Beruflich Dokumente
Kultur Dokumente
JOHN C. WILLIAMS
VA Healthcare System, Long Beach
STEVEN JAY LYNN
State University of New York at Binghamton
ABSTRACT
Recognition of the value of acceptance of the self, others, and the flux
of human experience, has philosophical and religious roots that date back
thousands of years. The past two decades have witnessed a swell of interest in
acceptance, as evidenced by an increase in acceptance-based therapeutic
interventions, and a growing appreciation of the paradoxical nature of
acceptance and personal change and the role of experiential avoidance
in psychopathology. In this article we review historical and contemporary
descriptions and definitions of acceptance, measures of acceptance, the
relation between acceptance and change, and the role of acceptance in
psychopathology and psychotherapy. Our central objective is to delineate
a rich conceptual scheme that encompasses the diverse ways in which
acceptance has been explicated in classical and contemporary writings,
and to highlight the need for further validation of this useful and
popular construct.
The notion that acceptanceof oneself, other people, circumstances, and the
world at largecan be a force for personal change has deep roots in Eastern
and Western culture. The benefits of acceptance are described in religious
texts (e.g., Buddhist Sutras, Bhagavad Gita, New Testament, Tao Te Ching, Yoga
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2010, Baywood Publishing Co., Inc.
doi: 10.2190/IC.30.1.c
http://baywood.com
DEFINING ACCEPTANCE
The term acceptance has a number of definitions. The etymological root of
accept is the Latin acceptare, the Old French accepter, and finally the Middle
English accept used by Chaucer and Wyclif in the 14th century (Onions,
1966). To accept is to receive willingly or with approval, to take toward
(i.e., ac + capere) rather than cast away (p. 7). Four modern definitions (Brown,
1993; Merriam-Webster, 1993; Weiner & Simpson, 1991) bear directly on the
present discussion:
1. taking or receiving something, as a pleasure, a satisfaction of a claim, or a
duty;
2. favorable reception, regard, or approval;
3. assenting to or believing; and
4. acceptableness.
These four definitions are found in a number of branches of psychology.
For example, one branch of social psychology deals with individuals acceptance
of group norms in the form of conformity, compliance, identification, and internalization (e.g., Brown, 1936; Cialdini & Goldstein; 2004; Hollander, 1960; Kelman,
1958; Menzel, 1957; Sherif, 1936). In another branch, social acceptance refers
to the effects of being or not being accepted by others, such as parental acceptance
of children (e.g., Burchinal et al., 1957), peers acceptance of adolescents (e.g.,
Kuhlen & Lee, 1943), or societys acceptance of the disabled (e.g., Ladieu et al.,
1948), or mentally ill (e.g., Roman & Floyd, 1981).
In clinical psychological science, the treatment compliance literature employs
the term acceptance to describe the extent to which a mental health patient
is willing to comply with medical, psychiatric, or psychological interventions
(e.g., Baile & Engel, 1978; Demyttenaere, 1997; Hunter, 1942; Imber et al., 1956;
Scheel et al., 2004). Other uses of the term vary broadly, from specific disciplines,
such as design acceptance (e.g., Madni, 1988), job acceptance (Marozas &
May, 1980), and technology acceptance (e.g., Colvin & Goh, 2005), to broader
scientific issues relevant to all disciplines such as the acceptance of theories
(e.g., Chow, 1992), models (e.g., Lynn & Fite, 1998), techniques (e.g., Hudson
et al., 1998), and measures (e.g., Dahlstrom, 1992). Whereas all of these forms of
acceptance conform in one way or another to the definitions given above, they
may be distinct research areas or broad principles with little or no bearing on
the type of acceptance under consideration here. As such, they may be considered
beyond the boundaries of the construct discussed in this review.
Experiential Acceptance
A title/keyword search of acceptance in PsychINFO returns over 28,000
citations, a substantial proportion of which are not relevant to the present discussion. This may stem from the fact that the form of acceptance under consideration
Tolerance
Acceptance requires that a person tolerate experiences as they are given;
otherwise one simply pursues pleasure, flees pain, and becomes more caught up
in judging experiences than in having them. The Stoics (e.g., Marcus Aurelius,
trans. 1965; Epictetus, trans. 1950; Seneca, trans. 1920) valued the ability
to tolerate or willingly withstand experiences because it increases self-control,
detachment from emotion, and indifference to pleasure and pain. Epictetus suggested selecting the worst seat at a social gathering, such as one without shade,
in order to develop an indifference to the sun and heat. Similarly, an avoidance
of snakes might diminish if one were able to tolerate progressive contact, similar
to modern behavioral exposure methods. Because acceptance involves making
contact with reality just as it is in the moment, it is necessary, lest one lapse
into avoidance, to be able to remain present and aware even when the stimuli
available are less than desirable Accordingly, tolerance can be considered an
ability to remain present and experience whatever is occurring in the moment.
Note, however, that this ability is not equivalent to resignation or helplessness in
the face of the aversive. It is a choice, which does not preclude concurrent efforts
to change what is occurring. Tolerance can be built up or acquired through willing
exposure to a wide variety of experiences, or to specific troublesome stimuli. In
this sense, tolerance is something that can be practiced as well as acquired.
Willingness
If one wishes to escape from one experience or lose oneself in another, this is
often possible. Acceptance, therefore, is a choice. Epictetus (1950) wrote that
when one is invited to entertainment, one should take what one finds. That is,
one should choose to participate in a event, even if it is not exactly to ones taste.
