BETH-00503; No of Pages 9; 4C:
Available online at www.sciencedirect.com
ScienceDirect Behavior Therapy xx (2014) xxx – xxx www.elsevier.com/locate/bt
What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure? Martin Wolgast Lund University
The present study seeks to investigate the extent to which the Acceptance and Action Questionnaire (AAQ-II) is successful in discriminating between experiential avoidance/psychological flexibility on the one hand and the supposed outcomes in terms of psychological well-being of having this trait on the other. This was done using exploratory factor analysis on an item pool containing the AAQ-II items, and items designed for the present study to measure distress and acceptance/ non-acceptance, to see what factors are identified and on which factor(s) the AAQ-II items had the highest factor loadings. Interestingly, the analysis found the items of the AAQ-II to be more strongly related to items designed to measure distress than items designed to measure acceptance/ nonacceptance with minimal references to functional outcomes. The results of the study are interpreted and discussed in relation to the widespread use of the AAQ in both clinical and scientific contexts and given the centrality of the measure in empirically validating the ACT model of psychopathology and treatment.
Keywords: AAQ-II; acceptance; ACT; experiential avoidance; psychological flexibility
DUE TO THE IMPACT OF—AND the widespread interest in—the so-called third wave of behavior therapies in general and in Acceptance and Commitment Therapy (ACT) in particular, the constructs acceptance, experiential avoidance, psychological flexibility, and psychological inflexibility have received a lot of
Address correspondence to Martin Wolgast, Lund University, Department of Psychology, Box 213, 221 00 Lund, Sweden; e-mail: [email protected]. 0005-7894/© 2014 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
scientific and clinical attention during recent years (see, for example, Aldo, Nolen-Hoeksema, & Schweizer, 2009; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Kashdan & Rottenberg, 2010; Öst, 2008). In ACT, “experiential avoidance” was originally put forth as a construct referring to the unwillingness to remain in contact with aversive private experiences and taking action to avoid and/ or alter them (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), and is conceptualized as critical in the development and maintenance of psychopathology (Hayes et al., 1999). In contrast, “acceptance” is often referred to as the willingness to experience aversive or unwanted private events while pursuing one’s values and goals (Hayes et al., 1999). In recent years, the emphasis on acceptance and experiential avoidance has shifted somewhat towards the broader concepts of psychological flexibility and psychological inflexibility (Bond et al., 2011). The definitions of psychological flexibility and psychological inflexibility, however, are quite similar to those of experiential avoidance and acceptance. Psychological flexibility is defined as “the ability to fully contact the present moment and the thoughts and feelings it contains without needless defense, and, depending on what the situation affords, persisting in or changing behavior in the pursuit of goals and values” (Hayes et al., 2006). Psychological inflexibility, on the other hand, refers to a “rigid dominance of psychological reactions over chosen values and contingencies in guiding actions” (Bond et al.), which often occurs when people attempt to avoid experiencing private events. In this view, acceptance and experiential avoidance are seen as examples of psychological flexibility and inflexibility, which are still appropriate to use in clinical contexts, where the present moment contains thoughts and feelings that people might not wish to be in contact with (Bond et al.). The concepts of psychological flexibility/
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
2
wolgast
inflexibility are mainly intended to broaden the applicability of the model to also include contexts where the avoidance of unwanted internal events are not the main focus (Bond et al.), for example, in sporting skills and job performance (Bond, Flaxman, & Bunce, 2008). As previously stated, the constructs of experiential avoidance/psychological inflexibility and acceptance/ psychological flexibility have received significant attention within clinical psychology during the last 15 years. In an empirical review made in 2007, Chawla and Ostafin identified 28 studies published between 1999 and 2006, specifically examining the role of experiential avoidance in the etiology, maintenance, and treatment of maladaptive behavior and psychopathology. The general conclusion was that experiential avoidance was significantly associated with a wide array of behavioral problems as well as psychopathology. Additionally, Hayes et al. conducted a meta-analysis in 2006 involving 32 studies and 6,628 participants, investigating the relationship between experiential avoidance and various measures of psychological well-being, psychopathology, and quality of life and concluded that experiential avoidance as measured by the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) accounted for 16% to 28% of the variance in health-related outcome measures. Other studies of individual differences in levels of experiential avoidance have found that it is related to likelihood of relapse in substance abuse (Stewart, Zvolensky, & Eifert, 2002), has a strong relationship to anxiety-related symptoms and mediates the relationship between other regulatory strategies (including cognitive reappraisal) and these symptoms (Kashdan, Barrios, Forsyth, & Steger, 2006), predicts severity of symptoms in specific psychiatric disorders such as GAD (Roemer, Salters, Raffa, & Orsillo, 2005), and mediates the relation between traumatic events and general psychological distress (Batten, Follette, & Aban, 2001; Marx & Sloan, 2002). Furthermore, in studies of psychological treatments and interventions, changes in experiential avoidance have been shown to mediate the effect of treatments explicitly aimed at reducing it (e.g., Bond & Bunce, 2000; Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Lillis, Hayes, Bunting, & Masuda, 2009). Additionally, in a recent review by Kashdan and Rottenberg (2010), it is shown that psychological flexibility—broadly defined—is a prominent factor in understanding psychological health. Hence, there seems to be empirical support for the suggestion that experiential avoidance/ psychological inflexibility is of significant importance in relation to the development, maintenance, and treatment of psychopathology. Before drawing
this conclusion, however, one needs to establish that the construct in question has been operationalized in a way that makes the conclusion valid. This is of particular importance in the present case: Many of the studies referred to above, and the vast majority of studies examining psychological flexibility/ experiential avoidance, have relied upon the AAQ as a valid operationalization of the construct. Thus, given the centrality of this specific measure in determining the results, it is important to critically reflect upon the measure and whether factors other than the psychological phenomena it is supposed to measure might explain parts of the findings from the studies. One such potential source of confounded measurement is if the items that are supposed to measure experiential avoidance/psychological flexibility, contain formulations related to adaptive or maladaptive outcomes in terms of psychological distress, well-being, or functioning. Indeed, in a few previous studies, the AAQ has been briefly criticized for not making a clear enough distinction between process and outcome (Chawla & Ostafin, 2007), and for not having sufficient discriminant validity in relation to negative affectivity or neuroticism (Gámez, Chmielewski, Kotov, Ruggero, & Watson, 2011). More often, however, the AAQ was criticized for having some shortcomings regarding comprehensibility and reliability (Bond et al., 2011), and when revising the measure and constructing a new version of the AAQ (AAQ-II; Bond et al.), the focus was mainly on addressing these last two issues. The relative lack of discussion regarding the construct validity of the AAQ appears remarkable given the centrality of the measure in validating central theoretical assumptions from an ACT perspective and the fact that many of the items are problematic in regard to the discussion above. For example, the nine-item version of AAQ-I contains the item, “When I compare myself with other people, it seems most of them are handling their lives better than I do” (Item 7), which clearly incorporates formulations related to outcome, thus risking circularity in measurements. Items 4, 5, and 9 can also be subjected to this kind of criticism. For example, Item 5 (“I am not afraid of my feelings”) might receive a high score either if the respondent has strong aversive feelings but is not afraid of them or if the respondent in general has low levels of negative emotionality and therefore does not experience feelings as a problem. Additionally, Item 4 (“I rarely worry about getting my anxieties, worries, and feelings under control”) might receive similar scoring based on significantly different processes: one might score high on the item if (a) one does not try to control one’s feelings; (b) if one regularly tries to control one’s feelings, is successful in doing so, and therefore does not worry about it; or (c) if one has very
