The Client Who’s Tried Everything

ACT and ISTDP Tackle One Challenging Case

The Client Who’s Tried Everything

How do you approach a first session with a client who’s tried all kinds of different therapies and yet continues to struggle? Steven Hayes, cofounder of Acceptance and Commitment Therapy (ACT), and Steve Shapiro, Intensive Short-term Dynamic Psychotherapy (ISTDP) trainer and adjunct faculty member of the AEDP Institute, are about to show you how they’d work with this client.

Meet Billy

Billy is a stylish, 50-year-old man who lives with his long-time girlfriend in her brownstone. He’s written a couple of successful screenplays and has recently started working on a novel. “I know I can write,” he tells you in his first therapy session. “I just don’t have much motivation. Mostly, I feel numb. It’s been like this for years.” He used to teach screenwriting but has been unemployed for a while now. “I’ve never gone through any major tragedies, and I had a truly happy childhood,” he says. “My parents divorced when I was eight, but they were both deeply kind, thoughtful people who coparented amicably. If anything, they were too good—they always made me a priority and made sure I felt loved and supported.”

Billy has seen several therapists before you—all of whom had been “great people who offered great therapy that just hadn’t worked.” He’d done EMDR, CBT, IFS, SE, art therapy, and psychodynamic therapy. “I’ve also done some couples therapy with my girlfriend,” he adds. “Six months ago, I did three sessions of psychedelic-assisted therapy, and it was interesting for sure, but I still have trouble getting out of a bed every morning, and my anxiety gets the better of me sometimes.” Billy has seen neurologists and doctors to rule out biological issues, and he’s had a couple of psychiatrists. “I’ve tried virtually every medication for depression under the sun. A few helped for a month or two, but mostly the side-effects outweighed the benefits, and getting off them was a huge ordeal.”

“I really trust the friend who referred me to you,” he says, a hopeful look on his face. “She says if anyone can help me, you can.”

A Case of Motivational Paralysis

By Steven Hayes, cofounder of Acceptance and Commitment Therapy (ACT)

Billy’s case is a good example of motivational paralysis, one I’d approach through the lens of Acceptance and Commitment Therapy (ACT), a process-based approach I originated a bit over 40 years ago. ACT is based on Relational Frame Theory, a research program on human language and cognition, and it’s designed to help people develop the ability to accept their thoughts and feelings without being overly influenced by them, allowing them to act in line with their values even when facing difficult emotions.

Sitting with Billy in this session, I pay close attention to his actual words, wanting to see how he describes emotions, motivation, and action. I notice that as soon as he acknowledges his skills, he dismisses his capacity to use them, attributing his inaction to a lack of motivation, which he contrasts with feeling numb.

Billy’s words reveal an unworkable relational network in which his ability to act is determined by his motivation, which hinges on him feeling a certain way. The hidden problem, fostered by our culture, is the empirically false belief that only certain feelings can result in healthy actions. This way of thinking traps clients and therapists alike into believing that the therapist’s task is to alter the client’s emotional state first so they can then live better and have a sense of well-being. Of course, when this doesn’t happen, the client’s mood takes a hit, leading to another round of motivational paralysis.

I like to think of feelings as echoes of the past contacting the present. We need to help clients like Billy learn to observe and describe these echoes, not suppress them, because our awareness of our present feelings (informed by our past experiences and the current context) is how we develop wisdom. But the moment we act as if only certain emotions pull us forward, like magical sled dogs, we’re basically saying that we have to control our emotions in a point-to-point way for a life worth living. Living according to this doctrine does not make for a happy life, and running from a lack of confidence, as Billy seems to be doing, is the least confident action we can take.

Where does Billy’s numbness dominate him so that he’s waiting for life to start? I think it comes from the erroneous belief that we must avoid so-called negative feelings and cling to so-called positive ones, even though we all know deep down that we can’t control feelings this way. Letting go of this agenda, of course, is easier said than done. People with motivational paralysis, like Billy, feel frightened, helpless, hopeless, and frustrated—and in desperation, they suppress these feelings too. Many, like Billy, will seek out therapist after therapist, looking for relief to no avail.

