Keywords

Introduction

The theoretical conceptualization of self-acceptance has been in development for the last century. Early research focused on studying self-acceptance in relation to acceptance of others, whereas more recently researchers have emphasized trying to understand the association of self-acceptance with other aspects of psychological well-being, and the differentiation of self-acceptance from self-esteem. To facilitate empirical work on these issues, a number of measures of unconditional self-­acceptance have been developed. Research using one of these measures, the Unconditional Self-Acceptance Questionnaire (USAQ), based on Ellis’s rational emotive behavior therapy (REBT) model, has uncovered extensive empirical support for an association of self-acceptance with psychological health. More research is needed, however, on aspects of the reliability and validity of this scale, and more generally on theoretical views of self-acceptance. This chapter will address these issues.

Early History of Self-Acceptance

Self-acceptance has been a focus of psychological theory, research, and assessment for at least a century. Early work on the subject often centered on the distinction between self- and other-acceptance. For example, Freud (1914/1957) proposed that the way people regarded themselves (“ego-love”) would be inversely related to how they viewed others (“object-love”): “We see … an antithesis between ego-libido and object-libido. The more the one is employed, the more the other becomes depleted” (p. 76). Conversely, other theorists proposed that views of self and other would be positively correlated. Adler (1927), for instance, posited that people who feel inferior and lack self-worth try to feel better by disparaging others. Likewise, Horney (1937) speculated that children who lack parental love do not develop the capacity to love themselves or others. Similarly, Fromm (1947) believed that people could only love others if they were first capable of developing self-love, concluding that “Love of others and love of ourselves are not alternatives. On the contrary, an attitude of love toward themselves will be found in all those who are capable of loving others” (p. 129).

Consistent with this emerging view of self-acceptance as having favorable implications for interpersonal functioning, psychodynamic therapists began to identify self-acceptance as an important treatment objective (Horney, 1950; Rank, 1945; Taft, 1933). In a historical review of the concept of acceptance, Williams and Lynn (2010) discussed case studies and chart review studies that seemed to corroborate the association of increased self-acceptance with ­successful therapy outcomes in diverse areas including alcohol dependence (Grant, 1929), postdivorce adjustment (Waller, 1930), and schizoid personality (Tidd, 1937).

More systematic and quantitative therapy process research was inspired by Rogers’ (1940, 1944) conceptualization of self-acceptance as a key interim goal, such that clients must be able to accept themselves to achieve insight in therapy. Empirical tests of this hypothesis began with a dissertation by Raimy (1948), who solicited judges’ ratings of 14 therapy clients’ verbalizations of positive and negative self-references during sessions. In the successfully treated cases, but not the less successful ones, the number and proportion of positive self-references increased as therapy progressed.

As conceptualizations of self-acceptance evolved, scale development followed. Sheerer (1949) elaborated upon Raimy’s work by developing an expanded coding scheme for rating clients’ statements in sessions as reflecting varying degrees of acceptance of self or of other. Self-acceptance and other-acceptance ratings showed a sizable positive correlation (r = 0.51) and tended to change in tandem, both showing increases over the course of treatment. Using a partially overlapping set of cases, Stock (1949) replicated Sheerer’s (1949) results, obtaining a correlation between self- and other-acceptance of r = 0.38.

Scale Development

Empirical work on self-acceptance accelerated in the 1950s with the development of several self-report measures of self- and other-acceptance. Availability of such scales made it feasible to use larger samples (due to the greater ease of scoring questionnaires, relative to coding therapy transcripts) and more diverse samples (as a function of not being tied to the therapy context) in studies of self-acceptance.

Expressed Acceptance of Self and Others Scale (Berger, 1952). One prominent self-report scale fostering research in the 1950s was Berger’s Expressed Acceptance of Self and Others Scale, which used slightly modified versions of Sheerer’s (1949) definitions of acceptance and respect for oneself and others. Some aspects of Berger’s multifaceted definition of self-acceptance are consistent with contemporary usage (e.g., “considers himself a person of worth on an equal plane with others,” p. 779), whereas others appear to incorporate predicted correlations of self-acceptance into its very definition (e.g., “is not shy or self-conscious,” p. 779), and still others read as a bit dated (“does not regard himself as totally different from others, ‘queer’, or generally abnormal in his reactions,” p. 779). The scale consists of 64 items, 36 of which pertain to self-acceptance, 28 to acceptance of others.