For the Stoics, in fact, exercise of the will was paramount. Acceptance involves
a free choice. That said, willingness may well involve surrender or compliance,
so long as it is not coerced. Marcus Aurelius (1965) wrote, for example, that our
freedom is never compromised when we follow the direction of someone who
puts us right. The benefits that can accrue from allowing another person to
guide ones behavior are integral to a host of spiritual traditions. In Eastern
meditative practices, for example, one accepts the instructions of a master and
agrees neither to add nor subtract from his or her instructions. Similarly, Blaise
Pascal (trans. 1966) accepts the counsel of his spiritual director because he
considers the directives to be essential to his spiritual development. Whether
directed by another, or simply determined by what is present, acceptance includes
the willingness to have an experience.
Limitations
It is difficult to say which of these ancient concepts should be considered central
components of contemporary acceptance and which may be better accounted for
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nonavoidance) was potentially beneficial and that the opposite could lead to
neurotic symptoms and distress.
1920s and 1930s
In the 1920s and 1930s, the term acceptance sometimes was used to describe a
way of behaving or relating to stimuli that emphasized openness toward reality
rather than defensiveness, negation, or denial (Ferenczi, 1926; Penrose, 1927).
Whereas a lack of acceptance was associated with intrapsychic conflict and
pathology, acceptance of oneself and ones situation contributed to positive
outcomes in mental health, such as adjustment after a divorce (Waller, 1930),
treatment for alcoholism (Grant, 1929), or personality disturbance (Tidd, 1937).
As such, self-acceptance was discussed as a therapeutic goal in the context of
psychodynamic psychotherapy (e.g., Rank, 1945; Taft, 1933). Even in these early
years, some noted the potential difficulties associated with assessing acceptance
in individuals. Peck (1929), for example, raised the concern that a patient could
appear more defensive while actually growing in acceptance, which can be
contrasted with later investigations of the role of social desirability in the measurement of acceptance (Crowne & Stephens, 1961); in particular, that high selfreported self-acceptance in fact may reflect defensiveness or lack of insight
(Zuckerman & Monashkin, 1957). Early acceptance theorists also began to posit
a positive correlation between self-acceptance and acceptance of others (e.g.,
Adler, 1926; Fromm, 1939; Horney, 1937).
1940s
In the 1940s, acceptance figured in the study and treatment of military personnel
during and after World War II. Wilson (1942), for example, wrote that admitting
and accepting the experience of fear associated with air raids was a protective
factor against stress disorders among civilian populations. Rogers (1944a) and
his colleagues (Rogers & Wallen, 1946) noted a host of adjustment problems
faced by returning soldiers, including hostility, vocational uncertainty, marital
and family problems, and disabilities due to injuries. Among the major treatment recommendations was to facilitate the patients acceptance of the daunting
feelings engendered by the war and also by the transition back to civilian life.
Beyond military applications, Rogers (1940, 1943, 1944b, 1947) and others
(e.g., Snyder, 1947) began to place the development of self-acceptance in a
position of primary importance in the therapeutic process. Rogers wrote that a
client should admit his real self with its childish patterns, its aggressive feelings,
and its ambivalences, as well as its mature impulses, and rationalized exterior
(Rogers, 1940, p. 162). For Rogers, self-acceptance was the foundation of
insight (Rogers, 1940, p. 163). Moreover, the self in self-acceptance included
the acknowledgment and experiencing of the entirety of internal experience, not
simply an esteemed self-concept. Beyond the self, acceptance extended to external
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1959); and some expected associations were not found, such as therapists higher
in self-acceptance and acceptance of others were not rated as better therapists
by supervisors (Streitfeld, 1959).
1960s
In the 1960s, investigators continued to examine the relationships between
self-acceptance, acceptance of others, psychopathology, and other constructs.
Empirical investigations continued to find that self-acceptance and acceptance
of others were correlated, and that neither was correlated with acceptance by
others (Rubin, 1967; Suinn, 1961; Suinn & Hill, 1964; Williams, 1962). Some of
these studies broadened the validity of this relationship beyond self-report and
laboratory studies to experimental interactions with specific groups, such as the
mentally ill (Holzberg, Gewirtz, & Ebner, 1964), to specific others, such as a
childs parents (Medinnus & Curtis, 1963), and to naturalistic studies on college
campuses (Graham & Barr, 1967).
A number of predicted associations with additional constructs also were
examined. Several researchers found that acceptance and anxiety were negatively related (Ohnmacht & Muro, 1967; Pilisuk, 1963). Interestingly, Suinn
and Hill (1964) also found that that anxiety disrupted the relationship between
self-acceptance and acceptance of others: increased anxiety was associated with
greater decreases in self-acceptance than in acceptance of others. Berger (1961,
1963) found that willingness to accept limitations was associated with college
achievement, but the relationship seemed to hold for liberal arts students but not
engineering students. Other investigations failed to find some expected relationships, and in the process the nomological network (Cronbach & Meehl, 1955)
of acceptance became more specific. Among these relationships, self-acceptance:
a) did not predict performance under stress (Goldfarb, 1961); b) was not affected
by experimentally induced success and failure experiences (Solway & Fehr,
1969); and c) was not related to hypnotizibility (Vingoe, 1967). Also during
this period, a number of investigators began to question the validity of the selfacceptance construct and the instruments used to measure it.
