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Tools, Not Schools, of Therapy
Part 5: Acceptance & Role-Playing models

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Copyright © 2008 by David D. Burns, M.D. Any reproduction, electronic or otherwise, is strictly prohibited without expression written permission of the author.

By David Burns, M.D.

In this newsletter, I’ll focus on the Acceptance (Spiritual) Model and the Role-Playing (Gestalt) Model. The Acceptance Paradox represents the spiritual core of CBT. Combined with one of the role-playing techniques, such as the Externalization of Voices or Feared Fantasy Technique, it can lead to emotional enlightenment. However, these are among the most challenging techniques for patients and therapists alike to master and comprehend.
People often equate CBT with the Self-Defense Paradigm. They think that CBT is based on:

• Defending yourself from attack, especially your own self-criticisms
• Emphasizing your strengths instead of dwelling on your shortcomings
• Thinking about yourself and your life more positively.

The Truth-Based Techniques, such as Examine the Evidence, the Experimental Technique, the Survey Technique and Reattribution, are all based on the Self-Defense Paradigm. Identify the Distortions, the Socratic Method and Let's Define Terms are based on self-defense as well. The spiritual vision behind these techniques is, “The truth shall make you free.” In many cases, these techniques can be immensely powerful, even life-changing.

However, for certain kinds of negative thoughts, the Acceptance Paradox will be vastly more effective. Instead of disputing your negative thoughts, you accept them with a sense of humor and inner peace, without any feelings of shame or humiliation. This causes a profound shift in the way you think and feel. You'll often experience a transformation in your personal values and beliefs as well. In fact, the Acceptance Paradox is the ultimate antidote to many of the Self-Defeating Beliefs that trigger depression and anxiety, such as Perfectionism and Perceived Perfectionism, as well as the Achievement, Love, and Approval Addictions.

Although the Acceptance Paradox is a psychological technique, it has spiritual implications, and can help patients develop a deeper understanding of their own religious heritage. Most religions, including Judaism, Christianity, and Buddhism, are based, at their deepest cores, on the Acceptance Paradox. The therapy I do is completely secular, and yet we are often working at a deeper level with our clients. And at the moment of profound change, many clients experience a spiritual as well as a psychological and emotional transformation.

The Acceptance Paradox and the Disarming Technique are very similar. When you use the Disarming Technique, you accept the criticism of another person. When you use the Acceptance Paradox, you surrender to your own inner critic.

A Catholic priest with a Ph.D. in ancient languages once attended a CBT workshop I conducted in Oklahoma. He said he was intrigued by the Disarming Technique, and explained that the Christian concept of "confession" of sins is actually based on a mistranslation of the original Aramaic text. The correct translation was not, "to confess," but rather, "to agree with." So the Disarming Technique and the Acceptance Paradox may really be spiritual concepts.

The Acceptance Paradox is equally compatible with Buddhism. The Buddhists say that our suffering does not result from reality, but rather from the judgments we make, and from our insistence that things should be different from the way they are, or that we should be better than we are. The Buddhist concepts of enlightenment and freedom from suffering are based on acceptance.

Of course, words are cheap. Bringing the Acceptance Paradox to life in a therapy session is far more challenging. It's like the difference between seeing a post card of the Grand Canyon and going to the Grand Canyon for the first time so you can actually see it with your own eyes. It takes your breath away! Perhaps you've had this experience.

The first time I saw the Grand Canyon, I was on a camping trip with a friend. We arrived late in the evening and couldn't see much because it was so dark. We camped out in sleeping bags next to our car. When I woke up in the morning, I realized that we were sleeping a few feet from the edge. The sun was just coming up. As I turned to look, I saw the Grand Canyon for the first time. Wow! I'd heard there was a big hole in the ground, but I had no idea it would be like that!

By the same token, when you suddenly grasp the Acceptance Paradox for the first time, it's a mind-boggling experience. However, this type of understanding usually only develops during one of the role-playing exercises, such as the Externalization of Voices or Feared Fantasy.

