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Dialectical Behavioral Therapy (DBT) is a type of cognitive-behavioral therapy developed by Marsha Linehan in the late 1980s, primarily aimed at treating individuals with borderline personality disorder (BPD). Over time, it has been adapted for a broader range of psychological issues, including mood disorders, substance use disorders, and eating disorders (Linehan, 2015). A core component of DBT is the emphasis on teaching patients skills to manage their emotions and reduce harmful behaviors. One of the most effective skills within the distress tolerance module of DBT is the ACCEPTS skill. This skill is designed to help individuals tolerate and survive crisis situations without resorting to impulsive actions that may be harmful (Chapman et al., 2006). This article explores the ACCEPTS skill in depth, examining its components, theoretical foundations, empirical support, and practical application.
Theoretical Foundations of the ACCEPTS Skill
The ACCEPTS skill is rooted in the broader framework of DBT, which combines cognitive-behavioral techniques with mindfulness practices derived from Zen Buddhism. The theoretical foundation of DBT is dialectics, which refers to the synthesis of opposites. In the context of therapy, this often involves balancing acceptance and change—helping clients accept their current circumstances while also working towards meaningful change (Linehan, 1993).
The ACCEPTS skill specifically falls under the category of distress tolerance skills, which are essential in helping clients manage emotional crises. Distress tolerance is not about making the distress go away, but rather about enduring it without making the situation worse. This approach is crucial for individuals who are prone to emotional dysregulation, as it helps them navigate difficult situations without resorting to self-destructive behaviors (Linehan, 2015).
ACCEPTS is an acronym that stands for Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, and Sensations. Each component represents a different strategy for managing distress. The underlying idea is that by engaging in alternative behaviors, individuals can distract themselves from the immediate emotional pain, thereby reducing the likelihood of impulsive reactions (Koerner, 2012).
Activities
The first component of ACCEPTS, “Activities,” involves engaging in positive, meaningful activities to distract from distressing emotions. These activities can range from simple tasks, like going for a walk or reading a book, to more complex ones, such as participating in a hobby or spending time with loved ones. The key is to choose activities that are absorbing and engaging enough to shift focus away from the distressing emotion (Linehan, 2015).
The rationale behind this component is grounded in behavioral activation, a therapeutic approach that encourages individuals to engage in activities that are likely to improve their mood (Jacobson et al., 2001). By participating in positive activities, individuals can break the cycle of rumination and negative thinking that often exacerbates distress.
Contributing
“Contributing” involves doing something kind or helpful for others. This can range from small acts of kindness, like helping a friend or volunteering, to larger-scale contributions, such as participating in community service. The idea is that by focusing on the needs of others, individuals can shift their attention away from their own distress and experience a sense of purpose and connection (Koerner, 2012).
This component is supported by research on the benefits of prosocial behavior, which has been shown to increase well-being and reduce symptoms of depression and anxiety (Lyubomirsky et al., 2005). When individuals contribute to the well-being of others, they often experience a boost in mood and self-esteem, which can be particularly helpful during times of distress.
Comparisons
The “Comparisons” component encourages individuals to compare their current situation with a time when they were in a worse situation, or to compare themselves with others who are less fortunate. The goal is not to minimize one’s own distress but to gain perspective by recognizing that things could be worse (Linehan, 2015).
This strategy is based on the cognitive-behavioral principle that our thoughts influence our emotions. By changing the way we think about our situation, we can alter our emotional response to it (Beck, 2011). Comparisons can help individuals reframe their distress in a way that makes it feel more manageable.
Emotions
“Emotions” refers to the strategy of generating different emotions to counteract distressing ones. For example, watching a funny movie or listening to uplifting music can create positive emotions that can help diminish the intensity of negative feelings. This component is grounded in the principle of opposite action, a DBT technique that involves doing the opposite of what one’s emotions are urging them to do (Linehan, 2015).
The effectiveness of this strategy is supported by research on emotion regulation, which suggests that deliberately cultivating positive emotions can reduce the impact of negative emotions and improve overall well-being (Gross, 2014). By intentionally generating positive emotions, individuals can create a buffer against distress.
