Importance of The Concept of Acceptance in Therapeutic Services

The role of acceptance becomes relevant in cognitive behavior therapy models when highly desired change is difficult, impossible or at least not imminent. Acceptance and mindfulness interventions provide alternative ways to reduce suffering, and to help clients let go of their “stuck” situations when change is not immediately available. This paper examines the similarities and differences that the concept of acceptance plays in the therapeutic models of Ellis, Hayes, and Linehan. However, before we can begin to discuss the role of acceptance in Albert Ellis’ Rational Emotive Behavior Therapy (REBT), Steven Hayes’ Acceptance and Commitment Therapy (ACT), and Marsha Linehan’s Dialectical Behavior Therapy (DBT), I believe it is essential to first consider Eastern and Western mythologies that continue to inspire the philosophy and culture of society.

Beginning in the East, upon Buddha’s later years, he held a flower sermon near a pond. His disciples gathered around him in silence as he held up a freshly-picked lotus flower – roots and all, dripping mud. All except for one of his disciples was unsure of the significance of Buddha’s message which resulted in a smile. Buddha recognized that his disciple, Mahakasyapa, understood that flowers not only symbolize hope of peace and beauty arising out of suffering (e.g., mud and muck) but that they embody both form and the formless at once. Buddha used the lotus flower as wonderful reminder that while all forms (e.g., behaviors, emotions, thoughts, people, material possessions) can be appreciated, they are fleeting.

Moving to the West, we find a beautiful young man who was also sitting by a pool of water admiring his own reflection. As a punishment from the gods for being cruel to those who love him he becomes trapped for eternity in his longing for himself. Eventually Narcissus dies and is transformed into a small flower that bares his name, Narcissus, commonly known as the daffodil. Some translations of the story suggest that this flower sprang up from where Narcissus died, so depending on one’s view of reincarnation he was either turned into a flower or their presence was mere coincidence. However, reflecting upon this lesson and curious reward from the gods for such self-possession, one begins to question if Narcissus finally saw through his image to the depths under his reflection, which resulted in him being able to surrender his image and become something delicate and beautiful. If that is the case then, I suppose the lesson from the gods is that we must not hold ourselves prisoner to an image (e.g., reflection of self) or difficult states (e.g., represented by the pool of water) in order to truly accept ourselves and navigate the world around us.

After reviewing the lessons from mythological stories, it becomes evident that REBT, ACT, and DBT combine elements of Eastern and Western philosophy with more traditional elements of Western psychotherapy to help their clients. In Linehan’s DBT, Eastern and Western philosophy is evident as the focus of the mindfulness exercises is to accept what is and to develop coping strategies with the world as we find it, and not attempting to change one’s image of the world. Linehan (1993a) suggested that mindfulness practices may also be helpful for individuals who are afraid of their own emotions. However, it is unclear the extent to which Eastern Philosophy has had an effect on the concept of acceptance in therapeutic models developed by Ellis and Hayes, beyond they Buddhist philosophy of acceptance. It appears that the true differences lie in the Western philosophy the theorist ascribes to. For example, Ellis appreciated Popper’s idea that the human mind, both the clinician’s and the patient’s, naturally made hypotheses, which resulted in REBT interventions focusing on confirming or rejecting hypotheses with empirical data. This paves the way for accepting things as they are and by using logic to evaluate the irrational beliefs to facilitate change. Hayes also includes the concept of acceptance; however, it is employed differently.

Hayes found the work of Stephen Pepper influential as he based ACT on the pragmatic philosophy of functional contextualism. This position stresses that the only evidence needed to determine a meaningful conclusion, acceptance, is practicality, or whether an idea works to help one achieve one’s goals. It becomes apparent that acceptance in ACT primarily focuses on accepting internal stimuli of thoughts and emotions. It is unclear if Hayes also includes accepting the external reality in the world or the behavior of others in his definition of acceptance. Hayes’ therapeutic stance has a conscious posture of openness and acceptance toward psychological events, even if they are formally negative, irrational, or psychotic. One is left with the thought that truth is relative and if something works for the individual then it is true for that person. Besides raising ethical and moral concerns, this does not validate that a person can have negative experiences and emotions that may be the contributing factor to their presenting problems. Understanding the fertile ground and contextual behavioral roots for which ACT emerged, one can see that Hayes promotes the pursuit of one’s values in order to achieve a meaningful life with a focus on behaviors. ACT focuses on changing the overt behaviors and their relationship with cognitions and emotions, rather than changing cognitions or emotions themselves. Through ACT, Hayes teaches his patients to stop trying to change their specific cognitions and emotions, to accept these negative internal experiences and at the same time to learn to perform behaviors that will help them achieve their goals and values despite the desire to escape uncomfortable experiences. It is his attempt to teach patients that they can have negative thoughts and emotions and still behave effectively. This stance also highlights the influence of behaviorism, in that people’s history of exposure to stimuli and reinforcers create who we are. DBT takes a different approach in relation to cognitions. Linehan’s approach does not rely on cognitive interventions to help clients regulate their emotions, instead she teaches them self-soothing techniques. These techniques provide a comforting, nurturing, kind, and gentle way to sooth their strong disturbed negative emotions. Even though this approach is not unique to DBT, it is a prominent component that helps patients to take the steps towards change even when they are overwhelmed by their emotions. In other words, acceptance is considered both an outcome and an activity in DBT, which makes it different from both REBT and ACT. As in the name of the therapy, the primary dialectic in DBT is between acceptance and change. Linehan believes that in order to facilitate change, a client must be aware of, and able to tolerate, the pain associated with the problem.