Rethinking Treatment Goals

Billy mentions that his past therapy experiences, aimed at getting rid of his depressed mood and anxiety, have not shifted things for him. Seemingly, for him, successful therapy involves eradicating his numbness, depression, and anxiety before any real action can be taken. There’s an expectation that feeling better is a prerequisite to living better. But this approach to life isn’t just ineffective, it forestalls what Billy truly needs: to learn how to open up to his past and feel the discomfort and pain that comes with life’s challenges. Ironically, the undesirable feelings Billy is currently experiencing could be motivating if he allowed them to be. Instead of focusing on feeling good, he needs to learn to feel good —to do a good job of feeling.

ACT’s concept of creative hopelessness is pivotal in Billy’s case. It involves acknowledging the futility of trying to control one’s internal experiences to control life’s outcomes, and abandoning the agenda to change them. Billy has invested decades, six forms of therapy, and myriad medications in this pursuit, yielding little progress.

When is enough, enough? When Billy allows himself to let go without knowing what comes next, his actual experience will have a chance to be let in. Helping Billy carefully and non-judgmentally see the rigged game he’s playing can help him see that his approach to problem-solving is itself the problem, and he can begin to imagine a different path toward healing.

Engaging the Body

To bypass Billy’s cerebral approach, I try to help him focus on his body. I ask him to spend some time in session feeling numb, in a very physical way, and explore whether this numbness is indeed such an enemy when purely thought of as a feeling.

I ask him to show me, using only his body, him at his worst when he feels numb. I notice, predictably, that his head moves down, his eyes close, and he draws his arms and hands inward. When I next ask him to show me, using only his body, him at his best when feeling that same degree of numbness, I see his head rise, his eyes open, and his hands and arms extend.

A 2022 study published in the Journal of Clinical Medicine reports that 95 percent of people show postures that are more open, aware, and ready for active engagement when they are “at their best” when dealing with emotional challenges. This suggests that, intuitively, we know that our mood and outlook aren’t determined by what we feel, but how we relate to what we feel.

With Billy, I draw out the paradox that he’s following an agenda his mind is giving him as he avoids and withdraws, even though his own body knows better. I ask him if he’s ready to trust his own hard-earned wisdom within by learning how to open up rather than closing down in the face of difficult emotions. Haltingly, he says he is, but that he doesn’t know how.

Tapping into Values

I notice a significant gap in Billy’s current narrative: there’s no mention of his values nor what he truly wants his life to be. By shifting his focus to ways of being that might tap into his embodied knowledge, I open the possibility for therapy to be transformative.

To get here, I follow the most apparent piece of vitality in his description of his situation. I ask him to explore what he felt while writing his screenplay. And as he does, we find that what he’s been running from is actually in alignment with living a life of purpose.

You’ve written screenplays that touched people,” I say to him. “Would you be willing to focus on a moment when you were in the flow and writing? Just think of a specific memory when writing felt like that.”

Billy nods, closes his eyes, and begins to visualize.

“In this moment you’re remembering, did you feel a sense of purpose?” I continue. “What were you giving voice to in your writing back then? What did you care about?”

Billy takes a deep breath and opens his eyes.

“I wanted to show that life doesn’t have to be perfect to be meaningful,” he says. “In the moment I remembered, I was working on a story  where my character’s life was a total tragedy, but I also wanted the reader to see that he was still a loving person, yearning to make a difference. I thought there was something worthwhile about that. Noble, even.”

Wow,” I reply.That’s such a powerful statement. And at your best, while you were writing, did it feel like you were able to help the reader see that deeper message? It sounds like it was important to you that they see it.”

“Yes, it was very important,” Billy replies. “I was damn good at it.”

Billy pauses as his eyes begin to well up.

“I can’t believe I’ve stopped writing.”

Well, maybe you somehow bought into the idea that you have to wait for the right feeling to write,” I offer. “But if life doesn’t have to be perfect to be meaningful, why wait? Your life isn’t perfect now. Nobody’s is. What if, instead of waiting to become someone else with different feelings, you could give voice to what’s meaningful to you now, with your thoughts and feelings and memories and sensations as they are?”

Billy wipes away his tears, and nods.

