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."

On brief clinical psychological testing, Mr J had mild cognitive impairment, which could have been a harbinger of dementia, depression, or most likely the result of his many medical problems and medications. No amount of pastoral counseling or psychoeducation around the aging process and our wonted decrease in activity level or explanation of the denervating effects of physical problems and prescription drugs could convince Mr J that his fatigue was not a matter deserving self-reproach and amenable to pharmacotherapy.

Mr J's problem was he could not accept a change in his own self-expectations in accordance with the inevitable movements of the life cycle. In Eriksonian terms, he was holding on to a role based in physical vitality that he could no longer physiologically fulfill, instead of moving into a position of teaching and mentoring that his experience and generosity would enable him to accomplish with dignity.

Clinician acceptance of patients
Several weeks after this encounter, I was called to see a patient, Mr P, who was in the ICU for a cardiac workup and who the consult stated was "anxious and had strange ideas." When I asked the patient why he thought a psychiatrist had been called to evaluate him, he said, "because I have a different lifestyle that people don't agree with"-and he was right. The man was representative of a type of person we in the western states call "mountain men." These are generally Vietnam veterans who choose to live in the wilderness and eschew civilization as profoundly, and for many of the same reasons, as the ancient anchorites.

Mr P lived in a tent or cabin and made his living off the land, panning for gold and cutting firewood, but he had the common sense to come to the city and the hospital when he experienced chest pain. The nurses reported that he was cooperating with the treatment and was polite, even engaging, and they felt he was just different, not crazy. Mr P confided to me that he sometimes wondered if the government had been conducting a study on him since the war ended, but many veterans I have examined in my career have held this belief, which is at least partly based in historical reality. He was able to entertain the possibility that this was not the case.

Mr P believed he had a special mission from God but that everyone else did as well. His mood was euthymic and his thought circumstantial but linear and exhibited its own logic. When asked about his anxiety he explained it coherently: "Since the war, I thought the enemy was outside me and I could defend against it; now I realize it is within me, the body, and there is not so much I can do to protect myself."

Mr P had no psychiatric history, no problems with the law, and no interest in psychotropic medications that in any event I would have considered immoral to prescribe for this patient. I suppose that if I had thumbed hard enough through my DSM-IV, I could have come up with a diagnosis, likely posttraumatic stress disorder, but it would have betrayed the man's values; so I told the medicine team he was simply "eccentric but not psychotic."

Some of the medicine residents had a hard time believing this and were frustrated that I would not diagnose or prescribe to "make the man normal."

Finally, a young critical care fellow who had himself served in the military told me, "I understand perfectly what he means." This physician's experience of another reality-that of war-had enabled him to accept a brother soldier's unusual perspective and path.

Clinician acceptance of self and other
The most disturbing example of this failure of acceptance of the outliers of human behavior I have encountered is in a certain kind of student and resident. Many of my fellow professors have commented on the moral absolutism of some contemporary trainees, which manifests in an inability to fathom the ambivalence of the human person. It is as if in answer to the familiar interview question of "what are your strengths and weaknesses" there is a short circuit in a binary program that produces an answer of either strength or weakness, not both. This breakdown is not to be found chiefly in rigid cognition but rather in an immature empathy that is unable to encompass in a single personality-whether of peers, professors, or patients-achievements and failures, vulnerability and competence, confidence and insecurity. Such emotional reductionism is bound to impede the physician's ability to establish rapport with patients and to form the therapeutic alliances that are the cornerstones of our profession.

The eclipse of traditional dynamic psychotherapy training, which emphasizes the complexity and contradictions of being human, is likely both a cause and an effect of this myopia in young psychiatrists' understanding of self and others. Yet it reflects a worrisome lack of skill to manage what the late William Styron called "darkness visible," an existential distress, as grounded in the burden of genetics as it is in the sorrow of life.¹⁰ Such despair, increasingly common in Americans, cannot yield to manualized interactions or even to a quadruple re-uptake inhibitor, but only to acceptance of the fundamental imperfection of the human condition.

Dr Geppert is chief of behavioral care consultation and medical director of the substance abuse residential rehabilitation treatment program at New Mexico Veterans Affairs Health Care System in Albuquerque. She is also assistant professor in the department of psychiatry and associate director of religious studies at the University of New Mexico in Albuquerque.

References:

References
1. Tillich P. The Shaking of the Foundations. New York: Scribners; 1948.
2. Linehan MM. Dialectical behavior therapy for borderline personality disorder. Theory and method. Bull Menninger Clin. 1987;51:261-276.
3. Chappel JN, DuPont RL. Twelve-step and mutual-help programs for addictive disorders. Psychiatr Clin North Am. 1999;22:425-446.
4. Viane I, Crombez G, Eccleston C, et al. Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain. 2003;106:65-72.
5. Kabat-Zinn J, Massion AO, Kristeller J, et al. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry. 1992;149:936-943.
6. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003;65:564-570.
7. Dryden W, Still A. Historical aspects of mindfulness and self-acceptance in psychotherapy. J Rational-Emotive Cog Behav Ther. 2006;24:3-28.
8. Improvement and recovery from eating disorders: a patient perspective. Eat Disord. 2002;10:61-71.
9. Warner R, Taylor D, Powers M, Hyman J. Acceptance of the mental illness label by psychotic patients: effects on functioning. Am J Orthopsychiatry. 1989;59:398-409.
10. Styron W. Darkness Visible: A Memoir of Madness. New York: Random House; 1990.