1970s
In the 1970s, the positive correlation between self-acceptance and acceptance
of others continued to garner empirical support (e.g., Jucha, Rendecka, & Zuraw,
1979; Kawagishi, 1972). In addition, low self-acceptance continued to be associated with psychopathology (e.g., Guidano, Liotti, & Pancheri, 1971) and was
also found to be associated with an external rather than internal locus of control
(Chandler, 1976; Lombardo & Berzonsky, 1975). Notably, Shepard (1979) contributed a substantial multitrait-multimethod construct validation study examining
self-acceptance, acceptance of others, and self-description. He found that selfacceptance had moderate construct validity, was correlated as expected with
acceptance of others, had limited discriminant validity with respect to selfdescription, and was a sensible model for the evaluative component of the
self-concept construct (p. 139). Also of note, researchers began to describe
specific stimulus domains of acceptance beyond the general categories of self
and other. One prominent example was acceptance of physical disability. First
measured by Linkowski (1971), acceptance of disability subsequently became a
domain of study in the physical disability literature (e.g., Boone, Roessler, &
Cooper, 1978; Evers, Kraaimaat, van Lankveld, Jongen, Jacobs, & Bijlsma,
2001; Groomes & Leahy, 2002; Kravetz, Faust, & David, 2000; Osuji, 1985;
Starr & Heiserman, 1977).
1980s
By the 1980s, acceptance, particularly self-acceptance, had been established
as a useful variable in mental health theory and research, and newer lines of
research began to focus on applied issues, such as self-acceptance techniques
in various mental health disciplines (Baisden, Lindstrom, & Hector, 1982;
Brandel, 1982; Kornblum & Anderson, 1982; Rudnick, 1982), and with specific
populations (Kus, 1988; Leavy & Adams, 1986; Tenzer, 1989). Construct validation also continued apace, with further examination of self-acceptance and other
constructs (e.g., Epstein & Feist, 1988; Long, 1986). The self-other correlation
also continued to be examined, with more specific hypotheses, such as the finding that self-accepting men were more accepting of women in less traditional
professional roles (Grube, Kleinhesselink, & Kearney, 1982). In a somewhat
different vein, novel acceptance treatments began to emerge, such as Morita
therapy, distinguished by less emphasis on accepting the self and more on
accepting specific internal experiences (e.g., anxiety) as natural objects, for the
purpose of increasing adaptive behavior (Ishiyama, 1983, p. 172; Ishiyama, 1987).
1990s
The 1990s were notable for the concurrence of established lines of acceptance
research and the emergence of new models of acceptance theory and treatment,
most notably what we have termed experiential acceptance. The self-acceptance
literature continued along established lines. The validity of the self-other correlation continued to be studied (e.g., Hurley, 1989, 1991, 1993; Hurley,
Feintuch, & Mandell, 1991; Hurley & Rosenberg, 1990), as did the relationship
of self-acceptance to a variety of variables, such as: psychopathology (Richter,
Richter, Eisemann, & Seering, 1995), treatment outcomes (Lemberg, 1993;
Weissman & Appleton, 1995), behavioral effects (Pufal-Struzik, 1998), height
and intelligence (Rienzi, Scrams, & Uhles, 1992), culture and occupation
(Long, 1991; Long, & Martinez, 1994), disability (Fukunishi, Koyama, &
Tombimatsu, 1995; Smart & Smart, 1991), and quality of life (Rogers, 1995).
Ryff (1995) included self-acceptance as one of six facets of well-being in her
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relationship between acceptance and other constructs (e.g., Levy & Ebbeck,
2005; Lundh, 2004) on the integration of acceptance techniques into other
therapies (e.g., Callaghan, Gregg, Marx, Kohlenberg, & Gifford, 2004; Lynn,
Das, Hallquist, & Williams, 2006), and on the efficacy of acceptance-based
interventions (e.g., Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Wilson,
Gifford, Bissett, Piasecki, Batten, et al., 2004b; Lau & McMain, 2005; Longmore
& Worrell, 2007; Roemer & Orsillo, 2002; Telford, Kralik, & Koch, 2006). In
the following review, we discuss a number of conceptual and empirical components of a nascent theory of experiential acceptance: the benefits of acceptance;
the development of acceptance-based treatments; the role of nonacceptance in
psychopathology; the constructs of thought suppression, experiential avoidance,
and emotional nonacceptance; and the paradox of acceptance and change.
Benefits of Acceptance
Ellis and Robb (1994) consider unconditional self-acceptance as crucial to
solid emotional and behavioral health (p. 91). Linehan (1994) believes that
moment-by-moment acceptance of the self and others is an important part of any
self-management, interpersonal effectiveness, or emotion regulation program
(p. 75). Dryden (1987, 1998) includes self-acceptance, high frustration tolerance,
and acceptance of uncertainty among criteria for psychological health. Other
theorists and researchers (Hayes et al., 1994; also Bond & Bunce, 2003; Greenberg
& Safran, 1987) have included among the benefits of acceptance:
1.
2.
3.
4.
5.
6.
Meta-analyses (e.g., Baer, 2003) and qualitative research reviews (e.g., Shapiro
& Walsh, 2003) have documented the promise of acceptance and mindfulness
techniques across many indices of psychological functioning.
Empirically, the benefits of acceptance are often described in terms of decreased
symptoms associated with acceptance-based treatment. In addition to the studies
noted above, there are a number of excellent conceptual and empirical reviews
that discuss acceptance-based treatments (e.g., Baer, 2006; Baer & Huss, 2008;
Hayes, Follette, & Linehan, 2004c; Hayes et al., 2006; Orsillo & Roemer, 2005).