“I wonder what else you could express in your writing,” I continue. “Not just this idea that life doesn’t have to be perfect, but other things that are important to you.”

***

The goal of this approach is to uncover Billy’s values and motivation hiding in plain sight. By asking these questions, I find that his values are already present—and inherently motivating. He has bought into an idea that he needs to meet certain emotional standards first, but that fused belief just hides these motivating values from view.

When we shift from passively waiting for some foothold to actually exploring Billy’s capacity for creation, we see things that he holds dear, things he can own. Who knows what else will show up as therapy continues. Creativity? Love? Connection? I’m eager to find out. These kinds of explorations could positively influence his relationships with his girlfriend, his family, with his therapist, and others.

Billy’s case shows that sometimes therapy needs to take a radical turn, to move from helping clients try to control the uncontrollable to helping them embrace the full spectrum of life’s experiences and uncover meaning and purpose. Shifts like these are the key to helping our clients unlock their full human potential.

A Case of What’s Absent

By Steve Shapiro, Intensive Short-term Dynamic Psychotherapy (ISTDP) trainer and adjunct faculty member of the AEDP Institute

Sometimes during our initial session with a client, what’s absent is just as important as what’s present. During my first session with Billy, I notice the absence of any “negative” feelings toward others. I’m also struck by his denial of childhood difficulties. Considering Billy’s significant suffering and poor treatment outcomes, it seems unlikely that he grew up without challenges or difficulties.

Psychotherapy isn’t all about feelings. It’s about the therapist hypothesizing what the client is doing with those feelings, which the client then either confirms or denies. The goal is to allow an increasingly complex and accurate picture of the client to emerge.

When I first meet Billy, I don’t know the reasons for his presenting problems—and neither does he!  A good therapist acts as a guide to collaboratively explore the unknown. As therapists, we need to understand the division of labor accurately. The therapist guides the process, and the client reveals the content: their thoughts and feelings.

As Billy and I work together, he continues presenting as excessively positive, cheerful, and complementary. He denies almost all negative feelings, thoughts, and impressions. This makes me curious about two key issues:

Directionality. I use this term in my experiential dynamic therapy trainings to convey where our feelings are directed within our minds and bodies. Do we focus on the other’s role and direct them outward? Do we tend to repress them and turn them inward? Where we direct our feelings will influence our symptoms and how they manifest. “Externalizers” will have more interpersonal conflict, whereas “internalizers” will have symptoms like depression and anxiety.

By his own description, Billy showed little evidence of outwardly expressing emotions like anger, sadness, or fear in his life, something I also observed in his sessions with me. I hypothesized that these emotions were being repressed and directed inward. This reflected an intrapsychic structure that was well integrated and syntonic (meaning he himself wasn’t aware of it). A syntonic defensive style is like being on automatic pilot, which keeps emotional conflicts and anxiety at a tolerable level, but at a cost. For Billy, the cost was feeling numb and disconnected from others.

Emotional physics. This term refers to the range of fundamental processes governing our internal experiences and how they interact to maintain a homeostatic balance. For example, through the lens of emotional physics, emotions don’t create difficulties—emotional conflicts do. I begin to wonder about Billy’s emotional conflicts. What’s getting in the way of him experiencing and expressing “negative” emotions? I wondered. What makes it risky or anxiety provoking to be anything but cheerful and pleasant?

The Fork in the Road

In our fourth session, Billy walks past me and sits down without looking up from his cellphone. He indicates with a raised hand that he’s busy, then taps his phone for nearly five minutes. When he’s done, he puts his phone away, meets my gaze, and smiles. “Sorry,” he says. “I just had to text my girlfriend about something.”

Contrary to many therapists’ fears, a direct but respectful exploration of what arises in the here-and-now of the therapeutic relationship can improve our working alliance with clients. Rather than accepting Billy’s apology and moving on, I address his texting. “Are you aware you just spent five minutes of a 45-minute session doing something different than what you’re here to do?” I ask, my voice warm and curious.

An irritated look flashes across Billy’s face, but the smile returns quickly. “Well, I wasn’t trying to offend you.”

“I’m not offended,” I say. “But I am curious because you said one of your goals in therapy is to feel connected with others and aligned in your life. I also noticed that in our last session, you spent nearly 10 minutes in the restroom. Again, you were here, but not here.”

