Chapter 24

Cultivating Psychological Acceptance

John P. Forsyth, PhDTimothy R. Ritzert, MA

Department of Psychology, University at Albany, State University of New York

Definitions and Background

The idea of acceptance is quite old. It appears in religious traditions, Eastern contemplative practices, and most psychotherapy approaches when discussing therapeutic alliance and process. More recently it entered into evidence-based psychotherapy as a core process, both of psychopathology and of therapeutic change. Psychological acceptance, as we frame it here, is “the voluntary adoption of an intentionally open, receptive, flexible, and nonjudgmental posture with respect to moment-to-moment experience” (Hayes, Strosahl, & Wilson, 2012, p. 272). Such an experience includes internal events (e.g., thoughts, emotions, memories, physical sensations, urges/impulses) and closely related contextual situations that evoke them. Thought of in this way, psychological acceptance is opening up to what life is offering, just as it is. Acceptance is a skill, not merely a set of techniques. It is also a process, and not simply an outcome.

Acceptance as a term can be readily misunderstood. It is not giving up, tolerating, or passively resigning. It is rather a behavior and a choice. It involves approaching (often distressing) psychological events and related situations, without unnecessarily trying to change, avoid, suppress, escape from, or prolong them. Choosing to approach and open up to difficult psychological experiences is, paradoxically, doing something new.

Acceptance entails a change in how one approaches psychological events (Cordova, 2001), responding to them with openness, flexibility, and compassion. Thus, a key component of this work is altering a client’s relationship with the experiences he is having anyway. Metaphorically the posture of acceptance can be demonstrated experientially with the simple gesture of standing up, with eyes wide open and somewhat playful, and stretching both arms as wide as one can. This receptive posture is contrasted with closing the arms and wrapping them around the torso as tightly as one can, standing rigidly with eyes tightly closed.

Acceptance is not about wallowing in distress, nor adopting a clever tactic to control difficult private content. Rather, acceptance is a process designed to help clients let go of needless struggle, live in the moment, make choices guided by personal values, and take actions that matter to them and stand to increase quality of life. When difficult psychological experiences show up, acceptance asks, “Are you willing to have that stuff, fully and without defense, just as it is, and carry it forward, if that meant you could do what truly matters to you?”

Research suggests that acceptance-based interventions work not by directly altering thoughts and emotions, but by reducing their unhelpful influence over behavior (Levin, Luoma, & Haeger, 2015). In the process, new possibilities open up, and change efforts can be guided more by self-regulation focused on vitality, joy, meaning, and purpose.

Why Acceptance Is Often Needed

Neuroscience teaches us that human beings are historical—our nervous systems are additive, not subtractive. What goes in stays in, short of brain insult or injury. Viewed this way, the difficulties our clients experience now are simply a product of everything that has come before.

As historical creatures, we come into this world much like empty vessels, differing in genetic predispositions but basically conscious containers for our experience. Like a chef creating a soup, life experience adds various ingredients to our vessels and continues to do so. Some ingredients are clearly discernable—the trauma, the fiftieth birthday party—and each ingredient has its unique taste, some sweet, others sour, others bitter. More subtle flavors emerge from whatever happens to be in the mix at any moment. There’s no healthy way to remove ingredients and flavors once they are added. New ingredients can be added, but these do not subtract from what is already present.

Language and cognition (see chapter 7) increase our ability to access our history. No verbally able human escapes the possibility of pain, because it can be brought to mind anytime, anywhere via language and cognition. Ironically, even though psychological pain is a normal part of the human experience (Eifert & Forsyth, 2005; Hayes et al., 2012), when experience is deemed unacceptable, pain is likely to increase because it leads to experiential avoidance (EA). EA is an unwillingness to experience psychological events even when efforts to escape or avoid such events have caused behavioral harm (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). EA appears to underpin many forms of psychological suffering precisely because when applied rigidly and inflexibly, it tends to increase pain and suffering and interfere with meaningful action (e.g., Chawla & Ostafin, 2007; Eifert & Forsyth, 2005). A large body of evidence suggests that EA is costly, effortful, and ineffective in the long term (e.g., Gross, 2002; Wenzlaff, & Wegner, 2000).

