From my first days in psychiatry residency, I’ve repeatedly heard about “coming to terms” as a goal of psychotherapy. So, for decades now, I dutifully nod my head knowingly when hearing or reading about “coming to terms.” But one day, I finally stopped to consider: What does “coming to terms” mean? Does coming to terms confer healing or respite from distress? If so, who would benefit from coming to terms and under which circumstances? What interventions should I, as the clinician, undertake to aid the patient to come to terms? And what does the patient need to do? And last, how does the patient know that he or she has finally come to terms and what benefits would they experience? Today I begin to develop answers to some of these questions and continue this topic in future posts. The good news is that coming to terms is important, it is achievable, and we can help!

What Does Coming to Terms Mean?

Dictionary definitions of ‘coming to terms’ invariably include ‘acceptance’ as both the process and aim of coming to terms. The experience that must be accepted is commonly described as a sad or distressing one.

First, a clarification on my use of the word ‘experience.’ This is the catch-all word I use to refer to the sad and distressing aspect of existence that is the focus of concern, that is, the focus that triggers consideration of whether to come to terms with it or not come to terms with it. An experience can refer to an event (or series of events) a person has lived through, such as a traumatic one; but it can also refer to an aspect of one’s self that one is sad or distressed about, such as the realization of one’s lack of talent in some area of endeavor; to the situation one finds one’s self in, such as a bad marriage; to a severe loss, such as death of a loved one or breakup with a significant other; or to the state of affairs of the world, such as societal turmoil or political defeat.

Since coming to terms is a process, this allows dividing the interval of time that started immediately following the distressing experience, and that continues into the present into three periods: 1) a time period prior to embarking on the process of coming to terms, 2) a time period of coming to terms, and 3) a time period when the coming to terms, that is, the process of acceptance, has been achieved. Of course, a person, our patient perhaps, may find themselves in any one of these periods. It helps to be able to identify which it is with the understanding they these phases of change gradually transition and overlap.

During the first time period (the time prior to embarking on the journey of coming to terms) the person may be 1) aware of feeling ongoing distress or other impact but not be aware that their distress or other impact is related to the distressing experience,  2) aware that their distress is related to the distressing experience but lacks awareness of the possibility of trying to gain acceptance and subsequent resolution, or 3) is aware of both their distress being related to the distressing experience and the possibility of coming to terms but for whatever reason is not yet ready to embark on coming to terms. This unwillingness or inability may relate to the taking of a moral stance, such as not wanting to forgive someone who caused harm, or to an emotional unwillingness to face the pain that could come from focusing on the triggering sad or distressing experiences, or to a belief that one does not have the agency or skill to successfully come to terms with them.

Thus, these factors can lead to years or decades of continued sadness and distress as well as various behavioral consequences to the ongoing lack of coming to terms, such as the use of various coping strategies whose goal is to decrease distress but whose outcome is to increase and prolong it. Many coping strategies turn out to be maladaptive; that is, not only are they unlikely to resolve the person’s distress, but can make it worse, especially in the medium to long term. Of course, no one uses maladaptive coping strategies knowing they are maladaptive; they’re doing the best they can. What often camouflages the maladaptive nature of certain coping strategies is that they often decrease distress in the short term, like drinking alcohol to quickly reduce distress, but increase the distress and its burden overall.

Then, at some point soon after or far distant in time from the distressing experience, the person embarks on a process of coming to terms with it. This implies that the distressed person realizes and / or decides that their life cannot go on as it is under the continued distress of the unresolved experience. Thus, the pain of continued lack of coming to terms overcomes whatever the source of their reluctance to come to terms is. If this process of acceptance was quick and easy, it wouldn’t be an issue and we wouldn’t be discussing it; we may not even have a word for it, but we do and this implies that coming to terms, at least for some people in some circumstances, is both desired and hard to achieve. It is at this point that a person may come to mental health treatment for help.

Next time I pick up here and discuss details of what needs to happen for successful coming to terms to occur, including what we as clinicians can do guide the patient to it. Feel free to email me with questions, concerns, comments, stories.

Thanks and take care.

Dr. Jack

“I carry the bars within me.” – Franz Kafka

“Time doesn’t always heal all wounds.” – A.J. Darkholme

“Healing is a coming to terms with things as they are, rather than struggling to force them to be as they once were or as we would like them to be, to feel secure or to have what we sometimes think of as our own way.” – Jon Kabat-Zinn

“We don’t see things as they are, we see them as we are.” – Anaïs Nin

“A mind forever Voyaging through strange seas of Thought, alone.” – William Wordsworth