Pushing Away
“Pushing Away” involves mentally distancing oneself from the distressing situation. This can be done by temporarily putting the problem on the back burner, using imagery to create a mental barrier, or physically removing oneself from the environment that is causing distress. The idea is to give oneself a break from the distressing thoughts and emotions, allowing time to pass and emotions to cool down (Koerner, 2012).
This strategy is related to the concept of psychological distancing, which involves taking a step back from one’s thoughts and emotions to gain perspective. Research has shown that psychological distancing can reduce the intensity of negative emotions and improve decision-making during stressful situations (Kross & Ayduk, 2011). By pushing away the distressing situation, individuals can create the mental space needed to respond more effectively.
Thoughts
The “Thoughts” component involves distracting oneself by focusing on neutral or pleasant thoughts. This can be done by counting, reciting a poem, or repeating a mantra. The goal is to occupy the mind with something other than the distressing thought, thereby reducing its power (Linehan, 2015).
This strategy is rooted in cognitive-behavioral techniques that emphasize the importance of thought control in managing emotions. By redirecting attention away from distressing thoughts and towards neutral or positive ones, individuals can reduce their emotional reactivity (Beck, 2011). Thought distraction can be a powerful tool for breaking the cycle of rumination that often accompanies emotional distress.
Sensations
Finally, “Sensations” involves using physical sensations to distract from emotional pain. This can include holding an ice cube, taking a hot shower, or engaging in any activity that creates a strong physical sensation. The idea is that by focusing on the physical sensation, individuals can temporarily override the emotional distress (Linehan, 2015).
This component is supported by research on sensory grounding techniques, which are commonly used in trauma therapy to help individuals stay present and reduce the intensity of flashbacks or emotional distress (Ogden et al., 2006). By engaging the senses, individuals can anchor themselves in the present moment, which can help reduce the impact of distressing emotions.
“When we meet real tragedy in life, we can react in two ways - either by losing hope and falling into self-destructive habits or by using the challenge to find our inner strength”
Empirical Support for the ACCEPTS Skill
The effectiveness of the ACCEPTS skill, like other DBT techniques, has been supported by empirical research. Numerous studies have demonstrated the efficacy of DBT in reducing symptoms of borderline personality disorder, including self-harm, suicidal behavior, and emotional dysregulation (Linehan et al., 2006). While the ACCEPTS skill itself has not been extensively studied in isolation, it is a key component of the distress tolerance module, which has been shown to be particularly effective in managing emotional crises (Chapman et al., 2006).
For example, a study by Neacsiu et al. (2010) found that individuals who received DBT skills training, including distress tolerance skills like ACCEPTS, showed significant improvements in emotion regulation and a reduction in maladaptive behaviors compared to those who received treatment as usual. The study highlighted the importance of distress tolerance skills in helping individuals manage intense emotions without resorting to self-destructive behaviors.
Moreover, research on distress tolerance more broadly supports the use of skills like ACCEPTS in managing emotional crises. Distress tolerance has been found to be a key predictor of treatment outcomes in individuals with BPD and other disorders characterized by emotional dysregulation (Bornovalova et al., 2008). By increasing an individual’s ability to tolerate distress, skills like ACCEPTS can reduce the likelihood of impulsive behaviors and improve overall functioning.
Practical Application of the ACCEPTS Skill
The ACCEPTS skill is typically introduced in the context of DBT skills training, which is a structured, educational approach that teaches clients how to manage their emotions and behaviors more effectively. Skills training is usually conducted in a group format, with clients meeting weekly to learn and practice new skills. The ACCEPTS skill is often taught early in the distress tolerance module, as it provides a practical, hands-on approach to managing emotional crises (Linehan, 2015).
Teaching the ACCEPTS Skill
When teaching the ACCEPTS skill, therapists typically begin by explaining the rationale behind distress tolerance. Clients are encouraged to view distress tolerance as a way to survive emotional crises without making the situation worse. The therapist then introduces each component of the ACCEPTS acronym, providing examples and guiding clients in identifying how they can apply each strategy in their own lives (Koerner, 2012).