While control strategies work well outside the skin, they are often misapplied inside the skin, where thoughts, memories, and emotions cannot be readily controlled or eliminated. In short, if you don’t want it, you’ve got it. What one can do is alter one’s relationship with thoughts and feelings. This is where acceptance can make a real difference.

Cultivating Psychological Acceptance

Cultivating acceptance involves creating a new context in which to experience thoughts and emotions. The remainder of this chapter offers practical guidance about how to cultivate acceptance.

Confront the Unworkability of Control

An important precursor to acceptance work is helping clients recognize which aspects of experience they cannot control, and to open up to doing something new. Normally, this can be done in the first or second session and then be revisited as needed. Two simple questions are central to this process:

When explored with compassion and gentleness, these questions begin to expose the unworkability and costs of the struggle itself. The client’s own experience often reveals that control works in the short term, mainly in terms of offering psychological relief. However, these brief honeymoons from pain are costly—emotionally, physically, and in terms of moments away from doing something important. In this very brief clinical dialogue, with a twenty-seven-year-old female client who has long-standing struggles with social anxiety, the therapist begins to draw this out.

Therapist: What’s it like for you when anxiety shows up?

Client: Well, I get a sinking feeling in my stomach, tense up, and don’t feel like doing anything. I just sit alone watching TV.

Therapist: So, if I hear you right, one of the things you do when anxiety shows up is sit alone in front of your TV? In your experience, how has that worked in taking care of the anxiety?

Client: (Confused.) Honestly, it only works for a bit. Really, I just sit there feeling badly about myself, and how everyone else is out there, having fun, living their lives—and I’m not.

Therapist: So, doing nothing and watching TV doesn’t seem to be helping and may even make you feel worse. And, your mind is telling you that you’re missing out. What else have you tried?

Eventually the therapist can simply reflect back what the client is saying (e.g., “It sounds like your experience is telling you that what appear to be sensible strategies end up not working in the long run. Does that sound about right?”). The intention is not to make the client feel bad, but rather to reveal the costs of the struggle itself and to help the client to consider the possibility that her own experience is valid, regardless of what her mind is saying.

Well-placed metaphors or exercises can draw out the costs of needless control efforts and orient the client toward new, more hopeful directions. Acceptance and commitment therapy contains numerous metaphors that can be readily used for this purpose (see Hayes et al., 2012; Stoddard & Afari, 2014). For example, a client might be given a short length of rope, and the tug-of-war with emotion can be acted out in therapy. The therapist’s dialogue can orient the client toward the seeming need to win this tug-of-war with internal “monsters” (emotions) even though the fight puts off the ability to do more useful things (e.g., as both therapist and the client tug on their ends of the rope).

Therapist: Your mind is telling you that you need to beat me before you can move on. What’s showing up for you now?

Client: I need to pull harder!

Therapist: And isn’t that like what you’ve actually been doing? Does it sometimes feel like this?

Client: Just like this.

Therapist: (Continuing to pull.) Have you ever won this tug-of-war once and for all? And notice also that you are not going to the dance you want to go to.

This kind of dialogue continues in the interaction (see Eifert & Forsyth, 2005; Hayes et al., 2012) until the client eventually sees an alternative: to let go of the rope. That action then becomes a physical metaphor for acceptance, and for the tricks of mind that keep it from being used.

It can be useful to have clients use an initial worksheet, recording (a) difficult situations, thoughts, and feelings that show up; (b) what they do in response to them (including times when they “picked up the rope”); and (c) short- and long-term consequences (i.e., what they have given up or missed out on when they got caught in a tug-of-war with their monsters).

Teach Perspective-Taking Skills

One cannot truly accept what one does not know or see. This is why acceptance pivots on perspective-taking skills, or learning how to observe psychological experiences just as they are. Defusion skills (learning to look at thoughts and emotions, rather than from them; see chapter 23) can facilitate healthy perspective-taking and acceptance.

