CHAPTER 24

Cultivating Psychological Acceptance

John P. Forsyth, PhD

Timothy 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 con-
templative practices, and most psychotherapy approaches when discussing thera-
peutic 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 tech-
niques. It is also a process, and not simply an outcome.
Acceptance as a term can be readily misunderstood. It is not giving up, tolerat-
ing, or passively resigning. It is rather a behavior and a choice. It involves approach-
ing (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, para-
doxically, 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
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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, dif-
fering in genetic predispositions but basically conscious containers for our experi-
ence. 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 ingre-
dients 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

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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, effort-
ful, 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 con-
trolled 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 revis-
ited as needed. Two simple questions are central to this process:

What have you tried so far to solve the problem(s)?

In your experience, how has that worked? In the short term? Long term?

When explored with compassion and gentleness, these questions begin to

expose the unworkability and costs of the struggle itself. The client’s own experi-
ence often reveals that control works in the short term, mainly in terms of offer-
ing psychological relief. However, these brief honeymoons from pain are
costly—emotionally, physically, and in terms of moments away from doing some-
thing 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?

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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 strat-
egies 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 expe-
rience 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 thera-
pist 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.

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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 accep-
tance 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 prac-
ticed, 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).

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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 nega-
tive 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 approach-
ing 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

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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 behav-
ior, 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 start-
ing 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 medita-
tions 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 avoid-
ance or self-soothing.
Framing acceptance work in the context of client values is particularly impor-
tant 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 men-
tioned 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?

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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 accep-
tance at home, first dancing alone and eventually taking a step in a valued direc-
tion by going out and dancing with her friends. When the anxiety monster showed

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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 sug-
gestions 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, recep-
tive, 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 sup-
ported, therapists need to practice acceptance with their own difficult psychologi-
cal 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 experi-
ence, and allowing client experience to guide therapy toward what works.

Make it experiential. Experiential exercises are more effective than mere instruc-
tions about how to accept thoughts and feelings (McMullen et al., 2008).
Intellectual conversations about acceptance are rarely helpful in therapeutic con-
texts. Acceptance is more like riding a bicycle: it is learned through direct experi-
ence. 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 hap-
pened? Both of our minds really got going there.” Then return to something
experiential.

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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 tempta-
tion 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 some-
thing 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.

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To make this discrimination, it can be useful to think functionally by consid-

ering questions such as these:

• Is this a problem that is old, a part of the client’s history, and/or one for
which reasonable control and change efforts have largely failed (think
long term)?

• Is the outcome of control and change efforts one of expansion and

increased vitality and range of functioning, or not?

• Based on the client’s experience with the problem, would doing more of
the same offer any hope?

• If the client no longer pursued the struggle and control agenda, would
that open up new opportunities that are seemingly unavailable now?

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.

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