The initial validation study of the scale was conducted with a large (N = 315) combined sample gathered from school, community, prison, and clinical settings. Convergent validity was assessed by correlating the self-acceptance scale scores and ratings of the participants’ levels of self-acceptance inferred from a writing sample, which was very high (r = 0.90), and internal consistency coefficients for the self-acceptance scale ranged from 0.75 to 0.89 (Berger, 1952). Concurrent validity was supported by research showing negative correlations between self-acceptance as measured by the Expressed Acceptance of Self and Others Scale and indicators of psychopathology (e.g., Berger, 1955).

Thus, the Expressed Acceptance of Self and Others Scale is clearly measuring something consistently, and something broadly associated with wellbeing. Its primary drawback as a measure of self-acceptance for current research is that we do not know whether the construct being measured is really self-acceptance per se. Conceptually, as noted earlier, the scale is grounded in an expansive definition of self-acceptance. Perhaps as a result, it has been deployed by subsequent researchers to index alternate constructs such as self-esteem, confidence, or perceived competence (e.g., Eagly & Whitehead, 1972; Neff, 2003), rather than self-acceptance.

Empirically, multi-trait multi-method matrix (MTMMM) data using the methodology advocated by Campbell and Fiske (1959) for test validation called into question the discriminant validity of the Expressed Acceptance of Self and Others Scale and other self-acceptance indicators. In particular, Shepard (1979) conducted an ambitious MTMMM study of self-acceptance, acceptance of others, and self-­description, with each being measured via seven distinct methods: checklist, rating scale (Expressed Acceptance of Self and Others Scale selected as the self-­acceptance rating scale), sentence completion, forced-choice questionnaire, semantic differential, Thematic Apperception Test, and Q-sort. The sample was drawn from a university community and consisted of 137 middle-class high school and college students, parents of high school students, and residents of a retirement community. Across the different methods of self-acceptance measures that were used, an average convergent validity coefficient of 0.55 was obtained. Self-acceptance showed discriminant validity from acceptance of others (average correlation of self- and other-­acceptance = 0.22), though less so from self-description (average correlation of self-­acceptance measure with a self-description measure = 0.41). Indeed, self-acceptance measures correlated better with self-description measures using the same measurement method (average r = 0.64) than with other methods used to measure the same construct, self-acceptance (average r = 0.55), suggesting a lack of discriminant validity and in particular excessive influence of method variance. In theory, self-­acceptance added a value component to self-description; whereas I might describe myself by endorsing “I am reserved around people I do not know well,” acceptance would entail believing “It is fine that I am reserved around people I do not know well.” The MTMMM data, however, suggested that the Expressed Acceptance of Self and Others Scale was not up to the task of validly making this discrimination.

California Psychological Inventory, Self-Acceptance Subscale (CPI; Gough, 1957). Another effort to construct a selfreport measure of self-acceptance is a subscale of the CPI (Gough, 1957). The CPI on the whole was based on the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1940), as many MMPI items were taken directly or rewritten for inclusion on the CPI. Although the MMPI was designed to assess degrees of maladjustment, the CPI was developed as a normal-range measure of personality and interpersonal traits. It has been cited at least 2,000 times (Gough, 2002). The original CPI (Gough, 1957) contained 480 true–false items with 18 subscales. The CPI has since been revised several times to bring item content up-to-date and to eliminate medically related items, and a short form was released in 2002 (Gough & Bradley, 2005).

The self-acceptance subscale was included in the CPI with the hope that it would, “identify individuals who would manifest a comfortable and imperturbable sense of personal worth, and who would be seen as secure and sure of themselves whether active or inactive in social behavior” (Gough, 1987, p. 10). Vingoe (1968) assessed the validity of the self-acceptance subscale in a study of college freshmen women who lived in an on-campus dormitory (N = 66). Participants were asked to rate themselves and their peers on different CPI subscales, and correlations were computed between self- and averaged peer-ratings. The convergent validity of the self-­acceptance subscale was supported, with a significant positive correlation between self- and mean peer-ratings (r = 0.44). However, the self-acceptance subscale has proven to be one of the least reliable subscales of the CPI, with test–retest reliability coefficients of 0.60 and 0.74, and internal consistency coefficients ranging from 0.51 to 0.58 (Gough, 1987; Megargee, 1972).