A variety of experiential exercises build perspective-taking skills, including formal and informal mindfulness exercises (see chapter 26). Traditional breath-focused meditation and other concrete mindfulness exercises (Kabat-Zinn, 2005) foster the ability to notice thoughts and feelings with openness. Therapists can also foster perspective taking by encouraging clients to speak as an observer of their experience in session (e.g., “I am noticing that I am experiencing an urge to shut down and withdraw.”). Therapists can model and shape perspective taking linked to emotional openness in their own talk (for instance, “I notice I am feeling a sense of urgency inside me…as if I need to quickly do something to be useful to you.”).

Nurture Self-Kindness and Compassion

Many clients are incredibly hard on themselves and relate to their history and difficult psychological and emotional content with resistance, anger, and self-blame, adding more suffering to their pain. Acceptance work is not about asking clients to like what they think and feel. Instead, we are inviting clients to change the quality of their relationship with the experiences they are having anyway. Instead of turning away, acceptance asks the client to soften, to open up, and to meet difficult content with kindness, friendliness, gentleness, and, dare we say, love.

Self-compassion and self-kindness are not feelings—they are actions to be practiced, both in and out of session. They involve expanded awareness that (a) pain in life is inevitable, and (b) all human beings confront obstacles, problems, and pain (Neff, 2003).

We often use the metaphor of a parent dealing with a difficult child as we begin this work:

When their child is upset or does something wrong, parents learn that yelling or telling the child to stop crying is sometimes ineffective and escalates the situation. Sometimes, parents opt for a softer approach. They don’t resort to fighting or punishing behavior simply because their child is behaving badly. They see through that first impulse (to react with negative energy), and instead wish for their child to know kindness and love, and so they respond in a caring way that shows that. I wonder if approaching yourself and your history in the same way might be helpful. Isn’t it true that self-blame has only escalated the situation? Isn’t it time for something new?

You might even ask clients to hold their painful content as if it were a young infant, cradling it close to their heart with compassion and kindness. Guided meditation exercises, such as “holding anxiety gently,” can be used to cultivate compassionate responses (see Forsyth & Eifert, 2016). After bringing the client into a state of eyes-closed open awareness, invite the person to do the following:

Take both of your hands and cup them to make the shape of a bowl, palms facing up. Allow them to rest softly in your lap. Notice the quality of those hands and the shape they are in. They are open and ready to hold something. As you get in touch with that, become aware that those very hands have been used by you in many ways. They have been used for work, for love, to touch and be touched [continue with half a dozen similar things]. Allow yourself to sink into the goodness contained in your hands.

From that place of goodness, see if you can allow, even if just for a moment, a small, tiny piece of your [name emotional concern here; e.g., anxiety] to settle there. Like a feather floating down, imagine that piece of it gently comes to rest in the middle of your kind and loving hands.

Take a moment to sink into that—this piece of [emotional concern] is now resting within the goodness of your hands. What is it like to hold it in this way? Simply notice, breathe, and sense the warmth and goodness of your hands. There’s nothing else to do here.

Foster Willingness and Mindful Acceptance

Willingness is a choice to be open to whatever the mind and history offer. It is a kind of leap of faith—a dive into the future, open but without truly knowing what will happen. Thus, when we ask clients if they are willing to experience what shows up, we invite them to exercise control in terms of their choices and behavior, not knowing what they may experience as they step into the unknown.

The goal is for them to be willing to have a mindful, compassionate stance toward their experiences as they show up. Learning this posture is fostered by starting small, focusing on developing acceptance skills, and then expanding to more difficult content. Mindfulness practices (Brach, 2004; see also chapter 26) provide a useful structure to learn how to apply willingness. For example, guided meditations that direct attention, one domain and area at a time, toward emotions, bodily sensations, thoughts, and the like (e.g., the “acceptance of thoughts and feelings exercise” from Forsyth & Eifert, 2016) can be used in session to practice mindful acceptance. For instance, a difficult memory can be dismantled into a series of thoughts, images, physical sensations, and/or urges, and each piece can then be explored and contacted willingly, mindfully, and compassionately (see the “tin can monster” exercise in Hayes et al., 2012). Such exercises are, in essence, a kind of exposure exercise, done in the context of willingness and self-compassion.

