Psychological Flexibility: Different Perspectives From Students & Early Career Professional For Stressful Times

Psychological Flexibility: Different Perspectives From Students and Early Career Professionals for Stressful Times

Dominique Reminick Keryn Kleinman

Combined Doctoral Program in Clinical and School Psychology, Kean University Aaron A. Gubi, PhD Mary Toolan, PsyD

Christopher King, JD, PhD NJPA ECP Committee Past-Chair

Editor’s Note

Iam very pleased to have the opportunity to introduce an article about psychological flexibility that was co-authored by Drs. Aaron Gubi and Mary Toolan, members of the NJPA ECP Committee, and two of Dr. Gubi’s students at Kean University, Dominique Reminick and Keryn Kleinman. The NJPA ECP Committee felt that this topic was particularly important and timely in light of all that is going on in New Jersey, across the country, and throughout the world, and we were glad to be able to include two of our junior colleagues at co-authors on this column. The first part of the entry, penned by Ms. Reminick, Ms. Kleinman, and Dr. Gubi, reviews the approaches used in acceptance and commitment therapy to increase psychological flexibility, and evidence supporting the role of increased psychological flexibility in positive ACT outcomes. The third part, contributed by Dr. Toolan, offers a conversational account of psychological flexibility during the pandemic, applicable to both clinical work and our personal lives under present circumstances.

NJPA ECP Committee

For my own part, the second in this collection, I add that I have found the dialectical world view taught in Dialectical Behavior Therapy (Linehan, 1993; 2015; King, n.d.), i.e., the acknowledgement and ongoing synthesis of competing truths from moment to moment, to be an invaluable way of going about psychological flexibility in my professional and personal life. My clients, trainees, colleagues, friends, and family would certainly attest to my enthusiasm for the approach. As they all frequently hear my replies of “There’s actually a dialectic here;” “Well, on the one hand, . . . and on the other hand, . . . ;” “Both truths can be valid;” “It’s all about synthesizing those two truths;” and “It’s not just taking the average, but using your wise mind to come up with something greater or creative to synthesize the dialectic.” I summarize some selfcare strategies (Norcross & Guy, 2007; Norcross & VandenBos, 2018) that seem to me to emanate from this perspective (King, n.d.).

Psychological flexibility has been defined as “the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values” (Hayes et al., 2006, p. 9). Conceptualized in its current form in the 1990s, it is considered the core therapeutic process within Acceptance and Commitment Therapy (ACT), a third-wave cognitive behavioral therapy (CBT) that incorporates mindfulness and acceptance into the traditional CBT framework (Hayes et al., 1999; Zettle, 2011). Born from the union of Relational Frame Theory (RFT), Applied Behavior Analysis

(ABA), and Functional Contextualism (FC), ACT views psychological inflexibility as a maladaptive process originating from the nature of human language, in which the dominance of language processes contributes to reduced sensitivity to contexts and contingencies, and leads to rigid, rule-governed behavior (Hayes et al., 2006; Torneke, 2010). Such inflexibility can result in psychological distress and impaired functioning; thus, the ultimate goal of ACT is to increase psychological flexibility in the service of one living a more meaningful life (Hayes et al., 2006). Unlike traditional CBT that seeks to directly modify maladaptive cognitions, ACT endeavors to help people change their relationship to their thoughts, rather than the thoughts themselves (Hayes et al., 2006). The model that ACT employs to this end is the ACT hexaflex, that is comprised of six core processes that work in conjunction to increase psychological flexibility (Ciarrochi et al., 2010). The ACT hexaflex consists of (1) cognitive defusion, in which one sees thoughts as merely thoughts rather than edicts of reality; (2) self as context, i.e., the “I” that notices having thoughts and experiences that fosters a perspective of self as an observer of life’s content; (3) acceptance, i.e., not avoiding unpleasant sensations that may arise; awareness, or noticing and non-judgmentally describing psychological and environment events as they occur; values, the “whos” and “whats” that are chosen as personally important; and committed action, rededication to making more moves toward one’s values (Ciarrochi et al., 2010). It is through exploring and embodying these mindfulness and acceptance processes, and their corresponding commitment and behavior change processes, that overall psychological flexibility can be developed and strengthened. The literature on psychological flexibility increasingly supports its role as a transdiagnostic process underlying psychological well-being (Ciarrochi et al., 2010; Stockton et al., 2018). Multiple studies have observed a relationship among psychological flexibility, psychological distress, and symptom severity that suggests that interventions that increase psychological flexibility decrease distress and improve both mental health and overall functioning (Fledderus et al., 2013; Levin et al., 2014; Lin et al., 2018). Further, psychological flexibility has been found to be associated with overall positive mental health and may serve as a protective factor for myriad psychological disorders, including depression and anxiety (Kashdan, 2011; Ramaci et al., 2019). Psychological flexibility has also been studied in randomized control trials (RCT), the gold standard for assessing treatment effectiveness. An RCT investigating the effectiveness of group ACT vs CBT treatment-as-usual for “treatment resistant” participants with various diagnoses found both interventions to relieve depressive symptoms, reduce stress, and improve quality of life by the end of treatment; however, only those in the ACT condition maintained improvements in depression at six month follow up (Clarke et al., 2014). Another multi-site RCT found that participants in the ACT intervention group showed significantly greater psychological flexibility posttreatment, as well as greater well-being and fewer stress, anxiety, and depression symptoms relative to waitlist controls (Grégoire et al., 2018). Overall, the research that has investigated psychological flexibility as a mechanism of change for improved psychological functioning and decreased distress has been quite promising.