Personal Orientation Inventory, Self-Acceptance Subscale (POI; Shostrom, 1964). Still another self-report measure of self-acceptance is a subscale of the POI which consists of 150 pairs of two-choice items and is designed to measure psychological wellbeing, mental health, and self-actualization (Shostrom, 1964). The 26-item self-acceptance subscale is intended to capture “affirmation or acceptance of self in spite of weaknesses or deficiencies” (Shostrom, 1973, p. 6). Increases in self-acceptance scores on the POI during participation in a sensitivity training group correlated as expected with increases in self-awareness reflected in judges’ ratings made on the basis of speech samples (Culbert, Clark, & Bobele, 1968).

Although there is a large body of research that uses the POI, few studies have investigated the psychometric properties of the self-acceptance subscale in particular. One-week retest reliability was high (0.77) in a college student sample (Shostrom, 1966). In a large sample of male prisoners (N = 500), the internal consistency of the POI self-acceptance subscale was modest (0.58) (Silverstein & Fisher, 1973), though it is not known how well this finding would generalize to other settings or to a mixed-sex sample.

There is also uncertainty regarding the discriminant validity of the POI self-­acceptance and self-regard subscales. One study in a college sample showed a significant positive correlation between the two (Knapp, 1965), and Shepard (1979) argued based on a content analysis that the items comprising the two subscales were not consistently distinguishable along the intended lines.

Scales of Psychological Wellbeing, Self-Acceptance Subscale (SPWB; Ryff, 1989), The SPWB is an 84-item measure of psychological wellbeing, containing six 14-item subscales including self-acceptance. The SPWB has been cited nearly 3,000 times. A respondent with high scores on the self-acceptance subscale “possesses a positive attitude toward the self; acknowledges and accepts multiple aspects of self, including good and bad qualities; feels positive about past life” (Ryff, p. 1072).

During initial scale development, the measure was administered to 321 young, middle-aged, and older adults. For the self-acceptance subscale, internal consistency (0.93) and 6-week retest reliability (0.85) were high. No age or sex differences in self-acceptance were evident. Concurrent validity of the self-acceptance subscale was supported by sizable correlations with positive (minus negative) affect (0.55) and with depression (−0.59).

Differentiation of Self-Acceptance from Self-Esteem

Although the focus in the beginning of the empirical study of self-acceptance was on understanding and measuring self-acceptance and its distinction from other-­acceptance (e.g., Raimy, 1948; Sheerer, 1949), emphasis has shifted over time to studying how self-acceptance differs from other constructs (e.g., Shepard, 1979), and in particular, self-esteem. The relevance of this consideration is apparent in Ryff’s (1989) test development research on the SPWB. As noted earlier, having a “positive attitude toward the self” was considered part of the definition of self-­acceptance, and a measure of self-esteem was included in her research “because of its apparent resemblance to the dimension of self-acceptance in the proposed formulation of psychological well-being” (p. 1073). Empirically, self-esteem correlated highly (r = 0.62) with the self-acceptance subscale of the SPWB.

Subsequent research and theorizing have suggested that it may be important to differentiate self-acceptance, as an aspect of psychological health, from high or favorable self-esteem. Low self-esteem, that is, a general negative rating of one’s worth, has obvious negative implications for emotional life and is a well-established correlate of depression (e.g., Parry & Brewin, 1988). What may be less obvious, however, is what could be wrong with high self-esteem or general positive evaluations of the self. Empirically, many of the purported benefits of high self-esteem (e.g., for increased achievement, better friendships, etc.) have proven elusive when studies measure these consequences objectively and use longitudinal designs that can support causal inference to some extent (Baumeister, Campbell, Krueger, & Vohs, 2005). High self-esteem can bleed into narcissism if accompanied by a sense that one is not only great and worthy but also more worthy and special than others. If the grandiose person’s favorable self-rating exceeds his or her objective performance and the perceptions of others, there may be unfavorable consequences in the long term (e.g., Robins & Beer, 2001) including rejection by peers (Perez, Pettit, David, Kistner, & Joiner, 2001). Indeed, highly favorable views of the self that are threatened in some manner have been linked to violent behavior (Baumeister, Smart, & Boden, 1996).

