What does the term acceptance mean within CBT? - Chapter 14

What is the idea behind "acceptance"?

Acceptance has taken a prominent place in CBT. Firstly, because it has been shown that acceptance has advantages over non-acceptance. Secondly, because it has been found that negative thoughts and emotions cannot be changed and therefore may need to be accepted. There are various definitions of acceptance, ACT (acceptance and commitment therapy) describes it as "taking an open, receptive, non-judgmental attitude." DBT (dialectical behavior therapy) adds that experience should not be held on or attempted to get rid of it. Experiential avoidance is the opposite of acceptance. Avoidance of private experiences (thoughts, feelings, memories, physical sensations and behavioral tendencies) is only effective in the short term, but can cause problems in the long term.

How is acceptance applied?

In therapy, acceptance is used in many different ways. For example, by coaching openness to the experience of exposure by, for example, asking to accept the discomfort for a short time. In mindfulness, they use equanimity, which means that you "only notice" thoughts and emotions. Many metaphors are used to achieve acceptance. Much research has been done into the effect of both acceptance and avoidance:

• Thought suppression: actively suppressing thoughts leads to a large increase in thought in the short term (rebound effect, think of the pink elephant). In the long term, it appears to be related to clinical problems such as depression and substance abuse. In addition, suppression has a high chance of failure under stressful circumstances and makes individuals sensitive to harmful environmental influences.
• Avoidance behavior: this is associated with poorer mental health and quality of life. It is associated with, among other things, depression, anxiety, specific phobias and increased pain.
• Expressive writing: clients are asked to "really let go of things and explore your deepest emotions and thoughts". Writing about your emotions has been shown to have positive effects on mood, better school performance and better health in healthy subjects and in broader populations.
• Acceptance compared to other coping strategies: Suppression and avoidance are associated with increased anxiety. Acceptance-oriented coping has proven to be more effective than control-based coping such as suppression, avoidance and cognitive restructuring (reappraisal). Another study found that reappraisal was just as effective as acceptance and more effective in changing the subjective feeling of fear and anger, but this was to be expected because acceptance is not aimed at reducing subjective distress. What can be said is that suppression leads to increased distress, but acceptance does not necessarily lead to reduced distress (which would be strange, because acceptance and reduction are two different things). What is strange is that these studies showed that acceptance did not affect task persistence, although this was expected. This may be due to the instructions about acceptance being too short.

What are the variants of CBT?

Acceptance was introduced in CBT by Ellis, with his Rational Emotive Therapy (RET). RET encourages unconditional acceptance of self and others and emphasizes that not the person, but their thoughts, feelings and behaviors should be judged. RET focuses on teaching acceptance and building tolerance because it thinks that psychopathology develops from not accepting things. Beck does not see acceptance as a mechanism of change, but does recognize it as a minor component. He sees it as a means to bring about cognitive change (acceptance of discomfort is necessary, for example, to enter exposure).

Newer variants of CBT have come to see adoption as a central mechanism:

• Acceptance-based behavior therapies: Extends regular CBT with acceptance-based components. It has proven effective in GAD, it has also been suggested that the acceptance process is an active change mechanism.
• Acceptance and commitment therapy: Acceptance is used as a way to stimulate contact with experiences that have been avoided. This aims to lead people towards a more active way of life. ACT has been shown to be effective in various disorders and at least as effective as other forms of treatment.
• Dialectical Behavior Therapy: DBT targets acceptance, mindfulness, emotion regulation, tolerance of distress and interpersonal skills. It has proven effective in borderline patients.
• Integrative Behavioral Couples Therapy: IBCT emphasizes that intimacy in a relationship can be achieved by accepting each other and each other's behavior. IBCT also helps the partners recognize and accept their own emotional states that arise in the interaction.
• Meta-cognitive therapy: Uses acceptance as a means to change attentional processes. Changing attentional processes is suggested to be the mechanism that changes thoughts.
• Mindfulness-based cognitive therapy: Clients are taught mindfulness meditation, which implies an open, non-judgmental attitude towards negative cognitions, emotions and physical states. It is especially effective in depressed people who do not respond to anything else and as a relapse prevention in people with recurrent depression.

What is the context of acceptance in CBT?

Acceptance is related to other components of CBT:

• Relaxation: this can be associated with acceptance (for example, in exposure, relaxation helps to accept arousal), but can also work against it (if the goal is distraction or reduction of difficult emotions and cognitions, then it is avoidance).
• Emotion regulation: adaptive emotion regulation can be mindfulness (acceptance), maladaptive regulation is avoidance or over-involvement.
• Exposure: acceptance serves to facilitate the exposure process through which fear reduction can take place. The reduction of anxiety would contribute to a better quality of life. However, one study has found that anxiety reduction is not associated with therapeutic outcomes. This suggests that exposure should include more psycho-education and acceptance because many people remain anxious after exposure.
• Cognitive restructuring: The idea that cognitive interventions that alter thoughts are responsible for therapeutic progress is increasingly questioned. It seems that, as with exposure, many people still have complaints after cognitive interventions, which could indicate that acceptance should play a greater role in therapy. This is supported by the effectiveness of mindfulness-based interventions.
• Behavioral activation: starting to undertake activities, even if your emotions and cognitions about them are negative, requires a degree of acceptance.

More research is needed into what the mechanism of action of CBT is and whether it is actually that good. More and more question marks arise as to whether tackling, challenging and changing thoughts is effective because often thoughts and emotions persist. At that point must be investigated whether acceptance is better.

Acceptance has taken a prominent place in CBT. Firstly, because it has been shown that acceptance has advantages over non-acceptance and secondly, it has been found that negative thoughts and emotions cannot be changed and therefore may need to be accepted. There are various definitions of acceptance, ACT (acceptance and commitment therapy) describes it as "taking an open, receptive, non-judgmental attitude." DBT (dialectical behavior therapy) adds that experience should not be held on or attempted to get rid of it. Experiential avoidance is the opposite of acceptance. Avoidance of private experiences (thoughts, feelings, memories, physical sensations and behavioral tendencies) is only effective in the short term, but can cause problems in the long term.