Psychology Practice Dialectics for Synthesis Toward Self-Care

In a prior NJPA member-only resource, I reconceptualized self-care strategies recommended by Norcross and Guy (2007) and updated by Norcross and VandenBos (2018) in Dialectical Behavior Therapy (DBT) skills terms. I explained that thinking dialectically is thinking flexibly. It is being open-minded to there always being two or more “truths” in any situation; entering into these paradoxes and shifting effectively between polar truths toward creative gestalts; and participating in this process over and over again. I also highlighted some common dialectics for synthesis: acceptance vs. change, emotion mind vs. rational mind, being vs. doing, and self-denial vs. selfindulgence. Finally, I referred to a variety of more specific dialectical issues pertaining to psychology practice. These dialectics included:

•periods of discomfort (prompts for change) vs. refreshment (“easies” to accept); •the cons vs. pros of the profession; •being employed vs. being an independent contractor (in one sense or another); •professional strengths vs. professional limitations; •professional failures vs. professional successes; •monetary professional wealth vs. wealth in terms of professional enjoyment; •expected or needed workaholism, professional perfection and celebrityism, and Olympian selfcare vs. good enough; •practicing therapy vs. practicing what you preach by seeking your own therapy; •being a psychologist among your colleagues vs. being a non-psychologist among your family and friends; • dedication to your clients vs. protecting your personal time; • a high number of clients and risky clients vs. a low number of clients and “safe” clients; • you and your client impacting one another as people vs. your unilateral obligation to meet your client’s needs; • clients’ transferences toward you vs. management of your countertransferences; • caring vs. challenging; • empathy and connection vs. healthy boundaries; • utilizing metaphors, paradoxes, and irony; • utilizing irreverence, including humor and absurdity; • the possibility that you caused client events vs. other potential causes; • success as a dichotomous outcome vs. success as a continuous process; and • personal failures vs. failed cases. I believe syntheses of these dialectics facilitate psychologist self-care, among other DBT skills that can support self-care.

Flexibility in Therapy During the Pandemic: A Therapist’s Perspective

An absolute that the pandemic continues to remind us of is that the truly unexpected can happen at any time. When the unexpected happens and continues to happen, albeit changing daily, it can be unsettling, confusing, and scary. Due to the worldwide pandemic crisis, significant changes have occurred that have impacted and altered everything entirely. The current pandemic crisis has quickly forced many people into situations never before experienced. Absolute changes, such as job security and health, have shifted quickly, as well as less tangible changes in thought and emotions. Prior schedules are set aside and even abandoned when such crisis occurs. Family responsibilities are rearranged. Basic needs change and in this case, something as normal and typical as running an errand is restricted and may even be wholly impossible. Choices, once large in number, are suddenly severely limited. Many changes are obvious and readily discerned, but subtler and shifting emotional dimensions may be less obvious. Changes in feelings of safety and security, comfort, fear, anxiety, and loss may occur daily if not hourly. When maintaining what was and going on “as normal” becomes no longer possible, what are your options? One notion includes being flexible; being open minded to the idea that something different may need to happen. Flexibility is to consider options and adapt to a new manner of things. What is controllable and what can rationally and literally be accomplished? Is being capable of adapting to a new, different, and changing requirement possible? Can needs be met on an “as needed” basis? Much is still unknown; therefore, remaining flexible about possibilities and unknown circumstances becomes a necessary adjustment to be realized. As the world, and our own microcosms navigate the struggles, adopting an attitude of flexibility may help us tolerate our stressors. Shifting your thought to acknowledging change can absolutely encourage feelings of preparedness and empowerment. As a therapist and a clinician, allowing yourself the space to do things differently and perhaps even on an “as needed” basis may become the “new normal.” Flexibility in thought may mean that when fixated on things being a certain way and consistent, new options are introduced including ideas of varying degrees. Understand the need to permit (both yourself and your clients) time to react and resettle as the crisis did not permit for prior preparation. Understanding our own needs will provide greater understanding of client needs. Accepting or even embracing flexibility is increasingly important as unknown circumstances surrounding this crisis are still occurring. So much is still unknown. Being flexible with clients may not only mean meeting