Self-Acceptance in Rational Emotive Behavior Therapy

REBT practitioners try to help patients navigate to avoid the sadness associated with low self-esteem and the vulnerabilities associated with high self-esteem by challenging the practice of “self-esteeming” or global self-rating altogether (Ellis, 1977). General self-rating can be questioned on logical grounds, given that everyone has strengths and weaknesses, and there is no obvious logical basis for aggregating them into one overall measure of worth ranging from high to low. Accordingly, “Ellis rejected any notion of a universalistic definition of what it means to be a good or bad person, and adopted the position that while it is beneficial for people to measure and evaluate their own traits and behaviors, it is not sensible to use their performances or other’s opinions of them as a basis for globally rating themselves.” (Bernard, Froh, DiGiuseppe, Joyce, & Dryden, 2010, p. 305).

The utility of general self-rating is also questionable in that it can create emotional vulnerability. In particular, a high global self-rating carries with it the implication that this rating could fall if future performances fail to measure up to the past ones forming the basis of the high self-rating. Just as parents are advised to be specific in expressing praise for efforts (“I like the way you tried all kinds of strategies on that math problem until you finally got it.”) rather than generically praising seemingly fixed attributes (“great job! You’re so smart”) (e.g., Dweck, 2007), so too the individual should foster more resilient, less easily overturned by future setbacks, emotional health by rating behaviors (“I did well at managing my time on that work project”) as opposed to the whole self (“I am a great person because I got that project done on time”).

In lieu of self-rating, REBT has long emphasized the desirability of unconditional self-acceptance, what Arnold Lazarus (1977) once called “an egoless state of being.” Unconditional self-acceptance in REBT “means that the individual fully and unconditionally accepts himself whether or not he behaves intelligently, correctly, or competently and whether or not other people approve, respect, or love him” (Ellis, 1977, p. 101). Unconditional self-acceptance may be distinguished from making any global, generalized evaluation of one’s worth or value.

Despite the frequent elaboration of this conceptual point of emphasis within REBT, for many years REBT research projects did not measure or analyze unconditional self-acceptance (Haaga & Davison, 1989), leaving a thin empirical basis for claims about the characteristics of self-acceptors. Accordingly, Chamberlain and Haaga (2001a) developed a test of self-acceptance, the USAQ. The USAQ, as slightly revised by Chamberlain and Haaga (2001b) to enhance internal consistency, includes 20 items rated on a 1 (“almost always untrue”) to 7 (“almost always true”) scale. Eleven items are reverse-scored (e.g., “To feel like a worthwhile person, I must be loved by the people who are important to me”), whereas the other nine are scored directly (e.g., “I believe that I am worthwhile simply because I am a human being”). Thus, total scores can range from 20 to 140, with higher scores reflecting greater self-acceptance. The psychometric properties of the USAQ-R are as follows.

Reliability. The initial version of the USAQ showed acceptable internal consistency (alpha = 0.72; Chamberlain & Haaga, 2001a), and rewording of three problematic items improved internal consistency (alpha = 0.86; Chamberlain & Haaga, 2001b). Subsequent studies in adult samples have reported satisfactory internal consistency for the USAQ-R in English (0.76–0.83; Davies, 2006; Hall, Hill, Appleton, & Kozub, 2009; Thompson & Waltz, 2008) and Serbian (0.75; Stankovic & Vukosavljevic-Gvozden, 2011).

Conversely, alpha was only 0.61 in a sample of British male youth (average age = 14) soccer players (Hill, Hall, Appleton, & Kozub, 2008). The readability of the USAQ-R is estimated at a grade level of 5.8, averaging across several formulae available at http://www.readability-score.com/. Fifth to sixth grade reading level is typical of major broadband normal adult personality inventories (Schinka & Borum, 1994) but may be excessive for youth samples.

A review of all English-language published articles citing the USAQ-R revealed no studies of its retest reliability, which is a major gap in knowledge about the test as a measure of a presumably enduring individual-difference characteristic.

