Acceptance and change are typically seen as opposites but might perhaps usefully be seen as independent constructs. This post explores an alternative way of thinking about acceptance and change.
Despite Beck et al.’s (1979) description of the importance of clients initially learning to ‘decentre’ from their thoughts, second wave, Beckian CBT is primarily a change-focused therapy. Traditional CBT focuses on evaluating one’s thoughts prior to changing habitual, inaccurate, and unhelpful ways of thinking. In contrast, third-wave behaviour therapies, such as dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and integrative behavioural couple therapy (IBCT), are defined by their focus on psychological acceptance. In DBT, acceptance and change are opposites requiring different sets of skills. Distress tolerance and mindfulness are psychological acceptance skills, while interpersonal effectiveness and emotion regulation are behavioural change skills (Linehan, 1993). In ACT, psychological acceptance is seen as a private (cognitive) behaviour, with emotional suppression or experiential avoidance as its opposite. In ACT, the willingness to accept all emotional experience is emphasised in the service of psychological flexibility (Hayes et al., 1999). In MBCT mindfulness is essentially a method of attentional control (Teasdale et al., 1995) that has been defined as “paying attention…on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). In IBCT, couples are encouraged to cultivate acceptance of difference in preference to behavioural change strategies characteristic of traditional behavioural couple therapy (Jacobson & Christensen, 1996).
While both second wave CBT and third wave behavioural approaches emphasise the importance of behavioural change, cognitive change and psychological acceptance are either explicitly or tacitly taken to be the opposite of each other. I have never been entirely happy or reconciled to his dichotomous view of acceptance and change. I wonder about the risk of offering acceptance strategies to people who might be better served by change strategies, although at times it can be hard to know what is realistically in one’s power to change. It seems to me that seeing change and acceptance as dichotomous risks confusing the attitude of acceptance with the behaviour of change. If each were treated as independent constructs, the opposite of acceptance becomes non-acceptance, while the opposite of change is no change.
How might this distinction help? Firstly, it introduces some conceptual clarity where psychotherapy aims to bring about change in one’s habitual modes of thinking and behaving. Moving from non-acceptance to acceptance when acceptance is seen as an attitude is a type of cognitive restructuring. In short, acceptance is change. Secondly, plotting the two constructs in a 2×2 matrix leaves us with four distinct quadrants rather than two options (Figure 1): acceptance + change; non-acceptance + change; acceptance + no change; and non-acceptance + no change.
Figure 1: Acceptance and change in two dimensions
In the top right quadrant, an attitude of acceptance of experience and of circumstantial limitations is combined with behavioural change. It is an empowered stance that discriminates between what is in one’s control and what is not. In CBT terms, it is a collaborative, experimental stance that enquires into what is possible and desirable, rather than assuming one knows a priori. I have called this wisdom after Reinhold Niebuhr’s Serenity Prayer:
God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.
The top left quadrant is an attitude of non-acceptance of aspects of experience or circumstances that are not in one’s control. It manifests as both the motivation and action to change what is perceived as intolerable. This state of mind is seen for example in perfectionism, or the fruitless search for a “cure” in someone with persistent physical symptoms or a refractory long-term health condition. Albert Ellis (1997) described it as “musturbation” to refer to “insistent demands and musts” (p. 95) that he believed were at the root of emotional disturbance. It is a state of anxiety and demandingness that, left unchecked, leads to disappointment and exhaustion. I have called this struggle in that it is a struggle with oneself or one’s circumstances that cannot be won. In psychotherapeutic terms, it is persisting in change strategies, or in holding out the hope of change despite evidence to the contrary.
The bottom right quadrant combines an attitude of acceptance with a reluctance to take action to change those aspects of a problem that are within the person’s sphere of influence. I have called this resignation because it is a form of acceptance that involves a willingness to tolerate the intolerable, despite having the power or resources to make desired changes. It might be seen when a person’s locus of control is primarily external. Resignation could also be thought of as a way of suppressing hope to avoid disappointment in the face of a fatalistic inevitability that renders action seemingly futile. In therapeutic practice it might be thought of as an unwillingness to attempt change strategies to protect the client from possible distress or failure or oneself from feelings of incompetence. At other times it might be due to a lack of knowledge or conviction in one’s skills to bring about change, or a lack of persistence with change strategies.
The bottom left quadrant combines non-acceptance with no change. It is perhaps the most disempowered and distressed position of all. I have called this stance defeat because its helplessness and paralysis in the face of the intolerable are akin to teh defeat and entrappment characteristic of depression (Taylor et al., 2011). It is a state of mind that leaves nowhere to go but to blame the world or blame oneself. It is associated with shame, anger, helplessness, and hopelessness. In CBT it might be seen in both the client’s defeat and the practitioner’s sense of defeat in being able to be of help. If this is frequent or occurs over a prolonged period, Rønnestad and Skovholt (2013) describe it as professional stagnation characterised by exhaustion and disengagement.
However, knowing what and how to change or accept can be difficult, for clients and therapists alike, and we will all struggle to make wise choices consistently. So, in the middle of the matrix is what I have called ordinary ambivalence. This is intended to normalise the non-linear, fluctuating process of change and acceptance – some days we are better at accepting what can’t be changed, some days we don’t stick to the changes we have committed to, sometimes we’re simply ambivalent. This is, I believe, both normal and understandable. We’d like to be wise, but we might have to settle for doing our best. Accepting that, and doing what we can anyway, might also be a form of wisdom.
References
Beck, A. T., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive Therapy of Depression. The Guilford Press.
Ellis, A. (1997). Must musturbation and demandingness lead to emotional disorders? Psychotherapy: Theory, Research, Practice, Training, 34(1), 95-98.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford Press.
Jacobson, N. S., & Christensen, A. (1996). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. Norton.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. Hyperion
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Publications.
Rønnestad, M. H., & Skovholt, T. M. (2013). The developing practitioner: Growth and stagnation of therapists and counselors. Routledge.
Taylor, P. J., Gooding, P., Wood, A. M., & Tarrier, N. (2011). The role of defeat and entrapment in depression, anxiety, and suicide. Psychological Bulletin, 137(3), 391-420.
Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33(1), 25–39. https://doi.org/10.1016/0005-7967(94)E0011-7
(c) Andrew Grimmer, 2024