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? low levels of anxiety and worries so that controlling them seldom seems to be an issue to worry about. Similarly, Item 9 (“If I could magically remove all painful experiences I’ve had in my life, I would do so”) might discriminate between subjects solely on the basis of how many “painful experiences” they have had in their lives, not only on the basis of how they relate to these experiences. As previously stated, a new version of the AAQ (AAQ-II) was published in 2011, consisting of seven items measuring psychological inflexibility or experiential avoidance (Bond et al., 2011), and it has since been translated into several languages (e.g., Cao, Ji, & Zou, 2013; Pennato, Berrocal, Bernini, & Rivas, 2013) and used in clinical studies (e.g., Meyer, Morissette, Kimbrel, Kruse, & Gulliver, 2013). The items of the AAQ-II are presented in Table 1. Unfortunately, the items in this new version can, based on their content, be subjected to the same criticism of confounding process or trait with outcome: for many of the items it is hard to distinguish if a specific response is grounded in levels of psychological inflexibility/experiential avoidance or, for example, in levels of experienced aversive emotions, memories, and worries. The authors of the AAQ-II briefly addresses the issue of discriminant validity by conducting a confirmatory factor analysis to test if the AAQ-II and the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996) are best represented by a oneor two-factor model. In this analysis a two-factor model (with BDI-II and AAQ-II as separate factors) provided a significantly better fit than a one-factor model (Bond et al., 2011), indicating that the scales do not measure the same construct. To claim that the AAQ-II does not measure the same construct as the BDI-II, however, addresses only parts of the problem
3
discussed above. It still remains unclear how well the scale distinguishes between experiential avoidance or psychological inflexibility as an approach or attitude toward private events on the one hand and the supposed outcome of this approach in terms of emotional problems and experienced life satisfaction on the other. Furthermore, the difference in item style and wording between the BDI-II and the AAQ-II renders a one-factor solution less likely for other reasons than that they refer to distinct underlying psychological traits or processes. In developing their broader, multidimensional measure of experiential avoidance (the Multidimensional Experiential Avoidance Questionnaire; MEAQ), however, Gámez et al. (2011) raised the problem with the discriminant validity of the AAQ and the AAQ-II in relation to neuroticism. They also compared the correlations between the MEAQ and the AAQ with measures of negative affectivity and neuroticism, and indeed consistently found the AAQ (both I and II) to be more strongly associated with neuroticism (Gámez et al.). Additionally, in a recently published article, where a brief version of the MEAQ is presented, this issue of confounded measurements is raised even more clearly, and the items selected for the brief version tries to further reduce this problem (Gámez et al., 2014). In part, the problem discussed above might be seen as a natural consequence of the explicitly functional framework in which the ACT model is situated. In this context it is logical that the focus is shifted from emotion regulation as traditionally defined toward effective living (Blackledge & Hayes, 2001). Nonetheless, when the acceptance or psychological flexibility is measured and operationalized as a psychological trait (e.g., Hayes et al., 2006) that can be compared to, or even explain the effects of, other
Table 1
Items of the AAQ-II, Distress and Acceptance Scales AAQ-II
Distress
Acceptance
1. My painful experiences and memories 1. I often feel depressed, worried 1. I often try to control or change my thoughts and make it difficult for me to live a life that I or anxious. feelings. would value. 2. I’m afraid of my feelings. 2. I worry a lot. 2. When I feel depressed, worried or anxious, I do not try to influence or change these feelings. 3. I worry about not being able to control 3. I have many problems in my life. 3. I let my thoughts and feelings come and go, my worries and feelings. without trying to control or avoid them. 4. My painful memories prevent me from 4. I have lots of painful memories. 4. I do the things I want to do, even if it makes me having a fulfilling life. feel nervous or anxious. 5. Emotions cause problems in my life. 5. I am not happy with the way my 5. When I feel anxious, worried or depressed, I note life is. these feelings but live my life the way I want to. 6. It seems like most people are handling 6. When I feel depressed, worried or anxious, I do their lives better than I am. not try to avoid these feelings. 7. Worries get in the way of my success. 7. When I feel depressed, worried or anxious, I try to influence or change these feelings. Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
4
wolgast
approaches to private events (Boulanger, Hayes, & Pistorello, 2010), it seems of central importance to clarify the distinction between the trait on the one hand and the outcome of having this trait or the extent to which one has, for example, emotional problems on the other. The purpose of the present study was to provide an empirical investigation of the extent to which the AAQ-II succeeds in making this distinction that goes beyond what can be achieved by correlating the scale with measures of similar and different constructs. In this context, it should be noticed that the study did not aim to develop a new and improved measure of experiential avoidance/ psychological inflexibility (indeed, the originators of the MEAQ have taken promising steps in that direction; Gaméz et al. 2011; Gamez et al., 2014). Rather, the purpose was to provide an in-depth empirical analysis of the most widely employed measure of experiential avoidance/psychological inflexibility, namely, the AAQ.
The Present Study: Purpose and Hypotheses As previously stated, the main purpose of the present study was to empirically investigate the extent to which the AAQ-II differentiates between psychological inflexibility/experiential avoidance as a psychological trait and the supposed outcome of having high or low levels of this trait in terms of psychological well-being and functioning. This was done using exploratory factor analysis (EFA) on an item pool containing the AAQ-II items, and items designed for the present study to measure distress and acceptance/nonacceptance, to see what factors are identified and on which factor(/s) the AAQ-II items had the highest factor loadings. Given the problematic design of the AAQ-II items described above, the hypothesis was that the items of the AAQ-II to a large extent would fall onto the same factor as items designed to measure distress rather than acceptance/nonacceptance. The choice to use exploratory rather than confirmatory factor analysis (CFA) in this part of the study was based upon findings indicating that CFA is overly restrictive when conducting item level analyses (e.g., Marsh et al., 2010).
Method participants Sample 1: ACT Therapists To validate the items constructed to measure acceptance and distress (see below), the items were presented in an online questionnaire to a sample of therapists working with ACT. Participants were recruited via a group on Facebook for therapists working with ACT and answers were obtained from 30 participants. Of these, 80% were licensed
psychologists, 10% were medical doctors, and 10% stated “other” as their profession. Thirty percent of the participants had worked with ACT between 1 and 5 years, 50% between 5 and 10 years, and 20% more than 10 years. Eighty percent stated that they had received training and education in ACT and 20% stated that they had educated and trained others in working with ACT. Sample 2: Sample for the Main Study For the analysis of the AAQ-II items in relation to the items constructed to measure distress and acceptance, convenience sampling was used for participants recruited on campus and other public places. To be eligible for the study, participants had to be fluent in Swedish and at least 18 years old. Four hundred and six individuals participated in the study by completing all of the questionnaires. Of these, 53% were women and 47% were men. The average age was 24.6 years, with a span from 18 to 63 (SD = 7.5). Seventy-nine percent stated “student” as their main occupation, 16% stated “employed,” 3% stated “unemployed,” and 2% stated “other.”