Norms. There have been no systematic epidemiological studies using the USAQ-R, so it is not possible to identify scores on the test suggestive of abnormally low or high self-acceptance. For what it is worth, however, the mean score in a college student convenience sample in Chamberlain and Haaga (2001b) was 82.78 (SD = 17.28). Mean scores within one-third of one standard deviation above or below this value have been reported for Canadian (Flett, Besser, Davis, & Hewitt, 2003), British (Davies, 2006, 2007a, 2007b) or Serbian (Stankovic & Vukosavljevic-­Gvozden, 2011) university students, a nonclinical British adult sample (Scott, 2007), and British middle distance runners with average age of 40 (Hall et al., 2009). The score distribution did not differ significantly from normality in Stankovic and Vukosavljevic-Gvozden (2011), and no significant sex differences have been obtained (Scott, 2007; Stankovic & Vukosavljevic-Gvozden, 2011). Thus, pending assessment of a truly representative sample, it seems that adult samples of either sex can be expected to average in about the mid-80s, with about two-thirds of respondents scoring 70–100, on the USAQ-R.

Validity. There have been no studies relating the USAQ-R to other indicators of self-acceptance, and as such its convergent validity is unknown.

What might be viewed as concurrent validity studies of the USAQ-R (cross-­sectional associations with measures of criteria to which a valid measure of self-­acceptance should relate) are also interpretable as studies of the correlates of self-acceptance. Such studies have found inverse relations of self-acceptance with depressive symptoms (Chamberlain & Haaga, 2001a; Flett et al., 2003; Scott, 2007; Stankovic & Vukosavljevic-Gvozden, 2011), self-rated proneness to depression (Chamberlain & Haaga, 2001b), anxiety (Chamberlain & Haaga, 2001a; Stankovic & Vukosavljevic-Gvozden, 2011), anger (Stankovic & Vukosavljevic-Gvozden, 2011), perfectionism (Flett et al., 2003; Hall et al., 2009; Scott, 2007), irrational beliefs (Davies, 2006, 2007b), irrational beliefs about parenting in particular (Gavita, David, DiGiuseppe, & DelVecchio, 2011), neuroticism, and conscientiousness (Davies, 2006). Positive correlations of USAQ-R scores have been obtained with happiness, life satisfaction, state mood after an imaginal setback in a lab study (Chamberlain & Haaga, 2001a), and mindfulness (Thompson & Waltz, 2008).

Multivariate analyses have shown USAQ-R scores to mediate the association of socially prescribed perfectionism with either depressive symptoms (Flett et al., 2003; Scott, 2007) or exercise dependence (Hall et al., 2009).

Cross-sectional correlations are of course indeterminate as to direction of causality. A creative experimental method employed by Davies (2007a) entailed reading and concentrating on self-statements varying in the degree of self-acceptance implied, or in other experimental conditions’ statements varying with respect to irrationality. Results indicated that priming irrational beliefs in this manner lowered self-acceptance scores (and priming rational beliefs raised them), whereas there was no reverse effect of self-acceptance priming on irrational beliefs. The specific beliefs showing this effect the most clearly were self-downing, need for achievement, and need for approval (Davies, 2007b). Further research in this vein would be interesting, in particular if converging operations were employed in priming self-­acceptance. It is not clear whether the manipulation of USA failed to alter irrational beliefs because self-acceptance is more an effect than a cause of rationality, or if the intended manipulation of USA actually failed to induce self-acceptance.

Discrimination from Self-Esteem. Surprisingly, despite the derivation of the USAQ from REBT theory with its emphasis on distinguishing self-acceptance from self-esteem, the scale has turned out to be just about as highly correlated with self-­esteem as were earlier measures of self-acceptance. Indeed, studies consistently show the USAQ to be strongly positively correlated with measures of self-esteem, with correlations ranging from 0.51 to 0.59 (Chamberlain & Haaga, 2001a, 2001b; Davies, 2006; Stankovic & Vukosavljevic-Gvozden, 2011; Thompson & Waltz, 2008). There are at least three possible ways to interpret this result. First, trait self-­esteem measures may be confounded by self-acceptance and thus lack discriminant validity. The frequently used Rosenberg (1965) Self-Esteem Scale, for instance, includes the reverse-keyed item “I certainly feel useless at times.” “Useless” of course conveys a negative self-rating, but “at times” implies that the negative self-­rating is conditional, and a person endorsing this item may be making as much of a statement about his or her lack of self-acceptance as about his or her low self-esteem.

Second, self-esteem and self-acceptance may actually be validly correlated. Assuming no mortals actually completely forego self-rating, perhaps those high in self-acceptance are more likely to rate themselves favorably when they do think in terms of global self-evaluation (Chamberlain & Haaga, 2001a).