It is also important to note that ACT is also based on relational frame theory (RFT), which holds the process of language and its dominance over direct experience that promote much of human suffering (Hayes & Wilson, 2003). Hayes makes a distinction between acceptance and tolerance, to mean the “active non-judgmental embracing of experience in the here and now: where acceptance involves undefended ‘exposure’ to thoughts, feelings, and bodily sensations as they are directly experienced” (Hayes, 2004, p. 21). This provided the foundation for the primary goal of ACT, which is to create psychological flexibility. This is accomplished through not only acceptance and mindfulness skills building, where the deliberate and nonjudgmental/non-evaluative engagement of the client’s experience in the present moment, but through commitment and behavior change skills as well (Dobson, 2010). Considering the role that language plays in the well-being of human-beings, I considered the way in which British novelist, Zadie Smith, viewed emotions such as shame, pride, and rage and how they affect how people view and navigate the world. One thing that I found profound was that Smith made points very similar to Ellis’ stance on the importance of emotion. Smith believes that emotions must be viewed as real even if they appear to be unfamiliar or alien to the person. Smith also includes Linehan’s view of validation as essential to effective communication in order to make steps towards understanding and change. She goes on to also support Ellis’ stance on replacing dysfunctional and maladaptive emotions with more adaptive emotions. As it is more effective than feeling no emotion for which the more adaptive emotion allows people to “function practically.” For example, Smith believes that shame is a productive emotion that can serve as a catalysis for change, as to be shameless is considered to be dangerous. Smith also supports Hayes stance that language limits a persons’ ability to accept adversity due to the tendency to make statements into rules. Smith used the example of Black Lives Matter and how it has a major impact on the conservatives in this country as it invokes intense rage because the arrangements of the words suggest that this excludes them indefinitely, instead of viewing the words non-judgmentally and as expressions of experience. This suggests that the various views in which acceptance is included in a therapeutic model, they all apply to life in a way that is effective for the healing process.

The similarities that exist among the therapeutic models are more apparent when one can put linguistics aside and understand their purpose and role in treatment. In REBT, Ellis teaches his patients to cultivate three types of unconditional acceptance, namely acceptance of oneself, others, and life. Linehan’s, uses term Radical Acceptance to refer to the same types of acceptance Ellis mentions. Both REBT and DBT help patients learn to replace rigid and maladaptive thoughts with more adaptive ones, thereby actively working to change while simultaneously accepting themselves and their situations as they are. For example, REBT stresses that clients accept both the external world and the internal world, whereas DBT focuses more on accepting ones’ internal experiences. However, Linehan’s therapeutic stance of validating clients’ reality is a form of acceptance of the external world. Therefore, their view of acceptance of external and internal stimuli is the same. The focus on what Ellis refers to as secondary disturbance and tolerance of discomfort is similar to Linehan’s focus on the acceptance and tolerance of internal experiences such as disregulated emotions. As both REBT and DBT, patients are learning that experiencing and acknowledging the discomfort associated with both experiencing adversity and learning to cope with it are necessary for change and for growth to occur.

