Accepting Acceptance

And when the night is cloudy, there is still a light that shines on me, / shine until tomorrow, let it be.
—John Lennon/Paul McCartney

Many years ago, a wise and steady religion professor handed a compulsive and driven undergraduate student a sermon by the liberal Protestant theologian Paul Tillich and advised her to read it as an antidote to the perfectionism that was causing her such unhappiness. The title of the sermon was actually "You Are Accepted" but I have always remembered it as "Accepting Acceptance"—a subconscious insight into the true nature of my own struggle. The sermon explores the psychological and theological meaning of sin and grace but is relevant for mental health care professionals shorn of any religious context or connotation. The 2 major points of the sermon are expressed in the following passage:

Grace strikes us when we are in great pain and restlessness. It strikes us when we walk through the dark valley of a meaningless and empty life. . . . It strikes us when our disgust for our own indifference, our weakness, our hostility, and our lack of direction and composure have become intolerable to us. It strikes us when, year after year, the longed-for perfection of life does not appear, when the old compulsions reign within us as they have for decades, when despair destroys all joy and courage. Sometimes in that moment a wave of light breaks into our darkness, and it is as though a voice were saying, "You are accepted. You are accepted, accepted by that which is greater than you and the name of which you do not know. Do not try to do anything now; perhaps later you will do much. Do not seek for anything; do not perform anything; do not intend anything. Simply accept the fact that you are accepted."¹

Lest anyone think this is a foray into subjective spirituality with no parallel in evidence-based psychiatry, consider that acceptance of dysregulated emotion is an essential aspect of Linehan's dialectical behavior therapy, which has been empirically validated as perhaps the only successful treatment for borderline personality disorder.² Acceptance is also one of the guiding values of 12-step programs, the path to freedom for thousands imprisoned in addiction.³ Acceptance of pain, in the sense of searching not for a cure but for improved functioning, has been shown to be associated with greater well-being and a return to normal activity among chronic pain patients.⁴ The effectiveness of the mindfulness meditation approach of Kabat-Zinn has been demonstrated widely from anxiety to immune function.^5,6 Developing one's awareness and acceptance of symptoms in mindfulness is an initial step to discovering wider possibilities for healing.

The existential and humanist schools of psychology, and the Buddhist philosophy and practice that partially inspired them, shared the axiom that paradoxically, change can only begin with acceptance understood as the antonym of acquiescence.⁷ Eating disorders with their black and white paradigms of "shoulds" respond more successfully to improvements in self-acceptance than to focus on calories and weight, which may only strengthen the obsession with food.⁸ Finally, even seriously mentally ill patients who are able to accept their diagnosis, not in the pejorative sense of labeling theory but in the adoption of an internal locus of control, have improved functioning and outcomes.⁹

Once reflected on, the concept of acceptance has multifarious implications for modern mental health care. My own work with patients and trainees has convinced me of the significance of acceptance, and I want to illustrate a few examples that may move readers to recognize similar echoes in their own practice. These encounters can be divided into 3 broad categories of failures to accept acceptance as a therapeutic tool: (1) patient self-acceptance, (2) clinician acceptance of patients, and (3) clinician acceptance of self and other.

Patient self-acceptance
Recently I saw a patient, Mr J, referred to my consultation clinic for refractory depression. Mr J was a minister in his 70s with a long list of chronic medical problems and an even longer list of potent medications prescribed to manage the symptoms of these illnesses. He insisted that his antidepressant—an SSRI at a therapeutic dose—was not working because he "could not do what he used to do." When I asked Mr J to clarify what kinds of activities he was no longer able to pursue, he responded, "I used to be able to keep the church's whole fleet of cars going and also spend days in the mission field." He had been taking a number of other reasonable agents, which he also claimed "did not get rid of my anxiety about not being what I used to be."