measures Acceptance and Action Questionnaire–II (AAQ-II) The AAQ-II (Bond et al., 2011) is a 7-item measure of psychological inflexibility/experiential avoidance. Answers are given on a 7-point scale ranging from 1 = never true to 7 = always true. The Swedish version of the scale used in the present study has been translated using a translation and back translation procedure and showed good internal consistency (α = .90) in the present study. Positive and Negative Affect Scale (PANAS) To assess dispositional positive and negative emotionality, participants completed the trait version of the PANAS (Watson, Clark, & Tellegen, 1988). The PANAS is a 20-item mood adjective checklist designed to measure the Positive Affect (PA) and Negative Affect (NA) factors and has shown satisfactory psychometric properties in previous research (Watson et al., 1988). To complete the PANAS, participants were instructed to use a 5-point scale (1 = very slightly or not at all; 5 = extremely) to indicate “to what extent you generally feel this way, that is, how you feel on the average” for each adjective. The Swedish version of the scale showed adequate internal consistency for both PA and NA in the present study (PA: α = .78; NA: α = .86). Distress Five items measuring psychological distress were rationally constructed using the items from the AAQ-II as templates in order to construct items
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? similar in wording and style and possible to answer on the same 7-point scale (with the same verbal anchors as used in the AAQ-II), though clearly measuring aspects of psychological distress. The items are presented in Table 1. Analyzing the items as a separate scale indicated good internal consistency (α = .85), which the deletion of any of the included items would reduce. The average score was 3.1 (scale mean divided by number of items) with a standard deviation of 1.4, and the average item score ranged from 2.6 to 3.8. Acceptance For the present study, 7 items were rationally constructed to assess acceptance/nonacceptance in a way that explicitly tried to separate strategy/trait from outcome or relative presence of distress. This was done in different ways depending on item content, but the main strategy was to include explicit formulations referring to the presence or absence of active control efforts and clear reference to actions performed in the actual presence of aversive inner states. As with the items measuring psychological distress, the items were constructed using the items from the AAQ-II as templates in order to produce items that were similar in wording and style and possible to answer on the same 7-point scale as the items from the AAQ-II, using identical verbal anchors. The items are presented in Table 1. Analyzing the items as a separate scale (with Items 1 and 7 reverse scored) indicated adequate internal consistency (α = .75), which the exclusion of any of the included items would reduce. The average score was 3.9 (scale mean divided by number of items) with a standard deviation of .93, and the average item score ranged from 3.2 to 4.7. Questionnaire to ACT Therapists In order to provide a test of the construct validity of the items in the Acceptance and Distress scales, a questionnaire was administered to therapists working with ACT (see above for sample description). The questionnaire listed all 12 items and the participants were asked to assess to what degree they judged that each item was measuring acceptance/nonacceptance (as standardly conceived in ACT) and psychological distress. Answers were given on a 5-point scale (1 = not at all; 5 = to a very large extent).
data analysis Data analysis proceeded through several steps. First, to test the construct validity of the constructed scales and item, the data from the questionnaire administered to ACT therapists were analyzed by comparing average scores on item and scale level to see whether there were significant differences in the extent to which the different items were judged as
5
measuring acceptance and distress. To further test the validity of the constructed scales, scale scores (Distress and Acceptance) were correlated with the PANAS-N and PANAS-P scales as a partial test of their conceptual validity. In these analyses the predicted outcome pattern was that the Distress scale would be positively correlated with the PANAS-N and negatively correlated with PANAS-P, whereas the opposite pattern was predicted for the Acceptance scale. In addition, given that the Distress scale was supposed to measure emotionality and experiential content whereas the Acceptance scale was designed to measure psychological and behavioral strategies in separation from emotionality, it was predicted that the conceptual overlap between the Distress scale and the PANAS would be greater than that between the PANAS and the Acceptance scale. Hence, the correlations between the Distress scale and the PANAS subscales were predicted to be significantly stronger than the correlations between the Acceptance scale and the PANAS subscales. In the second step of the data analysis, an exploratory factor analysis using principal axis factoring and promax rotation was performed on an item pool consisting of the items from the AAQ-II and the items from the Distress and Acceptance scales (in total 19 items). Promax rotation was used since the factors were expected to be correlated. Prior to running the analysis, parallel analysis (Thompson, 2004) was performed to determine the number of factors to extract.
Results construct validity of the distress and acceptance scales The data from the questionnaire administered to ACT therapists were analyzed to investigate the construct validity of the constructed items and scales. Results are presented in Table 2. On scale level, the Acceptance scale was assessed as measuring acceptance to a significantly larger extent than what the Distress scale did, t(29) = 14.37, p b .01, and the Distress scale was assessed as measuring distress to a significantly larger extent than what the Acceptance scale did, t(29) = 6.90, p b .01. In addition, the Acceptance scale was judged as measuring acceptance significantly better than distress, t(29) = 9.83, p b .01, whereas the opposite was true for the Distress scale, t (29) = 9.68, p b .01. When analyzing data on item level, the results from Bonferonni-corrected paired sample t-tests revealed significant differences between the mean on the acceptance and distress ratings for all items (all p-values b .001). Hence, the performed analyses indicated adequate construct validity for the constructed items as well as for the aggregated scales.
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
6
wolgast
Table 2
Ratings of Content by ACT Therapists, Scale and Item Means MAcceptance (SD) MDistress (SD) (N = 30) (N = 30)
Acceptance scale 1. I often try to control or change my thoughts and feelings. 2. When I feel depressed, worried or anxious, I do not try to influence or change these feelings. 3. I let my thoughts and feelings come and go, without trying to control or avoid them. 4. I do the things I want to do, even if it makes me feel nervous or anxious. 5. When I feel anxious, worried or depressed, I note these feelings but live my life the way I want to. 6. When I feel depressed, worried or anxious, I do not try to avoid these feelings. 7. When I feel depressed, worried or anxious, I try to influence or change these feelings. Scale average
4.2 4.1 4.9 4.8 4.9 4.5 3.7 4.4
(1.0) (1.1) (.3) (.4) (.3) (.7) (1.4) (.6)
2.1 1.6 2.0 1.9 2.7 1.7 1.7 1.9
(1.2) (.8) (1.4) (1.2) (1.4) (.9) (.9) (1.0)
Distress scale 1. I often feel depressed, worried or anxious. 2. I worry a lot. 3. I have many problems in my life. 4. I have lots of painful memories. 5. I am not happy with the way my life is. Scale average
1.6 1.9 1.8 1.6 2.2 1.8
(.7) (1.2) (.8) (.8) (.8) (.6)
4.1 4.0 3.9 3.5 3.9 3.9
(1.0) (1.1) (.7) (1.3) (1.0) (.9)
relationships between the constructed scales, the aaq-ii and the panas The constructed Distress and Acceptance scales were correlated with the PANAS-N and PANAS-P (see above under the data analysis section). Results are presented in Table 3 and are consistent with the predicted outcome pattern. To test the prediction that the correlations would be stronger between the Distress scale and the PANAS scales than between the Acceptance scale and the PANAS scales, Fisher’s r-to-z test was used to test whether the correlation coefficients differed significantly from each other in the predicted direction. The results supported the prediction (PANAS-P: z = 5.45, p b .01; PANAS-N: z = 7.26, p b .01), indicating that the Distress scale, as expected, contained a stronger component of emotionality and experiential content when compared to the Acceptance scale. When correlating the AAQ-II with the PANAS subscales, the results indicate correlations as strong as for the constructed Distress scales and significantly stronger than what was found for the constructed Acceptance scale (PANAS-P: z = 6.59, p b .01; PANAS-N: z = 8.18, p b .01). Table 3
Bivariate Correlations Between the Distress Scale, the Acceptance Scale, AAQ-II, PANAS-N and PANAS-P (N = 406)
PANAS-N PANAS-P ⁎ p b .01.