Frame Acceptance in the Context of Client Values

It helps to motivate acceptance by linking it to client values—chosen qualities of being and doing (see chapter 25) and other forms of positive motivation (see chapter 27). Doing so helps prevent acceptance from being a new form of avoidance or self-soothing.

Framing acceptance work in the context of client values is particularly important when doing exposure-based work. The aim is to help the client learn to change his relationship with unpleasant aspects of his history, while expanding the range of behavioral options. A brief dialogue with the socially anxious client mentioned earlier shows how the therapist began to draw this out.

Therapist: Last time, we talked about seeing what it might be like for you to go out dancing with some of your friends this coming weekend. I just wanted to check in with you to see where you are with that.

Client: I dunno… I’ve been thinking about it all week, and I’m really anxious about it.

Therapist: (Senses that the difficult content is showing up in the room and sees this as an opportunity to do some exposure-like acceptance work.) What’s showing up for you right now? Like, where do you feel it in your body?

Client: (Points to her stomach.)

Therapist: What sensations are there?

Client: It’s like butterflies… I feel queasy, like I might get sick, and then I’ll make a fool of myself.

Therapist: Okay, so let’s notice that. You’re sensing something in your body. And, your mind is protesting and jumping in as it does…telling you that this is unacceptable and you’re not okay. Let’s take a moment to notice that…thoughts showing up…and see if we can allow them to be here. Now, I’d like to invite you to do something, if you’re willing.

Client: Okay… But you’re not going to try to get me to grab that rope again, are you? (Smiling.)

Therapist: No, no rope this time. Instead, I’d like us to take a moment to see what’s really there. I’d like to invite you to close your eyes and get in touch with your breath like we’ve done many times before. When you start feeling connected to your breath, your safe refuge, I’d like you to notice that one sensation in your belly. Simply notice it, and with each breath see if you can make more space for the sensation within you to just be there. (Pausing for about thirty seconds or so.) As you soften to it, look again and see if this sensation is really your enemy. Can you soften to it and hold it gently, and with some kindness, as you see yourself out with your friends, dancing and enjoying the freedom in that? Take a few moments, and when you’ve noticed some space and tenderness, come back to just being here, and slowly open your eyes when you’re ready.

The therapist then explored other sensations, urges, and thoughts with the client—one at a time, with qualities of mindful awareness and gentle allowing. The therapist repeatedly checked in with the client to assess her willingness, and also what was new or different in her experience, as she explored difficult content, or barriers, that had gotten in the way of her going out and connecting with friends while dancing.

The client, in turn, felt encouraged to practice willingness and mindful acceptance at home, first dancing alone and eventually taking a step in a valued direction by going out and dancing with her friends. When the anxiety monster showed up on the dance floor, she did not “pick up the rope” but instead treated it with kindness and compassion. In session the following week, the client even joked that she danced “with her anxiety monsters at the club,” and she felt empowered and alive doing so.

Recommendations, Common Traps, and Clinical Errors

Acceptance work can be challenging for therapists. Below we outline some suggestions and some common traps and errors you may experience along the way.