Therapists may use role-playing, homework assignments, and other experiential exercises to help clients practice the skill. For example, clients might be asked to identify a recent situation in which they felt intense distress and then brainstorm ways they could have used the ACCEPTS skill to manage their emotions. By practicing the skill in a safe, supportive environment, clients can build confidence in their ability to use it during real-life crises (Linehan, 2015).
Using ACCEPTS in Crisis Situations
The ACCEPTS skill is most effective when used early in a crisis situation, before emotions escalate to the point where they feel overwhelming. Clients are encouraged to use the skill as soon as they notice signs of distress, such as racing thoughts, physical tension, or feelings of panic. By engaging in one or more of the ACCEPTS strategies, clients can create a buffer between themselves and their distressing emotions, reducing the likelihood of impulsive actions (Koerner, 2012).
One of the strengths of the ACCEPTS skill is its flexibility. Clients can choose the components that work best for them, depending on the situation and their personal preferences. For example, someone who finds physical activity particularly soothing might focus on the “Activities” component, while another person who gains comfort from helping others might lean towards “Contributing.” This flexibility allows clients to tailor the skill to their individual needs, making it more likely that they will use it in moments of crisis (Linehan, 2015).
Overcoming Barriers to Using ACCEPTS
While the ACCEPTS skill can be highly effective, there are often barriers that prevent individuals from using it, especially during a crisis. These barriers can include a lack of motivation, difficulty in remembering the skill when overwhelmed, or skepticism about its effectiveness. It is important for therapists to address these barriers during skills training to increase the likelihood that clients will use ACCEPTS when needed (Neacsiu et al., 2010).
One approach to overcoming these barriers is to integrate regular practice of the ACCEPTS skill into the client’s daily routine. By practicing the skill outside of crisis situations, clients can become more familiar with it and more confident in their ability to use it when distress arises. Additionally, therapists can help clients develop personalized reminders, such as notes or prompts, that encourage them to use ACCEPTS in moments of distress (Koerner, 2012).
Therapists can also help clients explore and address any skepticism they may have about the skill. This might involve discussing the empirical evidence supporting the effectiveness of distress tolerance skills or exploring the client’s previous experiences with similar strategies. By building trust in the process, therapists can help clients become more open to using ACCEPTS when they need it most (Linehan, 2015).
Integrating ACCEPTS with Other DBT Skills
The ACCEPTS skill is just one part of the broader distress tolerance module in DBT, and it is most effective when used in conjunction with other DBT skills. For example, clients may combine ACCEPTS with mindfulness practices to stay grounded in the present moment, or with emotion regulation skills to reduce the intensity of their emotions over time. By integrating ACCEPTS with other skills, clients can create a comprehensive toolkit for managing distress (Linehan, 2015).
For instance, mindfulness can be particularly helpful in enhancing the effectiveness of the “Pushing Away” component of ACCEPTS. By practicing mindfulness, clients can learn to observe their thoughts and emotions without becoming overwhelmed by them, making it easier to temporarily set aside distressing thoughts. Similarly, emotion regulation skills can complement the “Emotions” component by helping clients identify and cultivate positive emotions that counteract distressing ones (Koerner, 2012).
Case Example: Using ACCEPTS in Practice
To illustrate how the ACCEPTS skill can be used in practice, consider the case of “Sarah,” a 32-year-old woman with a history of borderline personality disorder and self-harming behaviors. Sarah frequently experiences intense emotions, particularly during conflicts with her partner. In the past, these emotions have led her to engage in impulsive behaviors, such as self-harm or substance use, as a way to cope with her distress.
During DBT skills training, Sarah learned about the ACCEPTS skill and began practicing it in non-crisis situations. She discovered that engaging in physical activities, such as going for a run or practicing yoga, was particularly effective in helping her manage her emotions. She also found that volunteering at a local animal shelter gave her a sense of purpose and helped her shift her focus away from her own distress.
