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Essential Secrets of Psychotherapy : Change or Acceptance?

What is the ultimate goal of psychotherapy?

Let's start with a simple word association experiment: When you think about psychotherapy, what is the first word that comes to mind to describe what therapy is all about? Take a few seconds. Got it? For many of you, my guess is that one, if not the very first, of those words was change. But what if I were to tell you that psychotherapy is really at least as much about acceptance as change?

When Sigmund Freud made the oft-cited and misunderstood statement that the purpose of psychoanalysis is to "transform neurotic misery into common unhappiness," he was speaking of change. But how is even such seemingly modest change accomplished in therapy? So much of the changes that happen in psychotherapy parallel a gradual process of acceptance: acceptance of life as it truly is, as opposed to the way we wish it to be. Acceptance of past childhood trauma and its pervasive unconscious influence in the present. Acceptance of ourselves for who we are, rather than who we are not. Freud's off-the-cuff comment may seem cynical. But when seen in the light of his own personal suffering from oral cancer during the final fifteen years of his life, and how he stoically faced that terrible fate, it is a mature and sober commentary on the absolute necessity of acceptance. Rather than reflecting his profound pessimism about the human condition, as many mistakenly conclude, Freud's remark recognizes deeply and personally the need for courageous acceptance of physical and emotional suffering, and the high price we pay for trying to avoid or deny life's tragic aspect.

The concept of acceptance is especially prominent in Eastern philosophy and religion, as well as in Christianity and other great religious systems. Nowhere, for example, in religious literature is this spiritual principle of accepting life's suffering more dramatically, movingly and elegantly depicted than in the archetypal image of the Crucifixion. Acceptance is key to spiritual enlightenment, as illustrated repeatedly in timeless texts like the Old Testament's Book of Job, the Hindu Bhagavad Gita, the noble teachings of Siddhartha Gautama (Buddha), and the Tao Te Ching. But even Buddhists, Hindus, Taoists and other spiritual seekers sometimes lose sight of the primacy of acceptance. Consider this complaint of one frustrated Buddhist meditation practitioner: "I've been meditating for thirty years--and I'm still angry!" He seeks to eradicate rather than accept his anger--and this is precisely what needs to change.

Drawing implicitly from these wisdom teachings of the East, clinical psychologist Dr. Marsha Linehan (University of Washington) incorporates this paradox or "dialectic" of change vs. acceptance in her increasingly popular Dialectical Behavior Therapy (DBT). DBT is a highly-structured form of Cognitive-Behavioral Therapy (CBT) with a distinctive spiritual or philosophical component. Specializing in the treatment of borderline personality disorder, Linehan recognizes the need in working with these challenging patients for teaching what she refers to as "radical acceptance"-- right alongside the necessity to change their distorted cognitions and self-destructive behavior. "Radical acceptance" is the tolerant embracing of how and who one is here and now, juxtaposed with acknowledging the necessity for change and growth. To support such self-acceptance, Linehan also integrates mindfulness and meditation principles into her treatment approach. Linehan (1993) makes the following five fundamental points regarding "radical acceptance":

Acceptance is acknowledgment of what is.Acceptance is non-judgmental, not a matter of deeming something good or okay.Freedom from suffering requires accepting rather than resisting reality.Choosing to tolerate pain or distress in the moment is acceptance.Accepting rather than avoiding painful emotions actually alleviates suffering.

Dr. Linehan's emphasis on the dialectical relationship between change and acceptance in treatment is an excellent example of what needs to happen in any truly effective psychotherapy. To begin with, there are certain things in life that cannot be changed, and some that can be--albeit often only with sustained effort. This recognition is reflected in the famous serenity prayer of Alcoholics Anonymous: "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." Also inherent in the AA approach is the requirement to accept one's utter powerlessness over alcohol (or other substances or addictive behaviors) as a prerequisite for change. The problem must be unequivocally accepted before it can be changed.

Basically what must change is our refusal to accept ourselves and others as we and they are right now. This is a true paradox. When people first come for psychotherapy, they frequently hope to change themselves and/or others in ways that are simply not possible. But, by definition, wanting to change something or someone implies there is something wrong-- some insufficiency, inadequacy, flaw, weakness, inferiority--an inherent imperfection that needs changing. Many patients hold beliefs of being unlovable and unworthy of love as they are. What is lacking is the ability to unconditionally accept themselves just as they are in this moment, despite their human imperfection. (See my previous post on the "inner child.") At the very same time, certain changes must clearly be made. Changes in self-defeating perceptions, attitudes, old myths of oneself, life-style, and other destructive behavior patterns. But the paradox is that sometimes it is only through acceptance of what Carl Jung called the shadow that such changes can happen.

The acceptance of life on its own terms--the inevitability of suffering, the vagaries of fate, the tragic quality of existence, the reality of evil, impermanence, loss, illness, aloneness, insecurity, finitude, aging and death--is as essential as any behavioral or psychodynamic technique, pharmacological intervention or cognitive restructuring designed to directly change or "fix" the troubled patient.(See my previous post on The Trauma of Evil.) Accepting our own neurotic tendencies, resistances, defense mechanisms (see previous post), complexes, biology, temperament, typology ( see previous post), feelings, thoughts, impulses, shortcomings, idiosyncrasies--and our innate capacity for destructiveness along with our strengths, talents and creative potentialities (the daimonic)-- is in itself a major therapeutic change for the discouraged, guilt-ridden, self-loathing, hyper-moralistic, narcissistic, repressed, dissociated or perfectionistic patient. Indeed, acceptance--of oneself, one's emotions, thoughts, behavior, problems, and one‘s proportionate responsibility for them--is precisely the kind of philosophical or spiritual reorientation required in psychotherapy for any real and lasting change to occur. And much of that enduring change adds up to acceptance.

This is an excerpt from Dr. Diamond's forthcoming book Psychotherapy for the Soul: Thirty-Three Essential Secrets for Emotional and Spiritual Self-Healing

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