The therapeutic stance and your own personal work. Acceptance work asks the therapist to go into difficult places with clients while modeling an open, receptive, and compassionate stance. That can be challenging, which is why therapist experiential avoidance predicts a failure to use exposure strategies (e.g., Scherr, Herbert, & Forman, 2015). For acceptance to be instigated, modeled, and supported, therapists need to practice acceptance with their own difficult psychological events. It is not necessary to be masters of acceptance, because coping models are actually more effective. When we, as therapists, are working to approach our own history and imperfections with kindness, compassion, and patience, it becomes easier to support client efforts to so the same.
Resist the temptation to offer easy explanations or quick fixes. Though in therapy the tendency to jump in and offer solutions, explanations, or promises about thinking and feeling better is great, doing so can backfire in the context of acceptance work. It is more important to focus on aligning with clients and their experiences as they are, and to move toward changes from that foundation of openness. This does not mean condoning what has not worked in the client’s experience, approving of unhealthy client behaviors, or “accepting” unhealthy environments or situations. It means starting with the validity of client experience, and allowing client experience to guide therapy toward what works.
Make it experiential. Experiential exercises are more effective than mere instructions about how to accept thoughts and feelings (McMullen et al., 2008). Intellectual conversations about acceptance are rarely helpful in therapeutic contexts. Acceptance is more like riding a bicycle: it is learned through direct experience. If you ever find yourself explaining acceptance, or trying to convince the client to accept, just stop, and say something like “Did you notice what just happened? Both of our minds really got going there.” Then return to something experiential.
Lay the groundwork, and avoid using acceptance in a control context. Acceptance with the goal of eliminating difficult private events is unlikely to be helpful in the long run. Going directly to acceptance without exploring the costs of needless control can backfire because clients see acceptance as a clever new way to “win the tug-of-war” rather than to do what is in the etymology of the word “acceptance”: to receive the gift that is inside difficult experiences. A stance that embodies kindness, curiosity, compassion, and openness is necessary before that gift is likely to be received.
Acceptance is a process, not a “one and done” technique. Often the temptation is great to focus on the techniques of acceptance, perhaps even doing them in a linear way, while missing that acceptance is a functional process. As a process, acceptance often unfolds gradually and is revisited again and again in various ways over the course of therapy and a lifetime. Many evidence-based methods (exposure, mindfulness, behavioral activation) contain the opportunity to learn acceptance as a process. Therapists who have a process focus will be more likely to work successfully with clients to cultivate acceptance.
Frame acceptance in the context of client values. Values dignify the hard work of therapy, particularly acceptance-based work. Without a positive life focus, acceptance can feel like wallowing in the muck, without a direction. The purpose is not to open up to pain for its own sake. The purpose is to foster what the client truly cares about. Thus, it is important to link this work to what matters to the client and to let the work of acceptance be about that.

Applications and Contraindications

Generally speaking, acceptance is most applicable to experiences inside the skin, whereas direct change efforts are often most applicable to the world outside the skin. Acceptance is not indicated when the client can effectively change something about the environment or behavior that would produce an increased quality of life. For instance, if a client is being subjected to racial discrimination in the workplace, it would not be helpful to accept this state of affairs. Rather, one might work with this client to help her accept the anxiety that comes with contacting a human resources department to report the discrimination. The same applies to some experiences within the skin, although here we need to be careful. If a client has a headache and experience and data suggest that aspirin would alleviate it without harm, there is no reason for him to not take the aspirin. Conversely, a person with chronic pain syndrome may need to learn to carry pain with her because, for example, the long-term impact of opiates is unhelpful.

To make this discrimination, it can be useful to think functionally by considering questions such as these:

It appears from the evidence that acceptance is much more broadly applicable than clients and clinicians initially suppose. That said, it is important to develop a context for acceptance-based work and skills and to be open to alternatives. Once a client has nurtured acceptance skills as a new and potentially more vital alternative to the typical change agenda, life itself can help the client learn when it is the best approach and when it is not.

Conclusions

Psychological acceptance is a radically empowering form of clinical change. Instead of changing first before being open to what is present, acceptance focuses on whether it is possible to be a functional, whole, and complete human being now. Though many clients enter therapy seemingly trapped in a cage of suffering and despair, desperate to find a way out, acceptance illuminates the door that has been open all along. There is enormous freedom in that. A growing evidence base shows that acceptance skills are central to psychological well-being and help guide and explain the impact of psychotherapy with many forms of human suffering.

References

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