In addition to symptom reduction, the benefits of acceptance in the context of
mental illness can also be conceptualized in terms of other treatment goals that
may occur whether or not symptom reduction takes place. These include modified
beliefs about symptoms, decreased distress about symptoms, and willingness
to experience symptoms while expanding adaptive behavioral repertoires. For
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& Nilsson, 2004; Kabat-Zinn, 1982; Kabat-Zinn, Lipworth & Burney, 1985;
McCracken & Eccleston, 2006). Recently, a large-scale study of severely
depressed people found that behavioral activation, an approach that stresses
accepting depressed feelings while actively engaging in social and occupational activities, proved to be superior to a purely cognitive treatment of
depression, and equal in effectiveness to pharmacological treatment (Dimidjian,
Hollon, Dobson, Schmaling, Kohlenberg, Addis, et al., 2006; Dobson, Hollon,
Dimidjian, Schmaling, Kohlenberg, Gallop, et al., 2008). Acceptance-based
approaches have also been successfully integrated into alcohol relapse prevention programs (e.g., Marlatt, 2002), and theory suggests that they may have
value in combination with hypnotic procedures (Lynn et al., 2006), in enhancing
athletic performance (Gardner & Moore, 2004), and in suicide prevention
(Williams & Swales, 2004). Nevertheless, it is not yet clear which aspects of
these programs (e.g., exposure, enhanced expectancy, acceptance) are implicated
in therapeutic changes.
Acceptance and Psychopathology
Conceptually, a corollary of the beneficial aspects of acceptance is that nonacceptance is associated with psychopathology. Although nonacceptance can
be a problematic term because it lacks specificity, in that it may refer to a host of
constructs that could be considered opposite to acceptance, such as denial, escape,
prejudice, avoidance, and noncompliance, it is sometimes used to describe low
levels of acceptance across a variety of behavioral and experiential domains.
Ellis and Robb (1994), for example, have noted that people experience anxiety
and depression when they do not accept themselves, others, and frustrating
circumstances. Similarly, low experiential acceptance has been conceptualized
as a contributing to or maintaining psychopathology (e.g., Hayes et al., 2004d;
Strosahl, Hayes, Wilson, & Gifford, 2004). This contention finds descriptive
support in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV;
American Psychiatric Association, 1994), insofar as avoidance, a form of
nonacceptance, is specified among the diagnostic criteria of mental disorders,
including avoidant personality disorder, obsessive-compulsive disorder, phobia,
posttraumatic stress disorder, and substance dependence. Analogously, attachmenta dimension of nonacceptance defined as a maladaptive attention to or
pursuit of certain stimuli over othersis described indirectly in the DSM-IV in
the form of preoccupations of one sort or another, as in body dysmorphic disorder;
hypochondriasis; eating disorders; pathological gambling; schizophrenia,
paranoid type; and narcissistic, obsessive-compulsive, and paranoid personality
disorders. From a behavioral perspective, Skinner (1972) suggested that the
time and energy consumed in the avoidance of punishment could be freed up
for more reinforcing activities (p. 76).
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1988). Thus, experiential avoidance may be a candidate for an organizing construct, though Chawla and Ostafin (2007) caution that it lacks theoretical integration and incremental validity relative to other constructs. Like thought suppression, avoidance is not only maladaptive, but also invokes ironic or paradoxical
processes (e.g., Hayes et al., 1999). For example, not only does avoidance
predispose or contribute to a variety of clinical syndromes, including depression
(see MacLeod, Bjork, & Bjork, 2003; Teasdale, Segal, & Williams, 1995)
and anxiety (Amir, Coles, Brigidi, & Foa, 2001), but the process of inhibiting
thoughts, feelings, memories, and other internal events increases the probability
that those very events will recur (Hayes & Wilson, 2003; Polivy & Herman,
1987; Strauss, Doyle, & Kreipe, 1994; Wegner et al., 1987). Both thought
suppression and experiential avoidance thus appear to be associated with a
rebound of unwanted content into consciousness.
Emotional Nonacceptance
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may be distinct but overlapping. Another difficulty is that mindfulness can refer to
a theoretical construct, a psychological process, and a set of practices (Germer,
2005), which may increase the complexity of differentiating it from acceptance.
ADDITIONAL FACETS OF EXPERIENTIAL
ACCEPTANCE
In this section we describe hypothesized facets of experiential acceptance
evident in both contemporary and ancient literature which remain as yet largely
speculative due to a lack of empirical scrutiny. Whenever possible, we have
chosen to call these facets by the names given to them in the psychological
literature. Where this is not possible or expedient, we have attempted to present
each facet in a way that is reasonably coherent and faithful to a sometimes diffuse
literature. We approach this task as descriptive rather than definitive. Our hope is
that these considerations will contribute to the development of testable hypotheses
to validate experiential acceptance more thoroughly.
Awareness
McCurry and Schmidt (1994) and others (e.g., Kohlenberg, 1994; Linehan,
1994; Marlatt, 1994) have observed that awareness is basic to the acceptance
process (p. 242); in order to accept a stimulus, one first must be aware of it.
Experiential acceptance may involve an ability to observe any internal or external
stimulus as it is occurring, in contrast to avoidance (Hayes, 1994), suppression
(Wegner, 1989), or denial (Linehan, 1994), or it may simply mean remaining
fully present with whatever stimuli are available (Gifford, 1994, p. 220).