Distress
Acceptance
AAQ-II
.64 ⁎ -.55 ⁎
-.24 ⁎ .23 ⁎
.67 ⁎ -.61 ⁎
factor analysis A principal axis factoring parallel analysis (Thompson, 2004) indicated that only the first three factors in the actual data exceeded the corresponding eigenvalues in a normally distributed random score matrix of the same rank. Hence, three factors were extracted in the subsequent EFA. The three factors had eigenvalues of 6.6, 2.5, and 1.6 and accounted for 36.8%, 14.1%, and 8.9% of the variance, respectively. Overall, the extracted factors accounted for 59.8% of the variance. Table 4 displays the pattern matrix of the three promaxrotated factors. Items that loaded at least .40 on one factor were assigned to a specific factor based on their highest loading. All of the items included in the analysis were assigned to a factor. As can be seen in Table 4, all of the items from the AAQ-II loaded on the same factor as the items designed to measure distress (Factor 1), whereas Factor 2 consists of items related to the control or avoidance of thoughts and emotions and Factor 3 consists of two items relating to behavioral flexibility and goal-directed behavior in the presence of aversive emotions. correlation between factors Given that the resulting factors were expected to be correlated, between factor bivariate correlations were computed to investigate the relationships between the identified factors (Table 5). Factor scores were created by summing the scores on the items assigned to each factor. The results reveal significant correlations between all three factors, where the strongest
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
7
what does the aaq-ii really measure? Table 4
Factor Loadings for Each Item on the Three Factors Item
Factor 1 b
I often feel depressed, worried or anxious .83 .81 Worries get in the way of my success a My painful memories prevent me from having .81 a fulfilling life a My painful experiences and memories make .79 it difficult for me to live a life that I would value a It seems like most people are handling their .77 lives better than I am a .72 I worry a lot b I have many problems in my life b .72 .68 Emotions cause problems in my life a .69 I have lots of painful memories b I worry about not being able to control my .61 worries and feelings a .57 I’m afraid of my feelings a .48 I am not happy with the way my life is b When I feel depressed, worried or anxious, I .01 do not try to influence or change those feelings c When I feel depressed, worried or anxious, I .08 try to influence or change those feelings c I often try to control or change my thoughts .23 and feelings c I let my thoughts and feelings come and go, .00 without trying to control or avoid them c When I feel depressed, worried or anxious, I .10 do not try to avoid those feelings c I do the things I want to do, even if it makes .07 me feel nervous or anxious c When I feel anxious, worried or depressed, I -.16 note those feelings but live my life the way I want to c
2
3
.02 -.05 -.00 -.03 -.06 .20 -.08
.18
-.03 -.13 .16 .05 -.00 -.11 .06 -.13 -.44 .10 .18 .08 .24 .05 -.11 -.34 -.73 -.18
.60
.34
.61 -.06 -.52
.36
-.55
.25
.09
.79
-.07
.44
a = Item from the AAQ-II; b = Item originally constructed to measure distress; c = Item originally constructed to measure acceptance/nonacceptance. Numbers in boldface indicate factor loading on the factor the item was assigned to.
correlation is found between Factor 2 (Control/ avoidance) and Factor 3 (Behavioral flexibility).
Discussion The present study sought to investigate the extent to which the AAQ-II is successful in discriminating
between experiential avoidance/psychological flexibility on the one hand and the outcomes in terms of psychological well-being of having this trait or behavioral pattern on the other. Based on a critical examination of the items of the AAQ-II, the assumption was that there exists a problem with regard to the discriminant validity of the AAQ-II in terms of an overlap between the way experiential avoidance/psychological flexibility is operationalized and measures of psychological well-being, thus risking circularity of measurements and an overestimation of the association between experiential avoidance/psychological flexibility and different health-related outcome measures. The findings of the performed exploratory factor analysis indeed showed that the items of the AAQ-II loaded on the same factor as items designed to measure general distress and did not load on the same factor as the items that were designed to measure acceptance/ nonacceptance as an explicit attitude or response to aversive psychological states. Furthermore, when comparing the association between the scales and the PANAS, the AAQ-II was found to have an identical pattern of correlations to the measures of negative and positive emotionality as the constructed Distress scale had, whereas the correlation was significantly weaker for the constructed Acceptance scale. In conjunction with the above, this strengthens the suggestion that the discriminant validity of the AAQ-II is highly questionable. There are important limitations to the present study that should be noted. First, the study is based on only one sample from a nonclinical population. In future studies it is important to study more samples and other populations—for example, using clinical samples to see if the results replicate or whether parts of the identified factor structure is due to method effects. In addition, the items constructed for the item-pool on which the factor analysis was made were rationally developed as a part of the present study, and though efforts were taken to separate process or strategy from distress and negative affectivity (which the empirical tests performed suggest that this effort was at least partially successful), it is hard to completely achieve this
Table 5
Bivariate Correlations Between the Factors (N = 406)
Factor 1 Factor 2 Factor 3
Factor 1 (AAQ + Distress)
Factor 2 (Control/avoidance)
1.00 .24 -.27
1.00 -.41
Factor 3 (Behavioral flexibility)
1.00
⁎ p b .01. Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
8
wolgast
distinction in a static and global self-report measure. Hence, parts of the criticism directed at the AAQ-II are probably valid for some of the items constructed in this study as well. The validation procedure used to handle this problem, where the content of the items were assessed by ACT therapists, however, strengthens the assumption that the constructed items have adequate content validity. Despite these limitations, the results of the study are interesting and important in light of the widespread use of the AAQ in both clinical and scientific contexts (Bond et al., 2011), and given the centrality of the measure in empirically validating the ACT model of psychopathology and treatment (e.g., Boulanger et al., 2010; Hayes et al., 2006). Indeed, the present study builds upon previous research (e.g., Chawla & Ostafin, 2007; Gámez et al., 2011) and suggests that the extent to which the relatively strong associations often found between psychological inflexibility/experiential avoidance— particularly when operationalized with the AAQ or AAQ-II—and measures related to psychological well-being are due to the psychological processes assumed in the theoretical models, or merely a consequence of measurement and operationalization (i.e., that they to a large extent measure the same thing), remains to be determined. Hence, based upon the findings of the study, one might question the appropriateness of using the AAQ-II in clinical research and stress the importance of the development of new measures of acceptance or psychological flexibility. In this context, the MEAQ, developed by Gámez et al. (2011), seems to be a more promising measure of experiential avoidance/psychological inflexibility than the AAQ-II, but might also suffer from some of the same limitations, such as strong correlations with neuroticism and an uncertainty as to what some items really measure. In addition, the risk of measuring confounding constructs has been even further reduced in the brief version of the MEAQ that was recently published (Gámez et al., 2014). Indeed, when taking into account the results of the present study, the brief version of the MEAQ (Gámez et al., 2014) seems to be the most appropriate measure for assessing experiential avoidance/ psychological flexibility, and clearly preferable to the AAQ-II. Finally, however, it is my opinion that a central part of the problem discussed in this article is that one tries to capture a dynamic and shifting psychological process with a static and global self-report measure. Instead, in light of the results from the present study, and as suggested by Kashdan and Rottenberg (2010), future studies should aim at developing alternative and more dynamic and contextually situated approaches to measuring psychological flexibility/
experiential avoidance and see how they relate to psychological well-being and functioning. Conflict of Interest Statement The author declares that there are no conflicts of interest.