Literature on the inclusion and effectiveness of acceptance in CBT is positive. For example, Porada and Milburn conducted an empirical investigation of the relationships between irrationality, self-acceptance, and dispositional forgiveness. They found that unconditional self-acceptance was significantly positively correlated with dispositional forgiveness. Using a regression analysis, they were able to indicate that subtypes of irrationality and self-acceptance predicted dispositional forgiveness of self, other, and situations. Being that there were no significant differences between sexes, it appears that holding irrational beliefs impedes the process of forgiving, and one’s level of self-acceptance predicts one’s disposition to forgive. This supports that notion that the inability to accept problems, experiences, situations, and so forth prohibits change (Dobson, 2010). This can be seen in the therapeutic model developed by Ellis and Linehan due to the inclusion of unconditional and radical acceptance. Being that ACT, places emphasis on acceptance of internal stimuli, it was impressive to see that a study conducted by Karol Wild compared the role of acceptance in REBT and ACT. She found that the outcome of acceptance and emotional level were similar in the two conditions. Wild noted that the ways in which the theorist conceptualizes acceptance and how it relates to cognitive processing are the primary differences between the therapeutic models. The differences in Western philosophy and academic affiliations could have been the contributing factor to Wild’s observations. Ellis had extensive clinical experience which impacted the development of his theory as compared to Linehan and Hayes, for which they conducted randomized clinical trials on the therapy they were developing. The ways in which the therapeutic models emerged is irrelevant as compared to the evidence that is supported by research. For example, a study evaluated the effectiveness of a DBT skills module, Walking the Middle Path, of adolescents and their families. This mindfulness-based activity along with the use of validation was perceived as most helpful among the DBT therapeutic model. When therapeutic models are able to produce positive outcomes when replicated by other therapist with different populations and engagement styles, it provides reassurance to the consumer, both the clinician and the client, that the model is effective. This is an important element when selecting models to use with clients. This is such a critical and ethical consideration for clinicians to keep in mind. So critical that Donald Meichenbaum created a checklist with 19 warning signs suggesting that an intervention’s efficacy and effectiveness were substantially exaggerated. Even though the concept of acceptance was mentioned by Ellis in 1957, it is far from a new concept, as with mindfulness. However, there has been an increased interest and inclusion of these concepts in therapeutic models. It is important that therapeutic models focus on effectiveness instead of solely appealing to society as a way to appear progressive. For example, Smith mentioned the way in which millennials and generation Z verbalize emotions. She noticed that this generation’s expression of emotions is rather distance from the bodily functions due to the high use of technology, however, it is through acceptance of internal and external stimuli that they find liberation. This could be also in reflection of the rise of mindfulness practices among young people.

Overall, the concept of acceptance appears to have had a positive impact on the effectiveness of various therapeutic models. Considering that each theory is influenced by the values and personality of the theorist, it was important to exam those aspects to understand how acceptance was conceptualized within the theory. For it became evident that Ellis, Hayes, and Linehan all have different approaches in the way in which acceptance is employed, however, it is their similarities that support the importance of acceptance to promote change within a patient or client. The differences among the models allow for therapist to be flexible in which tools may be effective or appeal to the needs of the client. Therefore, I do not believe that having different models with different theories and approaches as redundant but as useful in their own way. For example, DBT may be needed in more intense situations due to the skills building element, emphasis on validation, and the high dosage of the therapy. ACT may appeal to others who are highly motivated by achieving their goals despite it being uncomfortable, while REBT might apply to others who may view life more logically and is in need of replacing dysfunctional and maladaptive emotions with more functional and adaptive ones.

Drawing ones’ attention back to the generational shift of verbalizing emotions, it is interesting to consider how therapy will evolve. As a future therapist, I believe it is imperative to consider these factors to ensure people are receiving adequate treatment despite the change in emotional expression and the rise of virtual identities. However, it is also interesting to consider that the role of acceptance may be the essential need that all humans desire, resulting in the effectiveness of therapy. For example, it has been mentioned in ancient text (e.g., religious and philosophical) and it is ever more present today. As social media has created a platform for people to feel validated and acceptable through likes, retweets, and mentions. If people do not feel validated or accepted in their physical world, they can create a virtual identity that may help them fulfill that need. However, when the needs of validation and acceptance are not fulfilled in either realm, dysfunction and irrational beliefs may arise more intensely. Resulting in a therapist teaching the client ways in which they can accept internal and/or external stimuli while feeling validated and accepted at the same time. If acceptance is truly a basic human need, it leaves me to wonder why it is not included in all therapeutic models. Perhaps as Hayes suggest, language may prevent people from being able to agree on a definition that will allow them to integrate such concepts. Academic affiliations may have also had an influence on the delay of acceptance being included in therapeutic models. Being that psychology is considered a soft science, the concept of acceptance may have seemed too simple to have such an impact on mental health and overall well-being. As mentioned previously, Ellis, Hayes, and Linehan were all influenced by Eastern and Western philosophy as well as Western psychotherapy. Finding inspiration from various schools of thought is beneficial to the field for it prevents an echo-chamber effect that results in stagnation. Being that psychology is still considered a science, regardless of its perceived texture and depth, therapist will have to evaluate the evidence that supports the models and concepts they wish to include in their treatment. This is why I believe technology will allow future theorist to connect the gaps between previous therapeutic models, various schools of thought, and the needs of the society due to the increase of communication and information.

Personally I find it important to include the concept of acceptance when providing therapeutic services. I favor towards the work of Ellis and Linehan, due to their unconditional and radical acceptance of the self, others, and reality. I also value their inclusion addressing and accepting emotions as they may present as barriers towards a client’s goal. I also feel that it is important for clients to be educated on emotions especially because of the effects gender may have on the expression of emotions. For example, being sensitive is considered irrational and feminine, however, this is rather limiting for men as they too may feel intense emotions about something that may be viewed as feminine or irrational. This also applies for women who may feel makes them look weak if they ask for help or that they may appear too masculine if they voice their opinion and set boundaries. These concepts prevent humans from being able to express, experience, and accept emotions as a natural phenomenon that has helped us evolve and adapt to our surroundings. By not accepting ones’ emotions, people become silenced which prevents them from living a life that is worth living. If therapy does not include this element then I believe the treatment will do a disservice to both the client and the field.