Awareness is an area in which mindfulness and acceptance may overlap, in
that mindfulness implies directed attention (Kabat-Zinn, 1990). Mindfulness has
been described in fact as an aware non-attached state of mental acceptance
(Marlatt, 1994), and may also overlap with experiential acceptance because
it requires attention without evaluation, judgment, avoidance, or attachment
toward any stimulus.
Nonattachment
The most basic definition of nonattachment in experiential acceptance may
be letting go (e.g., Beattie, 1990), which means to release ones attachment
to internal or external stimuli (Koerner, Jacobson, & Christensen, 1994). Some
classes of stimuli that have been discussed in terms of attachment and experiential acceptance include the effects of drugs or alcohol (Marlatt, 1994), ones
personal goals (Ellis & Robb, 1994), or the results of ones efforts (Martell,
Addis, & Dimidjian, 2004; Suzuki, 1973). Nonattachment can also be described
in terms of constructs such as decentering (Segal et al., 2002, p. 41),
metacognitive awareness (Teasdale et al., 2002), metacognitive experiencing
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(Wells, 2000), and self as context (Strosahl et al., 2004, p. 44). Nonattachment
in these constructs involves the simultaneous observation of internal or external
events as they are experienced. For example, if one has the thought I am bad,
a nonattached perspective would include an observation such as I am having
a thought that I am bad, as opposed to an attached perspective, unable to distinguish the thought from reality.
Another aspect of nonattachment is behavioralone may accept the experience of impulses to act (e.g., to pursue or avoid stimuli) without acting on
them, sometimes called nondoing (Kabat-Zinn, 1994). Nondoing can be used
to distinguish nonattachment and nonavoidance, in terms of the function of a
behavior. For an alcoholic, acceptance of an urge to drink may involve not walking
into a bar. For a socially phobic person, however, acceptance of an impulse to
avoid socializing may involve walking into the same bar. The behaviors are
topographically opposite, but functionally similar: both represent nonattachment
to private urges. Another way of considering the relationship between attachment
and avoidance is that avoidance tends to be negatively reinforced through the
removal of an aversive stimulus, whereas attachment tends to be positively
reinforced through the addition or maintenance of an appetitive stimulus.
Nonjudgment
Nonjudgment is central to modern conceptualizations of acceptance (e.g.,
Cordova & Kohlenberg, 1994, Germer, 2005; Hayes, 2004a; Hayes & Wilson,
2003; Peterson, 1994) as well as mindfulness (Baer et al., 2006; Dimidjian &
Linehan, 2003; Kabat-Zinn, 1994; Kohlenberg, 1994; Linehan, 1993a). Nonjudgment is a conscious abstention from categorizing experience as good or bad
(Cordova & Kohlenberg, 1994), or right or wrong (Hayes, 1994; Linehan, 1994),
such as anxiety is bad. Nonjudgment is included in a number of cognitivebehavioral therapies that employ mindfulness and acceptance (e.g., ACT, DBT,
MBCT), as well as older therapies such as Rational Emotive Behavior Therapy
(REBT; David, Lynn, & Ellis, 2009; Ellis & Dryden, 1997). According to REBT,
beliefs mediate the emotional consequence of an activating event, and to that
extent judgments determine experience. Highly negative evaluation of internal
or external events has been characterized as awfulizing and catastrophizing,
which may potentiate anxiety and depression (Beck, Emery, & Greenberg,
1996; Ellis & Robb, 1994), and the expectation of negative events or their
continuing without relief can have serious negative consequences (see Abramson,
Alloy, & Hogan, 1997; Kirsch & Lynn, 1995). Nonjudgment in experiential
acceptance involves actively processing stimuli according to their descriptive
or concrete properties rather than evaluating them.
Radical Acceptance
Some theorists use the term radical acceptance to describe a Zen-like state of
acceptance, consisting of a thorough willingness to experience whatever is taking
place in the moment (e.g., Brach, 2003; Linehan, 1994). Radical acceptance
may be the positive extreme of experiential acceptance, in which, according to
Linehan (1994), one experiences total allowance now, and a constant accepting
in each successive moment (p. 80). As noted above, in the classical literature
acceptance is associated with wisdom and enlightenment, which can be profound and paradoxical. In a similar vein, some modern authors (e.g., Robbins,
Schmidt, & Linehan, 2004) have noted paradoxical effects of radical acceptance.
Fruzzetti and Iverson (2004) hold that by radically accepting a stimulus one has
experienced as negative, the valence of the stimulus may be reversed so that
it not only loses its aversive quality but acquires appetitive properties. It is
possible to imagine, for example, a person who is phobic of snakes subsequently
coming to own and enjoy them.
Tolerance
Whether tolerance should be considered an aspect of acceptance has been the
subject of some debate. For example, Fruzzetti and Iverson (2004) describe
acceptance as inclusive of simple tolerance (p. 177), but Hayes and colleagues
(2004a) assert that acceptance should not be equated with tolerance or resignation.
Some authors, such as Linehan (1994) and McCurry (1994), take issue with the
word tolerance itself, based on its association with stoical austerity, though Ellis
and Robb (1994) note, in fact, that elements of stoic philosophy were key
ingredients in the development of Rational Emotive Behavior Therapy. Tolerance
need not connote helpless resignation, as its etymological roots can be found in a
variety of verbs such as endure, permit, allow, indulge, bear, and carry (Onions,
1966, p. 929).