Acknowledgment I would like to express my gratitude to professor Lars-Gunnar Lundh for valuable comments on an earlier version of this manuscript. References Aldo, A., Nolen-Hoeksema, S., & Schweizer, S. (2009). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30, 217–237. http://dx.doi.org/10.1016/j.cpr.2009.11.004. Batten, S. V., Follette, V. M., & Aban, I. (2001). Experiential Avoidance and high risk sexual behavior in survivors of child sexual abuse. Journal of Child Sexual Abuse, 10(2), 101–120. http://dx.doi.org/10.1300/J070v10n02_06 Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck Depression Inventory II manual. San Antonio, TX: Psychological Corporation. Blackledge, J. T., & Hayes, S. C. (2001). Emotion Regulation in Acceptance and Commitment Therapy.Journal of Clinical Psychology, 57, 243–255. http://dx.doi.org/10.1002/10974679(200102)57:2b243::AID-JCLP9N3.3.CO;2-O. Bond, F., & Bunce, D. (2000). Mediators of change in emotion-focused and problem focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156–163. http://dx.doi.org/10.1037/ 1076-8998.5.1.156. Bond, F. W., Flaxman, P. E., & Bunce, D. (2008). The influence of psychological flexibility on work redesign: Mediated moderation of a work reorganisation intervention. Journal of Applied Psychology, 93, 645–654. http://dx.doi.org/ 10.1037/0021-9010.93.3.645. Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary Psychometric Properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–688. http://dx.doi.org/10.1016/j.beth.2011.03.007. Boulanger, J. L., Hayes, S. C., & Pistorello, J. (2010). In Kring, A.M. & Sloan, D.M. (Eds.), Emotion Regulation and Psychopathology (pp. 107–136). New York: Guilford Press. Cao, J., Ji, Y., & Zou, Z. -H. (2013). Reliability and validity of the Chinese version of the Acceptance and Action Questionnaire-Second Edition (AAQ-II) in college students. Chinese Mental Health Journal, 27, 873–877. Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology, 63, 871–890. http://dx.doi.org/10.1002/jclp.20400 Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, C. (2011). Development of a measure of experiential avoidance: The multidimensional experiential avoidance questionnaire. Psychological Assessment, 23, 692–713. http://dx.doi.org/10.1037/a0023242. Gámez, W., Chmielevski, M., Kotov, R., Ruggero, C., Suzuki, N., & Watson, C. (2014). The Brief Experiential Avoidance Questionnaire: Development and initial validation. Psychological Assessment, 26, 35–45. http://dx.doi.org/10.1037/ a0034473.
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336–343. http://dx.doi.org/10.1037/0022-006X.75.2.336. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25. http://dx.doi.org/10.1016/j.brat.2005.06.006. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Taormino, D., et al. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, 553–578. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. D. (1996). Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168. http://dx.doi.org/10.1037/0022006X.64.6.1152. Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behavior Research and Therapy, 9, 1301–1320. http://dx.doi.org/10.1016/j.brat.2005.10.003. Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–878. Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58–69. http://dx.doi.org/10.1007/ s12160-009-9083-x. Marsh, H. W., Lüdtke, O., Muthén, B., Asparouhov, T., Morin, A. J. S., Trautwein, U., & Nagengast, B. (2010). A new look at the big five factor structure through exploratory structural equation modeling. Psychological Assessment, 22, 471–491. http://dx.doi.org/10.1037/a0019227.
9
Marx, B. P., & Sloan, D. M. (2002). The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse. Behavior Therapy, 33(4), 563–577. http://dx.doi.org/ 10.1016/S0005-7894(02)80017-X. Meyer, E. C., Morissette, S. B., Kimbrel, N. A., Kruse, M. I., & Gulliver, S. B. (2013). Acceptance and Action Questionnaire—II scores as a predictor of posttraumatic stress disorder symptoms among war veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 521–528. http://dx.doi.org/10.1037/ a0030178. Öst, L2G (2008). Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behaviour Research and Therapy, 46, 296–321. http://dx.doi.org/ 10.1016/j.brat.2007.12.005. Pennato, T., Berrocal, C., Bernini, O., & Rivas, T. (2013). Italian version of the acceptance and action questionnaire-II (AAQ-II): Dimensionality, reliability, convergent and criterion validity. Journal of Psychopathology and Behavioral Assessment, 35, 552–563. http://dx.doi.org/10.1007/s10862-013-9355-4. Roemer, L., Salters, K., Raffa, S., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research, 29, 71–88. http://dx.doi.org/10.1007/s10608-005-1650-2. Stewart, S. H., Zvolensky, M. J., & Eifert, G. H. (2002). The relations of anxiety sensitivity, experiential avoidance, and alexithymic coping to young adults’ motivations for drinking. Behavior Modification, 26, 274–296. http://dx.doi.org/ 10.1177/0145445502026002007. Thompson, B. (2004). Exploratory and confirmatory factor analysis. Washington DC: American Psychological Association. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of Positive and Negative Affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. http://dx.doi.org/10.1037/ 0022-3514.54.6.1063.
R E C E I V E D : August 26, 2013 A C C E P T E D : July 4, 2014 Available online xxxx
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
Available online at www.sciencedirect.com
ScienceDirect Behavior Therapy xx (2014) xxx – xxx www.elsevier.com/locate/bt
What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure? Martin Wolgast Lund University
The present study seeks to investigate the extent to which the Acceptance and Action Questionnaire (AAQ-II) is successful in discriminating between experiential avoidance/psychological flexibility on the one hand and the supposed outcomes in terms of psychological well-being of having this trait on the other. This was done using exploratory factor analysis on an item pool containing the AAQ-II items, and items designed for the present study to measure distress and acceptance/ non-acceptance, to see what factors are identified and on which factor(s) the AAQ-II items had the highest factor loadings. Interestingly, the analysis found the items of the AAQ-II to be more strongly related to items designed to measure distress than items designed to measure acceptance/ nonacceptance with minimal references to functional outcomes. The results of the study are interpreted and discussed in relation to the widespread use of the AAQ in both clinical and scientific contexts and given the centrality of the measure in empirically validating the ACT model of psychopathology and treatment.
Keywords: AAQ-II; acceptance; ACT; experiential avoidance; psychological flexibility
DUE TO THE IMPACT OF—AND the widespread interest in—the so-called third wave of behavior therapies in general and in Acceptance and Commitment Therapy (ACT) in particular, the constructs acceptance, experiential avoidance, psychological flexibility, and psychological inflexibility have received a lot of
Address correspondence to Martin Wolgast, Lund University, Department of Psychology, Box 213, 221 00 Lund, Sweden; e-mail: [email protected]. 0005-7894/© 2014 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
scientific and clinical attention during recent years (see, for example, Aldo, Nolen-Hoeksema, & Schweizer, 2009; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Kashdan & Rottenberg, 2010; Öst, 2008). In ACT, “experiential avoidance” was originally put forth as a construct referring to the unwillingness to remain in contact with aversive private experiences and taking action to avoid and/ or alter them (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), and is conceptualized as critical in the development and maintenance of psychopathology (Hayes et al., 1999). In contrast, “acceptance” is often referred to as the willingness to experience aversive or unwanted private events while pursuing one’s values and goals (Hayes et al., 1999). In recent years, the emphasis on acceptance and experiential avoidance has shifted somewhat towards the broader concepts of psychological flexibility and psychological inflexibility (Bond et al., 2011). The definitions of psychological flexibility and psychological inflexibility, however, are quite similar to those of experiential avoidance and acceptance. Psychological flexibility is defined as “the ability to fully contact the present moment and the thoughts and feelings it contains without needless defense, and, depending on what the situation affords, persisting in or changing behavior in the pursuit of goals and values” (Hayes et al., 2006). Psychological inflexibility, on the other hand, refers to a “rigid dominance of psychological reactions over chosen values and contingencies in guiding actions” (Bond et al.), which often occurs when people attempt to avoid experiencing private events. In this view, acceptance and experiential avoidance are seen as examples of psychological flexibility and inflexibility, which are still appropriate to use in clinical contexts, where the present moment contains thoughts and feelings that people might not wish to be in contact with (Bond et al.). The concepts of psychological flexibility/
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
2
wolgast