Finally, perhaps the sizable positive correlation of the USAQ-R with self-esteem reflects at least in part a lack of discriminant validity on the part of the USAQ-R. Researchers who consider this hypothesis plausible have adopted two distinct strategies for addressing it empirically. First, one can control statistically for self-esteem in computing partial correlations of self-acceptance with other indicators. Using this method, self-acceptance was not significantly related to depression, happiness, or life satisfaction (Chamberlain & Haaga, 2001a). However, it was negatively correlated with anxiety and narcissism (Chamberlain & Haaga, 2001a) as well as labile self-esteem and depression proneness (Chamberlain & Haaga, 2001b) and irrational beliefs (Davies, 2007b). Self-acceptance, controlling for self-esteem, was also positively associated with being objective about one’s own performance in a public speaking task and negatively associated with (presumably defensive) denigration of peers who had ostensibly provided critical evaluation of the subject’s speech (Chamberlain & Haaga, 2001b).

An alternate strategy for measuring self-acceptance independent of self-esteem was developed by Davies (2006). A joint factor analysis of the USAQ along with a self-esteem measure revealed that 11 USAQ items belonged on the first factor along with self-esteem items. The other nine USAQ items formed a second factor distinct from self-esteem, scores on which were not significantly correlated with self-­esteem. This purified self-esteem-free self-acceptance indicator was not correlated with any of the Big five personality dimensions but was negatively correlated with irrational beliefs (Davies).

Future Research Directions on Unconditional Self-Acceptance

In sum, research using the USAQ-R paints a flattering picture of the self-acceptor. People scoring high in self-acceptance report being less depressed, anxious, angry, perfectionistic, or irrational. They are higher in self-esteem, but this association—even if viewed entirely as an undesirable measurement problem—does not seem to account for all the results. Self-acceptance, independent of self-esteem, appears to be associated with low anxiety, low narcissism, low depression proneness, low levels of irrational beliefs, and a greater ability to be objective about one’s own behavior and gracious in response to criticism. Research on causal models is scarce, but mediational models indicate that self-acceptance may help explain a link between socially prescribed perfectionism and depression, and initial experimental work indicates that low self-acceptance may be a consequence rather than cause of irrational beliefs.

Many measurement and substantive questions about unconditional self-­acceptance remain. As noted earlier, there is no research on the retest reliability or the convergent validity of the USAQ-R. It could also be useful to develop a peer-­report version of the USAQ-R for completion by people who know the respondent well. Ryff (1995) made a similar point in relation to the SPWB as a self-report measure, noting that in certain contexts respondents may be prone to giving unrealistic but socially desirable descriptions of themselves as highly self-accepting.

Also, no research has tested whether REBT increases self-acceptance, whether it does so specifically (i.e., more powerfully than do other psychotherapies) or preferentially (i.e., more so than it influences self-esteem), or whether its effects on psychological disorders are mediated by its effects on self-acceptance. There is therefore a pressing need for treatment research on self-acceptance.

It would also be helpful to get a greater sense of the developmental origins of unconditional self-acceptance, in particular whether specific parenting or teaching practices that cultivate self-acceptance could be identified.

There is no information on normal age-related changes in self-acceptance, for instance whether old age might tend to increase it as the struggle to attract a mate and to achieve a certain level of professional accomplishment begins to recede for most people.

Associations of unconditional self-acceptance with clinical disorders remain largely untested. Whether unconditional acceptance of the self is associated with acceptance of more circumscribed aspects of psychological functioning (e.g., distress tolerance, low experiential avoidance) is unknown.

Finally, the specific mechanisms by which high self-acceptors protect themselves from excessive distress in the wake of setbacks are unknown. That is, it is one thing to say that self-acceptors become less distressed by negative feedback and therefore have no need to denigrate those giving them the feedback (Chamberlain & Haaga, 2001b), but a further question of interest is how in particular they achieve this effect. It could be for instance that they use specific self-instructions (“her perception that I messed up does not make me a louse; I just need to consider the feedback carefully and decide whether there is anything I can take from it to try to do better next time”) that others might be encouraged to emulate. Or it could be that self-acceptance, at least in adulthood, is an overlearned response not requiring explicit attention except perhaps in more extreme negative situations.