're talking about here.

Dr. Steven Hayes (27:18)

It exactly does. And you know, on the ringing, there are things that we can do in our professions, in our associations, and our collaborations, working, picking the companies that we work with, who help you maybe push back, and set some limits. You know, all of that can be done without disappearing into it. And so, yeah, I think that metaphor ringing in your ears.

You you can't pick up a screen and look at it and not see its relevance to what's going on today. The world's changing so fast. That's a kind of hum in the background that we all are experiencing. And some of it's just stressful as heck. What's going to happen with AI? Is it going to take all our jobs? Are we going to have systems of care that require that you first have a a six month course of therapy with a chat bot?

I can imagine that. And in our work, we're going to be there as whole human beings called therapists sitting with whole human beings called clients. And in addition to all the rest of that, the ringing in the ears of the what ifs and so forth, for those moments, I think, need to be put in their proper place.

And part of the proper place is not ignoring them. I don't know how many times, if I'm talking to people who are in need of help, that they're not worried about some of the same things I'm worried about. Have to just talk to your friends, talk to your family. I bet you they're worried about some of the things you're worried about.

The world is changing really, really, really fast. We're going through, something parallel to the printing press or industrialization. Everybody knows that. And that was not easy. But your foremothers and fathers did it or you wouldn't be here. And okay, let's carry the ball forward with these challenges, with these ringing in our ears. But not in a way that makes it impossible to hear the voices of those who need our help and who are helped by us.

If you work with somebody who's lifted up in some way, that affects their friends, the friends of their friends, and the friends of the friends of their friends, statistically. So, yeah, it may look like you're just working with a very small, no, you're working with a big part of humanity.

And so it's worth our time to learn how to be whole and free as therapists and to teach our clients how to be amid the cacophony, amid the noise.

Dr. Elisabeth Morray (29:52)

That seems to be a beautiful note to end on. And I thank you for showing up in support of the people in our community who are doing this holy work and who are eager to continue to grow and to serve. And so deeply appreciate the work that you've done to enable people like me to serve people in our community and to help them on their journeys. So thank you for your time today. It's been really a pleasure to talk to you.

Dr. Steven Hayes (30:21)

Great pleasure. And working in our organizations and so forth, that I think has a chance to put some of this healing knowledge into the world. So it's worth our attention and thanks for the opportunity to share that. Much appreciated.