inflexibility are mainly intended to broaden the applicability of the model to also include contexts where the avoidance of unwanted internal events are not the main focus (Bond et al.), for example, in sporting skills and job performance (Bond, Flaxman, & Bunce, 2008). As previously stated, the constructs of experiential avoidance/psychological inflexibility and acceptance/ psychological flexibility have received significant attention within clinical psychology during the last 15 years. In an empirical review made in 2007, Chawla and Ostafin identified 28 studies published between 1999 and 2006, specifically examining the role of experiential avoidance in the etiology, maintenance, and treatment of maladaptive behavior and psychopathology. The general conclusion was that experiential avoidance was significantly associated with a wide array of behavioral problems as well as psychopathology. Additionally, Hayes et al. conducted a meta-analysis in 2006 involving 32 studies and 6,628 participants, investigating the relationship between experiential avoidance and various measures of psychological well-being, psychopathology, and quality of life and concluded that experiential avoidance as measured by the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) accounted for 16% to 28% of the variance in health-related outcome measures. Other studies of individual differences in levels of experiential avoidance have found that it is related to likelihood of relapse in substance abuse (Stewart, Zvolensky, & Eifert, 2002), has a strong relationship to anxiety-related symptoms and mediates the relationship between other regulatory strategies (including cognitive reappraisal) and these symptoms (Kashdan, Barrios, Forsyth, & Steger, 2006), predicts severity of symptoms in specific psychiatric disorders such as GAD (Roemer, Salters, Raffa, & Orsillo, 2005), and mediates the relation between traumatic events and general psychological distress (Batten, Follette, & Aban, 2001; Marx & Sloan, 2002). Furthermore, in studies of psychological treatments and interventions, changes in experiential avoidance have been shown to mediate the effect of treatments explicitly aimed at reducing it (e.g., Bond & Bunce, 2000; Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007; Lillis, Hayes, Bunting, & Masuda, 2009). Additionally, in a recent review by Kashdan and Rottenberg (2010), it is shown that psychological flexibility—broadly defined—is a prominent factor in understanding psychological health. Hence, there seems to be empirical support for the suggestion that experiential avoidance/ psychological inflexibility is of significant importance in relation to the development, maintenance, and treatment of psychopathology. Before drawing
this conclusion, however, one needs to establish that the construct in question has been operationalized in a way that makes the conclusion valid. This is of particular importance in the present case: Many of the studies referred to above, and the vast majority of studies examining psychological flexibility/ experiential avoidance, have relied upon the AAQ as a valid operationalization of the construct. Thus, given the centrality of this specific measure in determining the results, it is important to critically reflect upon the measure and whether factors other than the psychological phenomena it is supposed to measure might explain parts of the findings from the studies. One such potential source of confounded measurement is if the items that are supposed to measure experiential avoidance/psychological flexibility, contain formulations related to adaptive or maladaptive outcomes in terms of psychological distress, well-being, or functioning. Indeed, in a few previous studies, the AAQ has been briefly criticized for not making a clear enough distinction between process and outcome (Chawla & Ostafin, 2007), and for not having sufficient discriminant validity in relation to negative affectivity or neuroticism (Gámez, Chmielewski, Kotov, Ruggero, & Watson, 2011). More often, however, the AAQ was criticized for having some shortcomings regarding comprehensibility and reliability (Bond et al., 2011), and when revising the measure and constructing a new version of the AAQ (AAQ-II; Bond et al.), the focus was mainly on addressing these last two issues. The relative lack of discussion regarding the construct validity of the AAQ appears remarkable given the centrality of the measure in validating central theoretical assumptions from an ACT perspective and the fact that many of the items are problematic in regard to the discussion above. For example, the nine-item version of AAQ-I contains the item, “When I compare myself with other people, it seems most of them are handling their lives better than I do” (Item 7), which clearly incorporates formulations related to outcome, thus risking circularity in measurements. Items 4, 5, and 9 can also be subjected to this kind of criticism. For example, Item 5 (“I am not afraid of my feelings”) might receive a high score either if the respondent has strong aversive feelings but is not afraid of them or if the respondent in general has low levels of negative emotionality and therefore does not experience feelings as a problem. Additionally, Item 4 (“I rarely worry about getting my anxieties, worries, and feelings under control”) might receive similar scoring based on significantly different processes: one might score high on the item if (a) one does not try to control one’s feelings; (b) if one regularly tries to control one’s feelings, is successful in doing so, and therefore does not worry about it; or (c) if one has very
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? low levels of anxiety and worries so that controlling them seldom seems to be an issue to worry about. Similarly, Item 9 (“If I could magically remove all painful experiences I’ve had in my life, I would do so”) might discriminate between subjects solely on the basis of how many “painful experiences” they have had in their lives, not only on the basis of how they relate to these experiences. As previously stated, a new version of the AAQ (AAQ-II) was published in 2011, consisting of seven items measuring psychological inflexibility or experiential avoidance (Bond et al., 2011), and it has since been translated into several languages (e.g., Cao, Ji, & Zou, 2013; Pennato, Berrocal, Bernini, & Rivas, 2013) and used in clinical studies (e.g., Meyer, Morissette, Kimbrel, Kruse, & Gulliver, 2013). The items of the AAQ-II are presented in Table 1. Unfortunately, the items in this new version can, based on their content, be subjected to the same criticism of confounding process or trait with outcome: for many of the items it is hard to distinguish if a specific response is grounded in levels of psychological inflexibility/experiential avoidance or, for example, in levels of experienced aversive emotions, memories, and worries. The authors of the AAQ-II briefly addresses the issue of discriminant validity by conducting a confirmatory factor analysis to test if the AAQ-II and the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996) are best represented by a oneor two-factor model. In this analysis a two-factor model (with BDI-II and AAQ-II as separate factors) provided a significantly better fit than a one-factor model (Bond et al., 2011), indicating that the scales do not measure the same construct. To claim that the AAQ-II does not measure the same construct as the BDI-II, however, addresses only parts of the problem
3
discussed above. It still remains unclear how well the scale distinguishes between experiential avoidance or psychological inflexibility as an approach or attitude toward private events on the one hand and the supposed outcome of this approach in terms of emotional problems and experienced life satisfaction on the other. Furthermore, the difference in item style and wording between the BDI-II and the AAQ-II renders a one-factor solution less likely for other reasons than that they refer to distinct underlying psychological traits or processes. In developing their broader, multidimensional measure of experiential avoidance (the Multidimensional Experiential Avoidance Questionnaire; MEAQ), however, Gámez et al. (2011) raised the problem with the discriminant validity of the AAQ and the AAQ-II in relation to neuroticism. They also compared the correlations between the MEAQ and the AAQ with measures of negative affectivity and neuroticism, and indeed consistently found the AAQ (both I and II) to be more strongly associated with neuroticism (Gámez et al.). Additionally, in a recently published article, where a brief version of the MEAQ is presented, this issue of confounded measurements is raised even more clearly, and the items selected for the brief version tries to further reduce this problem (Gámez et al., 2014). In part, the problem discussed above might be seen as a natural consequence of the explicitly functional framework in which the ACT model is situated. In this context it is logical that the focus is shifted from emotion regulation as traditionally defined toward effective living (Blackledge & Hayes, 2001). Nonetheless, when the acceptance or psychological flexibility is measured and operationalized as a psychological trait (e.g., Hayes et al., 2006) that can be compared to, or even explain the effects of, other
Table 1
Items of the AAQ-II, Distress and Acceptance Scales AAQ-II
Distress
Acceptance
1. My painful experiences and memories 1. I often feel depressed, worried 1. I often try to control or change my thoughts and make it difficult for me to live a life that I or anxious. feelings. would value. 2. I’m afraid of my feelings. 2. I worry a lot. 2. When I feel depressed, worried or anxious, I do not try to influence or change these feelings. 3. I worry about not being able to control 3. I have many problems in my life. 3. I let my thoughts and feelings come and go, my worries and feelings. without trying to control or avoid them. 4. My painful memories prevent me from 4. I have lots of painful memories. 4. I do the things I want to do, even if it makes me having a fulfilling life. feel nervous or anxious. 5. Emotions cause problems in my life. 5. I am not happy with the way my 5. When I feel anxious, worried or depressed, I note life is. these feelings but live my life the way I want to. 6. It seems like most people are handling 6. When I feel depressed, worried or anxious, I do their lives better than I am. not try to avoid these feelings. 7. Worries get in the way of my success. 7. When I feel depressed, worried or anxious, I try to influence or change these feelings. Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
4
wolgast
approaches to private events (Boulanger, Hayes, & Pistorello, 2010), it seems of central importance to clarify the distinction between the trait on the one hand and the outcome of having this trait or the extent to which one has, for example, emotional problems on the other. The purpose of the present study was to provide an empirical investigation of the extent to which the AAQ-II succeeds in making this distinction that goes beyond what can be achieved by correlating the scale with measures of similar and different constructs. In this context, it should be noticed that the study did not aim to develop a new and improved measure of experiential avoidance/ psychological inflexibility (indeed, the originators of the MEAQ have taken promising steps in that direction; Gaméz et al. 2011; Gamez et al., 2014). Rather, the purpose was to provide an in-depth empirical analysis of the most widely employed measure of experiential avoidance/psychological inflexibility, namely, the AAQ.