One evening, Sarah had an argument with her partner, which triggered intense feelings of anger and sadness. In the past, she might have responded by cutting herself or drinking alcohol. However, this time, Sarah remembered the ACCEPTS skill. She decided to use the “Activities” component by going for a run, which helped to release some of her pent-up energy. When she returned home, she spent time with her dog, which provided comfort and further distracted her from her negative emotions.
By the time Sarah finished these activities, her emotions had subsided enough that she was able to calmly talk to her partner about the argument. Instead of resorting to self-destructive behaviors, Sarah used the ACCEPTS skill to manage her emotions and handle the situation in a healthier way.
This case example demonstrates how the ACCEPTS skill can be applied in real-life situations to prevent impulsive behaviors and manage emotional crises more effectively. With practice, clients like Sarah can learn to use ACCEPTS as a first line of defense against overwhelming emotions, reducing the risk of harmful behaviors and improving their overall quality of life.
Limitations and Considerations
While the ACCEPTS skill is a valuable tool within the DBT framework, it is not without limitations. One potential limitation is that it may not be sufficient on its own for managing more severe emotional crises or long-standing patterns of emotional dysregulation. In such cases, ACCEPTS should be used in conjunction with other therapeutic interventions, such as ongoing DBT therapy, medication, or additional support services (Linehan, 2015).
Another consideration is that the effectiveness of ACCEPTS may vary depending on the individual’s level of emotional intensity and their ability to access the skill in the moment. For individuals who experience extreme emotional dysregulation, such as those with severe borderline personality disorder or trauma-related disorders, additional support may be needed to help them effectively use the skill (Koerner, 2012).
Furthermore, cultural and individual differences may impact how the ACCEPTS skill is perceived and utilized. For example, some individuals may have cultural or personal values that prioritize certain components of the skill over others. Therapists should be mindful of these differences and work with clients to adapt the skill in a way that aligns with their values and preferences (Neacsiu et al., 2010).
Finally, it is important to recognize that while ACCEPTS can be effective in managing short-term distress, it is not intended to address the underlying causes of emotional dysregulation. Long-term change requires a comprehensive approach that includes addressing the root causes of distress, such as unresolved trauma, dysfunctional relationships, or maladaptive thought patterns (Linehan, 2015).
Conclusion
The ACCEPTS skill is a powerful tool within the distress tolerance module of Dialectical Behavioral Therapy. By providing a structured approach to managing emotional crises, ACCEPTS helps individuals tolerate distress without resorting to impulsive or harmful behaviors. Each component of ACCEPTS offers a different strategy for distraction and emotion regulation, allowing individuals to choose the approach that works best for them in any given situation.
While the ACCEPTS skill is not a standalone solution, it is an essential part of a broader DBT framework that helps individuals develop the skills needed to navigate life’s challenges with greater resilience and effectiveness. Empirical research supports the use of distress tolerance skills like ACCEPTS in improving treatment outcomes for individuals with emotional dysregulation, and practical application of the skill demonstrates its potential to make a meaningful difference in clients’ lives.
Therapists and clients alike should approach the ACCEPTS skill with an understanding of its theoretical foundations, its practical applications, and its limitations. By doing so, they can maximize the potential benefits of this skill, helping individuals lead more balanced, fulfilling lives even in the face of emotional distress.
The ACCEPTS Skill Book Recommendations
Here is a collection of the best books on the market related to the ACCEPTS skill:
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References
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- Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44(3), 371–394. https://doi.org/10.1016/j.brat.2005.03.005
- Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 3–20). Guilford Press.
- Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255–270. https://doi.org/10.1093/clipsy.8.3.255
- Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. Guilford Press.
- Kross, E., & Ayduk, O. (2011). Making meaning out of negative experiences by self-distancing. Current Directions in Psychological Science, 20(3), 187–191. https://doi.org/10.1177/0963721411408883
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
- Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.
- Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060–1064. https://doi.org/10.1001/archpsyc.1991.01810360024003
- Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 131(6), 803–855. https://doi.org/10.1037/0033-2909.131.6.803
- Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832–839. https://doi.org/10.1016/j.brat.2010.05.017
- Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. Norton & Company.