These roots contribute to three modern denotations of tolerance (Weiner &
Simpson, 1991, p. 2075) . First, as an ability to endure pain or hardship, acceptance
may include an ability to tolerate emotional distress (e.g., Afari, 1994; Cordova
& Kohlenberg, 1994; Fruzzetti & Iverson, 2004; Linehan, 1994; Wulfert, 1994),
especially when such tolerance takes the place of maladaptive behaviors or in
the service of ones values (Hayes & Strosahl, 2004). Tolerance can represent an
ability to endure the moment, even if the moment is unpleasant and one intends to
improve it. Second, as a disposition to be patient with the opinions or practices of
others, including a freedom from bigotry or undue severity in judging others,
tolerance is consistent with acceptance of others (e.g., Ellis & Robb, 1994; Fruzzetti
& Iverson, 2004; Gandhi, 1999; Greenberg, 1994; Linehan, 1994). Third, tolerance
is consistent with behavioral principles, such as habituation, an acquired ability to
experience a stimulus based on repeated exposure, and exposure therapy (e.g.,
McAllister & McAllister, 1995; ODonohue & Krasner, 1995), in which repeated
contact with a stimulus results in a decrease in arousal and an expansion of the
behavioral repertoire. Tolerance then may be built up toward specific stimuli,
such as ones own emotions or the situations that engender them. Altogether, these
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External stimuli associated with acceptance have been defined mainly with
respect to two types of stimuli: other people and situations. Together, internal and
external acceptance would appear to cover most domains of experience. Within
the domains of internal and external, however, there are more possible classes of
stimuli beyond the five sub-domains listed here (e.g., pain is a specific stimulus
domain associated with unique treatment paradigms and measurement instruments within the acceptance literature).
Measurement of Acceptance
Classic Self-Acceptance Scales of the 1950s
Scales designed to measure acceptance have developed over the years along
with emerging conceptualizations of the construct. Early measures of acceptance
were developed in the 1950s based on contemporary conceptualizations of selfacceptance and acceptance of others, drawing on theorists such as Adler, Ellis,
Horney, Fromm, Perls, Rogers, and Sullivan. In general, acceptance in these
measures was operationalized as a positive attitude toward the self and others.
Although at least eight acceptance measures were developed in the 1950s (see
Crowne & Stephens, 1961), only four were used widely: Bergers (1952)
Expressed Acceptance of Self and Others Scale, Bills (1958; Bills, Vance, &
McLean, 1951) Index of Adjustment and Values, Feys (1954) Acceptance of
Self and Others Scale, and Phillips (1951) Self-Others Questionnaire, each
of which accumulated some degree of reliability and validity data (Fey, 1955;
Omwake, 1954; Sheerer, 1949). These measures were used in studies supportive
of a number of hypotheses about acceptance, including the prediction that selfacceptance and acceptance of others were positively correlated, that acceptance
was negatively correlated with psychopathology, and that measures of acceptance
tended to converge on a single construct.
Within a decade of the development of these measures, however, a number of
investigators began to question the validity of the self-acceptance construct and
the instruments used to measure it, on conceptual and methodological grounds.
The major criticisms were that the construct was poorly defined, varying substantially across researchers and theorists, and that the instruments were conceptually unsound, poorly constructed, and confounded with social desirability
(e.g., Block & Thomas, 1955; Crowne & Marlowe, 1964; Crowne & Stephens,
1961; Kinkler & Myers; 1963; Stone, 1964). Although only a few acceptance
scales were used much beyond the studies in which they were developedthe
rest being constructed for a specific research purpose and never again cited
the critics of acceptance measures tended to review them together. Some scales,
however, received relatively more validation over time than others.
Bergers (1952) scale has received the widest use and most thorough validation. Composed of 64 items (36 self-acceptance and 28 acceptance of others),
29
the inclusion of multiple acceptance-related scales, and the intentional differentiation between self-acceptance and self-regard. That said, although the selfregard and self-acceptance scales generally correlate in the .20 range (Shostrom,
1973), Shepard (1979) was unable to distinguish the two scales at the item
level, and other studies have suggested that fewer dimensions overall may be
more parsimonious (e.g., Klavetter & Mogar, 1967). Further, although the selfacceptance and self-regard scales were used in the major construct validation of
the self-acceptance construct to date (Shepard, 1979), few studies have reported
the reliability and validity of the self-acceptance subscale alone.
California Psychological Inventory (CPI; Gough, 1957, 1987)The CPI is a
434-item assessment of normal personality (Gough, 1957; Gough & Bradley,
1996). A 260-item shorter version is also available. The CPI has a research
base of approximately 2,000 citations, and is based on a normative sample of
6,000 men and women (see Gough & Bradley, 1996). The CPI includes 29
subscales. The Self-Acceptance subscale measures sense of personal worth,
self-acceptance, and capacity for independent thinking and action; being secure
with and sure of oneself (Megargee, 1972, p. 67). The CPI also includes a
Tolerance subscale, which measures permissive, accepting, and nonjudgmental
social beliefs and attitudes (p. 91). Like the POI, a major strength of the CPI is
its established reliability and validity. Also like the POI, however, the body of
research supportive of the CPI relates to the scale as a whole rather than individual
subscales. Although the CPI has been used in a number of acceptance studies
(e.g., Ganter, 1962; Greene, Baucom, & Macon, 1980), few studies have reported
reliability and validity data for the self-acceptance subscale, with the exception
of Vingoe (1968). Additionally, factor analytic studies generally have not found
structural evidence of a self-acceptance factor (Crites, Bechtoldt, Goodstein,
& Heilbrun, 1961; Mitchell & Pierce-Jones, 1960; Nichols & Schnell, 1963;
Pumroy, 1962; Springob & Struening, 1964).