The Present Study: Purpose and Hypotheses As previously stated, the main purpose of the present study was to empirically investigate the extent to which the AAQ-II differentiates between psychological inflexibility/experiential avoidance as a psychological trait and the supposed outcome of having high or low levels of this trait in terms of psychological well-being and functioning. This was done using exploratory factor analysis (EFA) on an item pool containing the AAQ-II items, and items designed for the present study to measure distress and acceptance/nonacceptance, to see what factors are identified and on which factor(/s) the AAQ-II items had the highest factor loadings. Given the problematic design of the AAQ-II items described above, the hypothesis was that the items of the AAQ-II to a large extent would fall onto the same factor as items designed to measure distress rather than acceptance/nonacceptance. The choice to use exploratory rather than confirmatory factor analysis (CFA) in this part of the study was based upon findings indicating that CFA is overly restrictive when conducting item level analyses (e.g., Marsh et al., 2010).
Method participants Sample 1: ACT Therapists To validate the items constructed to measure acceptance and distress (see below), the items were presented in an online questionnaire to a sample of therapists working with ACT. Participants were recruited via a group on Facebook for therapists working with ACT and answers were obtained from 30 participants. Of these, 80% were licensed
psychologists, 10% were medical doctors, and 10% stated “other” as their profession. Thirty percent of the participants had worked with ACT between 1 and 5 years, 50% between 5 and 10 years, and 20% more than 10 years. Eighty percent stated that they had received training and education in ACT and 20% stated that they had educated and trained others in working with ACT. Sample 2: Sample for the Main Study For the analysis of the AAQ-II items in relation to the items constructed to measure distress and acceptance, convenience sampling was used for participants recruited on campus and other public places. To be eligible for the study, participants had to be fluent in Swedish and at least 18 years old. Four hundred and six individuals participated in the study by completing all of the questionnaires. Of these, 53% were women and 47% were men. The average age was 24.6 years, with a span from 18 to 63 (SD = 7.5). Seventy-nine percent stated “student” as their main occupation, 16% stated “employed,” 3% stated “unemployed,” and 2% stated “other.”
measures Acceptance and Action Questionnaire–II (AAQ-II) The AAQ-II (Bond et al., 2011) is a 7-item measure of psychological inflexibility/experiential avoidance. Answers are given on a 7-point scale ranging from 1 = never true to 7 = always true. The Swedish version of the scale used in the present study has been translated using a translation and back translation procedure and showed good internal consistency (α = .90) in the present study. Positive and Negative Affect Scale (PANAS) To assess dispositional positive and negative emotionality, participants completed the trait version of the PANAS (Watson, Clark, & Tellegen, 1988). The PANAS is a 20-item mood adjective checklist designed to measure the Positive Affect (PA) and Negative Affect (NA) factors and has shown satisfactory psychometric properties in previous research (Watson et al., 1988). To complete the PANAS, participants were instructed to use a 5-point scale (1 = very slightly or not at all; 5 = extremely) to indicate “to what extent you generally feel this way, that is, how you feel on the average” for each adjective. The Swedish version of the scale showed adequate internal consistency for both PA and NA in the present study (PA: α = .78; NA: α = .86). Distress Five items measuring psychological distress were rationally constructed using the items from the AAQ-II as templates in order to construct items
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? similar in wording and style and possible to answer on the same 7-point scale (with the same verbal anchors as used in the AAQ-II), though clearly measuring aspects of psychological distress. The items are presented in Table 1. Analyzing the items as a separate scale indicated good internal consistency (α = .85), which the deletion of any of the included items would reduce. The average score was 3.1 (scale mean divided by number of items) with a standard deviation of 1.4, and the average item score ranged from 2.6 to 3.8. Acceptance For the present study, 7 items were rationally constructed to assess acceptance/nonacceptance in a way that explicitly tried to separate strategy/trait from outcome or relative presence of distress. This was done in different ways depending on item content, but the main strategy was to include explicit formulations referring to the presence or absence of active control efforts and clear reference to actions performed in the actual presence of aversive inner states. As with the items measuring psychological distress, the items were constructed using the items from the AAQ-II as templates in order to produce items that were similar in wording and style and possible to answer on the same 7-point scale as the items from the AAQ-II, using identical verbal anchors. The items are presented in Table 1. Analyzing the items as a separate scale (with Items 1 and 7 reverse scored) indicated adequate internal consistency (α = .75), which the exclusion of any of the included items would reduce. The average score was 3.9 (scale mean divided by number of items) with a standard deviation of .93, and the average item score ranged from 3.2 to 4.7. Questionnaire to ACT Therapists In order to provide a test of the construct validity of the items in the Acceptance and Distress scales, a questionnaire was administered to therapists working with ACT (see above for sample description). The questionnaire listed all 12 items and the participants were asked to assess to what degree they judged that each item was measuring acceptance/nonacceptance (as standardly conceived in ACT) and psychological distress. Answers were given on a 5-point scale (1 = not at all; 5 = to a very large extent).
data analysis Data analysis proceeded through several steps. First, to test the construct validity of the constructed scales and item, the data from the questionnaire administered to ACT therapists were analyzed by comparing average scores on item and scale level to see whether there were significant differences in the extent to which the different items were judged as
5
measuring acceptance and distress. To further test the validity of the constructed scales, scale scores (Distress and Acceptance) were correlated with the PANAS-N and PANAS-P scales as a partial test of their conceptual validity. In these analyses the predicted outcome pattern was that the Distress scale would be positively correlated with the PANAS-N and negatively correlated with PANAS-P, whereas the opposite pattern was predicted for the Acceptance scale. In addition, given that the Distress scale was supposed to measure emotionality and experiential content whereas the Acceptance scale was designed to measure psychological and behavioral strategies in separation from emotionality, it was predicted that the conceptual overlap between the Distress scale and the PANAS would be greater than that between the PANAS and the Acceptance scale. Hence, the correlations between the Distress scale and the PANAS subscales were predicted to be significantly stronger than the correlations between the Acceptance scale and the PANAS subscales. In the second step of the data analysis, an exploratory factor analysis using principal axis factoring and promax rotation was performed on an item pool consisting of the items from the AAQ-II and the items from the Distress and Acceptance scales (in total 19 items). Promax rotation was used since the factors were expected to be correlated. Prior to running the analysis, parallel analysis (Thompson, 2004) was performed to determine the number of factors to extract.