“True,” he admits with a sheepish smile. “But I did have to go to the bathroom.” He pauses. “And maybe a part of me didn’t want to be here last week . . . and today. I know I’m paying you to help me, but sometimes you pry, and I guess I want to be left alone.”

“There’s a healthy side of you that wants to be here and do the work so you can feel better,” I say, “and another side that wants to be left alone.” I was highlighting what I call the “fork in the road”—Billy’s choice between defensively excluding unacceptable emotions and accepting his own complex humanity.

“Yeah,” Billy says, his leg bouncing. He sighs. “Now that you bring up last week, I guess I try to distract myself when I feel uncomfortable.”

For most clients, their motivation to do psychotherapy and their resistance to doing it are constantly fluctuating. This is because the focus of the work is on exploring their characteristic ways of thinking and feeling as well as how they relate to others—things that are deeply personal and often vulnerable and painful. For our exploration to be productive, I need to help clarify his defensive patterns, such as the tendency to have one explicit intention (getting better through therapy) while anxiety-reducing behaviors reveal a different intention (maintaining a cheerful façade). My work is to familiarize him with hidden parts of himself, not abolish them, while helping him regulate anxiety in new ways.

“So the feelings you have toward me are hidden behind texting or bathroom breaks,” I say.

“I’m not hiding things from you on purpose,” he says quietly. “I hardly ever let myself feel what I feel. It’s sad.”

“It is,” I murmur in agreement. “And it’s also not like you do it on purpose.”

“I don’t want to do it anymore,” Billy says.

Over time, a fuller range of feelings, memories, emotional conflicts, and insights emerge from beneath Billy’s cheerful protective barrier. “It’s totally new for me to sit and talk with someone and feel like it’s okay to be angry, sad, scared, whatever,” he tells me. He begins learning to express “negative” reactions toward people he cares about rather than simply behaving the way he thinks others expect him to.

***

The focus of effective psychotherapy needs to be on destructive internal patterns evident now, not events from the past. It’s the way these past events influence how we relate to ourselves and others now that causes suffering. In my work with Billy, we didn’t need to dwell on his feelings about his parents’ divorce because the way he coped during that time in his life was still evident in the “numb” way he related to himself and to me. One thing that makes the challenging task of changing lifelong patterns easier for therapists is that clients inescapably exhibit automatic and unchanging coping patterns without the therapist’s deliberate intervention. Healing isn’t all about facilitating a dramatic, cathartic breakthrough of feelings with clients. Only with increased awareness of his destructive coping patterns was Billy able to see the problem clearly and decide to risk making different choices. Increasingly, he chose the vulnerability of responding authentically over the protection of hiding behind his defensive coping patterns. Over time, he reported feeling happier and more relaxed, as well as increased intimacy with others.

 

 

 

Steven Hayes

Steven C. Hayes, PhD, is the co-founder of Acceptance and Commitment Therapy (ACT), best-selling author of Get Out of Your Mind and Into Your Life and Nevada Foundation Professor at the Department of Psychology at the University of Nevada.  An author of 44 books and nearly 600 scientific articles, he has shown in his research how language and thought leads to human suffering, and has developed ACT as a way of correcting these processes.  Hayes has been president of several scientific societies and has received several national awards, such as the Lifetime Achievement Award from the Association for Behavioral and Cognitive Therapies.

 

 

Steve Shapiro

Steve Shapiro, PhD, is a clinical psychologist with over twenty-five years of clinical and teaching experience who has been practicing various forms of Experiential Dynamic Therapy (EDT), since the mid-1990’s, including Intensive Short-Term Dynamic Psychotherapy (ISTDP) and Accelerated Experiential Dynamic psychotherapy (AEDP). For 16 years, he was the Director of Psychology and Education at Montgomery County Emergency Service (MCES), an emergency psychiatric hospital, where his work with a range of severe disorders and those committed involuntarily to treatment informed his approach to transforming resistance with challenging patients with trauma histories and excessive anxiety and dysregulation. He’s a founding member and currently an adjunct faculty member of the AEDP Institute in New York City.