Scales of Psychological Well-Being (SPW; Ryff, 1995)The SPW is an 84-item
scale of psychological well-being composed of six 14-item scales constructed to
measure the dimensions of autonomy, environmental mastery, personal growth,
positive relations with others, purpose in life, and self-acceptance. The reliability
and validity of the SPW were demonstrated in the original development studies
and follow-up appraisals (e.g., Ryff, 1989, 1995; Ryff & Keyes, 1995; Ryff
& Singer, 2006). Self-acceptance is included among those dimensions that
encompass a breadth of wellness that includes positive evaluations of oneself
and ones past life (Ryff, 1995, p. 720). The Self-Acceptance scale is operationalized as follows. A high scorer possesses a positive attitude toward the self;
acknowledges and accepts multiple aspects of self, including good and bad
qualities; feels positive about past life (p. 727). Measures of happiness show
modest to strong associations with the Self-Acceptance scale (Ryff, 1995).
Based on the validation of its six-factor model, the SPW may be considered a
31
A variety of new instruments have been developed that operationalize experiential acceptance. The AAQ (Hayes et al., 2004a) was developed to measure
acceptance, operationalized primarily as experiential avoidance. It was validated
initially on 10 samples collected during separate investigations of experiential
avoidance. A 32-item version of the scale was developed using an item pool based
on the theory of experiential avoidance employed in ACT, in which experiential
avoidance was defined as the phenomenon that occurs when a person is unwilling
to remain in contact with particular private experiences . . . and takes steps to
alter the form or frequency of these experiences and the contexts that occasion
them, even when these forms of avoidance cause behavioral harm (p. 554). The
AAQ has a substantial research base, having been used in at least 70 studies
investigating the role of experiential acceptance in clinical disorders, such as
anxiety (e.g., Tull & Roemer, 2007), depression, (e.g., Cribb, Moulds, & Carter,
2006), and personality (e.g., Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006),
as well as general psychological vulnerability (e.g., Kashdan, Barrios, Forsyth,
& Steger, 2006), well-being (e.g., Kashdan & Breen, 2007), job performance
(e.g., Bond & Flaxman, 2006), and pain tolerance (Feldner, Hekmat, Zvolensky,
Vowles, Secrist, & Leen-Feldner, 2006). The AAQ has also been instrumental
in the development of other scales (e.g., Baer et al., 2004; Gratz & Roemer,
2004; McCracken, Vowles, & Eccleston, 2004).
A number of versions of the scale are in use at present, with 9, 10, and 16 items,
as well as the initial 49-item pool, sometimes used in factor analytic studies
(R. Baer, personal communication, 2006). The AAQ is generally considered
to be composed of one general factor of experiential avoidance, or conversely
experiential acceptance with reverse coding (e.g., Hayes et al., 2004a). That
said, the AAQ appears to operationalize, in adition to nonavoidance of aversive
stimuli, facets reflecting willingness to experience unpleasant emotions and a
capacity for productive action in the face of those stimuli and emotions.
The AAQ may be considered the current gold standard measure of experiential
acceptance. Nevertheless, the factor structure has not yet been resolved, due in
part to the fact that there are a number of versions of the AAQ in use. Additionally,
the internal consistency has not always been optimal. These issues, however,
may be resolved when the revised AAQ (AAQ-R) is published. Although the
factor structure may include dimensions associated with willingness and action,
the AAQ was constructed to measure experiential avoidance, and may therefore
measure only one dimension of acceptance.
In addition to the AAQ, there are a number of other measures that have
been used to measure and validate various types of avoidance, including: the
Cognitive-Behavioral Avoidance Scale (CBAS; Ottenbreit & Dobson, 2004),
which measures avoidance across several dimensions, including cognitive versus
behavioral avoidance, active versus passive avoidance, and social versus nonsocial avoidance; the White Bear Suppression Inventory (WBSI; Wegner &
Zanakos, 1994), which measures the tendency to suppress unwanted thoughts;
the Thought Control Questionnaire (TCQ; Wells & Davies, 1994), which
measures the specific strategies used to control unpleasant or unwanted thoughts;
and the Escape-Avoidance subscale of the Ways of Coping Questionnaire (WCQ;
Folkman & Lazarus, 1988), which measures coping characterized by escape
and avoidance, such as wishing a situation would go away, or by eating, drinking,
smoking, or using drugs to feel better. The CBAS, WBSI, TCQ, and WCQ
represent some of the core instruments that have been used to operationalize
and validate the construct of avoidance, and have also shown moderate correlations with the AAQ.
Experiential Acceptance Subscales in
Multidimensional Measures
33
In the past decade, a number of measures have been developed to assess mindful
awareness. These measures differ somewhat in their operationalization and use.