When I do workshops for mental health professionals, I often ask how many of the therapists in the audience sometimes struggle with feelings of self-doubt. Nearly all the hands go up. Then I ask them what kinds of negative thoughts they have when they're feeling that way. They volunteer thoughts like this:

• I don't know what I'm doing with my patients.
• There are so many patients I'm stuck with.
• I should know how to help them, but I don't.
• Other therapists are smarter than I am.
• I'm a fraud. I don't really know anything.
• I'm so inadequate. I'm always screwing up!

Do any of these thoughts sound familiar? If you like, you can jot down a few of your own negative thoughts here:

Then I ask for several volunteers to come forward so I can illustrate the difference between the Acceptance Paradox and the Self-Defense Paradigm. I explain how the Externalization of Voices works, and tell them that I'll play the role of their negative thoughts, using the second person, "You." Their job is to defeat me, using the first person, "I." They can use the Self-Defense Paradigm, the Acceptance Paradox, or both.

When I attack them with their own negative thoughts, they nearly always respond defensively. Then I ask them if their response felt strong or weak, and who won the exchange. They tell me that I won, and that their attempt at self-defense wasn't effective. Then we do a role-reversal, so I can model a different way of responding, as in this example. In this example, keep in mind that this is not psychodrama or encounter. We are both the same person; it’s just that one of us is playing that negative voice in the client’s mind, and one of us is playing the positive voice. And in this example, the client is a therapist who is feeling insecure.

Negative Thoughts (played by volunteer from audience): You're so inadequate! You're always screwing up! What's wrong with you?

Positive Thoughts (played by David): That’s not entirely correct. I’m not always screwing up. But there’s an awful lot of truth in what you’re saying. I have many inadequacies. In fact, there's probably nothing about me that couldn't be improved. But hey, once you get to know me better, you'll see that the flaws you mentioned are only the tip of the iceberg!

Negative Thoughts (played by volunteer from audience): You don't know anything.

Positive Thoughts (played by David): You know, the older I've gotten, the more aware I've become of just how little I know. And sometimes, I get to thinking that there's almost nothing I'm really certain about. But that's kind of exciting, because there's so much room for learning, for research and for new developments, new methods. Most of the important discoveries are still ahead of us, and I accept that.

Negative Thoughts (played by volunteer from audience): Okay, if you admit that you don't know anything, that proves you're a fraud. Other people know more than you.

Positive Thoughts (played by David): Lots of people know so much more than I do, not only in the field of psychotherapy, but in all fields. But in spite of how little I know, I have been able to help many of my patients, and that’s a been a real joy. If that makes me a fraud, then I’m just going to accept that and be the best little fraud I can be!

Negative Thoughts (played by volunteer from audience): You can joke about it if you want, but this is serious. If you're a fraud, then you can't help any of your patients.

Positive Thoughts (played by David): That's actually not true. Many of my patients have improved a great deal, and lots of them have told me how much they've appreciated the work we've done together. But there are always patients I’m stuck with, and so much I’d love to learn. I wish I knew a great deal more.

Negative Thoughts (played by volunteer from audience): Sure, maybe you've helped a few of the easier cases, but anyone could've helped them. The fact is, you've got many patients who aren't improving. If you were a better therapist, you could help them.

Positive Thoughts (played by David): Oh, you're right about that! And it would be great to have more skill so I could work more effectively with all patients. In fact, that’s why I attended this workshop.

Negative Thoughts (played by volunteer from audience): Oh, so you admit that there are lots of other therapists who are smarter and better than you are?

Positive Thoughts (played by David): Absolutely! I have no doubt about it.

Negative Thoughts (played by volunteer from audience): Well, that's just shameful. Maybe you should leave therapy to the experts and pursue a more suitable career. Perhaps you'd make a good janitor or hairdresser.

Positive Thoughts (played by David): You know, I've actually thought about that. Given all the hassles of managed care, I might actually make more money as a hairdresser. But I've also thought about the fact that most of my patients really seem to like me, and do seem to benefit from our work together, in spite of my flaws. In fact, they seem to like me more when they see that I'm human and real. And the great majority of them seem to improve in spite of my "averageness." So I think I'll just keep trucking along.
Now ask yourself—who was the "winner" and who was the "loser"? Who looked like the bigger jerk? When you use the Acceptance Paradox, you win by losing. You achieve victory through surrender. I hope my example has made this concept somewhat clear. You almost have to observe this technique, or participate in it, before you suddenly “get it.”