via phone or video conferencing, but also may require responding to a crisis call, or altered hours of availability and manners of payment. Topics typically discussed by a client may shift as other subject matter becomes more prominent, thus requiring flexibility in treatment. Inherent in flexibility and gaining the ability to adapt is to be in the space of waiting, while knowing that there may not be an “answer” or resolution in the near future. However, there is support to facilitate coping with the newer circumstances. Adopting a flexible mindset may provide ourselves and our clients with the comfort of knowing that although there is still much that is unknown within this crisis, we are capable of coping and even adjusting our outlook. Knowing that within the unknown, there is space to remain and to be. Perhaps “embracing” the unknown is a big ask, but simply being is often what is left. We are left with our thoughts, emotions and actions that will benefit from flexibility. Trust is gained by knowing and experiencing, tolerating and being resilient. Additional trust is gained by knowing that after the initial “fight or flight” response, we can take deep breaths, speak aloud “I don’t know what is going to happen, but that’s ok.” All the while, focusing on what you can do in the present to activate the brain to plan, organize thoughts, and create options thus allowing the parasympathetic nervous system a chance to realize that the danger, however real, is not necessarily imminent. Just as in the therapeutic situation, one approach, one methodology, one technique is not at all suited for each and every person. Each client necessitates essential flexibility: a new therapeutic relationship, a new strategy, a new and remodeled collection of ideas, an individualized case conceptualization, and more before the therapeutic alliance is established and therapy can be accomplished. Just as in life, we need to find the level of flexibility that feels comfortable. Even then, flexibility requires being flexible to what might need to be adjusted or changed the next moment or day when the situation requires just that!

References Furnished upon request About the Authors

Dominique Reminick, MA is a third-year doctoral student in the Combined Clinical and School Psychology PsyD program at Kean University in Union, NJ, where she manages Kean’s Center for Autism Assessment and Research Services (CAARS). In 2020, she served as a board member for the New Jersey Psychological Association for Graduate Students (NJPAGS), and held the Member-at-Large position for the Committee on Diversity and Inclusion. Her recent research focuses on traumainformed care in school settings, with an emphasis on supporting diverse student populations. Keryn Kleiman is a third-year doctoral student at Kean University’s Combined Clinical and School psychology PsyD program. She is currently a doctoral extern at the Center for Anxiety and also serves as a doctoral assistant at Kean, where she manages clinic-related research efforts, including designing and implementing a study evaluating a compassion-focused acceptance-based therapy for anxiety, mood, and trauma-related difficulties. Previously, Keryn served as a doctoral extern in the Ridgefield Park School District. Prior to entering graduate school, Keryn worked as a research assistant at the Regulation of Emotion in Anxiety and Depression lab at Columbia University and a junior research scientist at the Family Translational Research Group at New York University. Mary Toolan, EdS, PsyD is in private practice in Springfield, NJ. As a former practicing school psychologist, Dr. Toolan often conducts complete psycho-educational evaluations and consults with area schools, and families. Dr. Toolan enjoys providing individual and couples therapy specializing in supporting children, adolescents, adults, and couples manage their anxiety, depression, relationship difficulties, conflicts, life changes and stressors, and grief. Aaron Gubi, PhD is a licensed psychologist and certified school psychologist. He is an assistant professor and serves as Clinic Director of Kean Psychological Services, the community training clinic for the Doctoral Program (PsyD) in Combined School-Clinical Psychology at Kean University. His clinical interests include conducting psychological assessments and providing therapy with children, adolescents, and young adults, with particular interests in trauma, autism spectrum disorders, and disabilities. He also holds part-time positions with a private practice and an adolescent residential treatment facility, and currently serves as the interim editor of the NJ Psychologist.