For example, the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al.,
2004) is based on mindfulness skills taught in Dialectical Behavior Therapy
(DBT; Linehan, 1994) and was designed to measure mindfulness in the
general population. In contrast, the Freiburg Mindfulness Inventory (FMI;
Walach, Buchheld, Buttenmller, Kleinknecht, & Schmidt, 2006) is based on
Vipassana principles and was designed to measures changes in mindfulness
in meditators over the course an ongoing practice. Similarly, the Toronto
Mindfulness Scale (TMS; Lau et al., 2006) was designed as a state measure
of mindfulness, for use immediately following a meditation session. The
Cognitive and Affective Mindfulness ScaleRevised (CMS-R; Feldman, Hayes,
Kumar, Greeson, & Laurenceau, 2007), based on contemporary mindfulness
theory, is a multi-dimensional scale that appears to measure changes in
mindfulness over the course of psychotherapy. In contrast, the Mindful Awareness
and Attention Scale (MAAS; Brown & Ryan, 2003) and Mindfulness Questionnaire (MQ; Chadwick, Hember, Mead, Lilley, & Dagnan, 2005; see Baer et al.,
2006) assess single dimensions of mindfulness, respectively, present attention and
awareness, and a mindful approach to distressing thoughts and images. Other
35
wisdom, morality, and mindfulness. Both the EQ and NAS are new scales, but
with further validation each may be a useful addition to the complement of
measures available to validate the structure of experiential acceptance.
Distress tolerance is a common construct in the affect dysregulation literature,
and the Distress Tolerance Scale (DTS; Simons & Gaher, 2005) assesses the
capacity to experience and withstand negative psychological states (p. 83).
The DTS fits a single factor model in the initial validation study, though it was
developed to address four domains: tolerance of emotional distress, subjective
appraisal of distress, absorption in negative emotion, and attempts at regulation.
The DTS may also be a useful measure in the validation of acceptance.
CONCLUSIONS AND FUTURE DIRECTIONS
Our survey has revealed that the term acceptance has been established across
a wide range of disciplines, and that even within clinical science it has been
conceptualized broadly. Self-acceptance has been considered a component of
psychological health since it was first described a century ago, and this contention
has found support in subsequent empirical investigation. For example, higher
self-acceptance is associated with lower levels of psychopathology, validated with
host of studies using multiple methods measuring a spectrum of psychopathology.
Additionally, self-acceptance correlates positively with measures of adjustment,
well-being, satisfying interpersonal relationships, affect regulation, and other
correlates of mental health. Another well established relation is the positive
correlation between self-acceptance and acceptance of others (note, however, that
being self-accepting does not correlate with being accepted by others). One area of
further study includes examining the divergence of self-acceptance definitions:
some conceptualizations and measurement instruments are closer to
nonjudgmental self-awareness, others to unconditional positive self-regard, and
still others to self-esteem.
Experiential acceptance appears to be negatively related to psychopathology,
and constructs integral to the development and maintenance of psychopathology
(e.g., thought suppression, experiential avoidance, and emotional nonacceptance)
can be defined more generally as nonacceptance. In addition, experiential
acceptance appears to be positively related to emotional regulation, frustration tolerance, well-being, and other indicators of mental health. Accordingly,
acceptance-based interventions have been efficacious in treating a wide range of
problems (e.g., mental disorders, marital discord, pain syndromes), and specific
interventions have been developed for a growing number of conditions and
populations. Treatment packages, such as ACT and DBT, have a substantial
base of efficacy research and often serve as the model upon which the more
targeted interventions are based. Nevertheless, additional trials are necessary
to evaluate the role of exposure as well as placebo and nonspecific effects in
these treatments.
Our review has raised important issues related to the construct validity of
experiential acceptance, which may be of interest as areas for future research.
The first issue relates to content validity. Classical, modern, and contemporary
conceptualizations vary in the inclusion, exclusion, and emphasis of the hypothesized facets we have described (e.g., nonavoidance, nonjudgment, selfacceptance), and acceptance measures differ in the way the construct is operationalized. Relatedly, the structural validity of acceptance also remains to be
investigated. Indeed, no single measure captures acceptance as broadly as it has
been explicated in the literature.
The second issue relates to convergent validity. It is not clear, for example,
whether contemporary conceptualizations of acceptance are distinct from earlier
notions of self and other acceptance. Although they appear to diverge theoretically
(e.g., positive self-regard vs. nonavoidance), this has not been investigated.
Relatedly, there are a growing number of new acceptance measures; however,
the extent to which they converge on a single construct or show incremental
validity with respect to existing measures remains to be determined.
The third question relates to discriminant validity. It is difficult to disambiguate
experiential acceptance from other constructs, particularly mindfulness, although
the structural validity of mindfulness has received the most attention (e.g., Baer,
Smith, & Allen, 2004; Baer, et al., 2006). Thus it is difficult to say, for example,
which facets of acceptance reviewed belong to which construct, or if there may
be a unifying construct present. Moreover, although mindfulness and acceptance
can be cultivated, there may be significant innate differences among people
that vary in terms of temperament and attentional style. The genesis of individual
differences, including why some people are more tolerant of painful emotions
than others, remains largely unexplored. More refined and inclusive measures
of acceptance will help investigators to address the nature, extent, and determinants of individual differences, and assist researchers in addressing the
following questions related to psychotherapy and personal change: Do some
dimensions of acceptance account for more robust changes than other dimensions across diverse psychotherapies? Are some aspects of acceptance (e.g.,
self-acceptance) non-specific ingredients of effective psychotherapy, or do some
dimensions of acceptance produce more specific or perdurable treatment effects?
And, finally, how can we strive for goals while maintaining a present-centered,
accepting mindset?
We have much to learn about the flip-side of acceptancenonacceptance; in
particular, its relationship with psychopathology through escape from experiences, and the resulting negative effects through ironic processes. An important
question is whether the causal arrow points in the other direction, such that
psychopathology engenders a lack of acceptance of self and others, attempts to
suppress distressing emotions, and a failure to attend to moment-to-moment
experience. In all likelihood, there is a recursive relation between psychopathology and acceptance, although this has yet to be established. The question of the
37
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