The choice between the Acceptance Paradox and the Self-Defense Paradigm isn't black-and-white. You can blend the two. In the dialogue above, I used self-defense twice. When the negative thoughts said, "You can't help any of your patients," and "You constantly screw up," I defended myself because those criticisms were blatantly false. But I also included liberal doses of the Acceptance Paradox. In fact, we all have plenty of patients we feel stuck with, and we all make therapeutic mistakes, as well as mistakes in our teaching, and in the many other roles we play in life.

One of the secrets of the Acceptance Paradox is to transform vague, judgmental criticisms into specifics. For example, let’s assume you have the negative thoughts said, "My therapeutic style stinks." You can agree that there’s lots of room for improvement, and ask for some specifics. Do I need to improve my Empathy skills? Or my capacity to identify suicidal urges? Or my ability to deal with therapeutic resistance? Well, there are specific tools and exercises I learned in the Burns workshop that can address these deficiencies and help me improve. This response tends to leave the inner critic speechless because most of the destructive power in a negative thought results from the Overgeneralizations and hidden Should Statements. Once things become specific, the pain tends to diminish or disappear. This is also a Buddhist concept.

Remember that the Externalization of Voices is not a battle between two people. It's a battle between the negative and positive voices in your own mind. Or, if you are using this technique to help a patient, it is the two voices in his or her mind. Make sure that the person playing the role of the positive thoughts always uses the first person, "I." If the person playing the positive thoughts uses the second person, "You," the technique will fail miserably.

If the patient "sees" it right away, you've hit a home run, and the patient will experience profound relief. Then you can do several role-reversals to make sure he or she really has grasped this notion, intellectually and emotionally. In my experience, most patients won't be able to grasp the Acceptance Paradox initially. If the patient doesn't see it, you can continue to model it, using frequent role-reversals. I've had many patients who couldn't comprehend the Acceptance Paradox until we'd worked with the Externalization of Voices for several sessions. Then it was as if somebody had turned flipped a switch in their brain, and they suddenly saw the light.

The Acceptance Paradox is difficult to comprehend because our culture is steeped in the values of Western European civilization. We emphasize the importance of individualism and pride. We think we're supposed to be "winners" and defend ourselves from attack. The Acceptance Paradox is more compatible with Eastern philosophy. Instead of fighting, you surrender. In the process of "losing," you paradoxically "win."

Patients may have trouble comprehending the Acceptance Paradox because they think that they have accepted themselves. They believe that they've discovered the horrible truth about themselves, and feel convinced that they're irreversibly flawed, worthless, and hopeless. These feelings can be so painful that many patients turn to suicide as the only escape from their suffering.

These patients haven't distinguished healthy from unhealthy acceptance. As you can see n below, unhealthy acceptance is characterized by feelings of hopelessness, self-hatred and despair. In contrast, healthy acceptance is characterized by feelings of hope and joy and involves a celebration of life.

Patients may resist true self-acceptance because they think that something awful will happen if they accept themselves. They may think they'll have to settle for a life of mediocrity and unhappiness, and give up on their dreams of greatness. They may also think that if they accept their flaws, they'll never grow or change.

These fears result from a lack of understanding of the Acceptance Paradox. The problem is not that we have deficiencies or flaws, but that we have the urge to hide them in shame. When we insist we shouldn't be like that, and we struggle to be better than we are, we get stuck, and nothing changes. In contrast, when you accept your flaws without a sense of shame, it becomes far easier to learn from them and grow. In fact, you could argue that self-acceptance is the most fundamental change that a human being can make.

Paradoxically, the moment you accept yourself, you have changed.
I hope you'll try the Externalization of Voices with a friend or colleague. You'll see that the Acceptance Paradox is far more challenging than it looks. Practice will be necessary if you want to use this powerful therapeutic tool in your clinical work. In fact, you won't be able to bring this technique to life for your patients until you've brought it to life for yourself. You should expect to stumble quite a few times before you "get it," but you'll find that it's well worth the effort. The Acceptance Paradox has been life-changing for me personally, and it's one of the best gifts we can share with our patients.

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