Results construct validity of the distress and acceptance scales The data from the questionnaire administered to ACT therapists were analyzed to investigate the construct validity of the constructed items and scales. Results are presented in Table 2. On scale level, the Acceptance scale was assessed as measuring acceptance to a significantly larger extent than what the Distress scale did, t(29) = 14.37, p b .01, and the Distress scale was assessed as measuring distress to a significantly larger extent than what the Acceptance scale did, t(29) = 6.90, p b .01. In addition, the Acceptance scale was judged as measuring acceptance significantly better than distress, t(29) = 9.83, p b .01, whereas the opposite was true for the Distress scale, t (29) = 9.68, p b .01. When analyzing data on item level, the results from Bonferonni-corrected paired sample t-tests revealed significant differences between the mean on the acceptance and distress ratings for all items (all p-values b .001). Hence, the performed analyses indicated adequate construct validity for the constructed items as well as for the aggregated scales.
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
6
wolgast
Table 2
Ratings of Content by ACT Therapists, Scale and Item Means MAcceptance (SD) MDistress (SD) (N = 30) (N = 30)
Acceptance scale 1. I often try to control or change my thoughts and feelings. 2. When I feel depressed, worried or anxious, I do not try to influence or change these feelings. 3. I let my thoughts and feelings come and go, without trying to control or avoid them. 4. I do the things I want to do, even if it makes me feel nervous or anxious. 5. When I feel anxious, worried or depressed, I note these feelings but live my life the way I want to. 6. When I feel depressed, worried or anxious, I do not try to avoid these feelings. 7. When I feel depressed, worried or anxious, I try to influence or change these feelings. Scale average
4.2 4.1 4.9 4.8 4.9 4.5 3.7 4.4
(1.0) (1.1) (.3) (.4) (.3) (.7) (1.4) (.6)
2.1 1.6 2.0 1.9 2.7 1.7 1.7 1.9
(1.2) (.8) (1.4) (1.2) (1.4) (.9) (.9) (1.0)
Distress scale 1. I often feel depressed, worried or anxious. 2. I worry a lot. 3. I have many problems in my life. 4. I have lots of painful memories. 5. I am not happy with the way my life is. Scale average
1.6 1.9 1.8 1.6 2.2 1.8
(.7) (1.2) (.8) (.8) (.8) (.6)
4.1 4.0 3.9 3.5 3.9 3.9
(1.0) (1.1) (.7) (1.3) (1.0) (.9)
relationships between the constructed scales, the aaq-ii and the panas The constructed Distress and Acceptance scales were correlated with the PANAS-N and PANAS-P (see above under the data analysis section). Results are presented in Table 3 and are consistent with the predicted outcome pattern. To test the prediction that the correlations would be stronger between the Distress scale and the PANAS scales than between the Acceptance scale and the PANAS scales, Fisher’s r-to-z test was used to test whether the correlation coefficients differed significantly from each other in the predicted direction. The results supported the prediction (PANAS-P: z = 5.45, p b .01; PANAS-N: z = 7.26, p b .01), indicating that the Distress scale, as expected, contained a stronger component of emotionality and experiential content when compared to the Acceptance scale. When correlating the AAQ-II with the PANAS subscales, the results indicate correlations as strong as for the constructed Distress scales and significantly stronger than what was found for the constructed Acceptance scale (PANAS-P: z = 6.59, p b .01; PANAS-N: z = 8.18, p b .01). Table 3
Bivariate Correlations Between the Distress Scale, the Acceptance Scale, AAQ-II, PANAS-N and PANAS-P (N = 406)
PANAS-N PANAS-P ⁎ p b .01.
Distress
Acceptance
AAQ-II
.64 ⁎ -.55 ⁎
-.24 ⁎ .23 ⁎
.67 ⁎ -.61 ⁎
factor analysis A principal axis factoring parallel analysis (Thompson, 2004) indicated that only the first three factors in the actual data exceeded the corresponding eigenvalues in a normally distributed random score matrix of the same rank. Hence, three factors were extracted in the subsequent EFA. The three factors had eigenvalues of 6.6, 2.5, and 1.6 and accounted for 36.8%, 14.1%, and 8.9% of the variance, respectively. Overall, the extracted factors accounted for 59.8% of the variance. Table 4 displays the pattern matrix of the three promaxrotated factors. Items that loaded at least .40 on one factor were assigned to a specific factor based on their highest loading. All of the items included in the analysis were assigned to a factor. As can be seen in Table 4, all of the items from the AAQ-II loaded on the same factor as the items designed to measure distress (Factor 1), whereas Factor 2 consists of items related to the control or avoidance of thoughts and emotions and Factor 3 consists of two items relating to behavioral flexibility and goal-directed behavior in the presence of aversive emotions. correlation between factors Given that the resulting factors were expected to be correlated, between factor bivariate correlations were computed to investigate the relationships between the identified factors (Table 5). Factor scores were created by summing the scores on the items assigned to each factor. The results reveal significant correlations between all three factors, where the strongest
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
7
what does the aaq-ii really measure? Table 4
Factor Loadings for Each Item on the Three Factors Item
Factor 1 b
I often feel depressed, worried or anxious .83 .81 Worries get in the way of my success a My painful memories prevent me from having .81 a fulfilling life a My painful experiences and memories make .79 it difficult for me to live a life that I would value a It seems like most people are handling their .77 lives better than I am a .72 I worry a lot b I have many problems in my life b .72 .68 Emotions cause problems in my life a .69 I have lots of painful memories b I worry about not being able to control my .61 worries and feelings a .57 I’m afraid of my feelings a .48 I am not happy with the way my life is b When I feel depressed, worried or anxious, I .01 do not try to influence or change those feelings c When I feel depressed, worried or anxious, I .08 try to influence or change those feelings c I often try to control or change my thoughts .23 and feelings c I let my thoughts and feelings come and go, .00 without trying to control or avoid them c When I feel depressed, worried or anxious, I .10 do not try to avoid those feelings c I do the things I want to do, even if it makes .07 me feel nervous or anxious c When I feel anxious, worried or depressed, I -.16 note those feelings but live my life the way I want to c
2
3
.02 -.05 -.00 -.03 -.06 .20 -.08
.18
-.03 -.13 .16 .05 -.00 -.11 .06 -.13 -.44 .10 .18 .08 .24 .05 -.11 -.34 -.73 -.18
.60
.34
.61 -.06 -.52
.36
-.55
.25
.09
.79
-.07
.44
a = Item from the AAQ-II; b = Item originally constructed to measure distress; c = Item originally constructed to measure acceptance/nonacceptance. Numbers in boldface indicate factor loading on the factor the item was assigned to.
correlation is found between Factor 2 (Control/ avoidance) and Factor 3 (Behavioral flexibility).
Discussion The present study sought to investigate the extent to which the AAQ-II is successful in discriminating
between experiential avoidance/psychological flexibility on the one hand and the outcomes in terms of psychological well-being of having this trait or behavioral pattern on the other. Based on a critical examination of the items of the AAQ-II, the assumption was that there exists a problem with regard to the discriminant validity of the AAQ-II in terms of an overlap between the way experiential avoidance/psychological flexibility is operationalized and measures of psychological well-being, thus risking circularity of measurements and an overestimation of the association between experiential avoidance/psychological flexibility and different health-related outcome measures. The findings of the performed exploratory factor analysis indeed showed that the items of the AAQ-II loaded on the same factor as items designed to measure general distress and did not load on the same factor as the items that were designed to measure acceptance/ nonacceptance as an explicit attitude or response to aversive psychological states. Furthermore, when comparing the association between the scales and the PANAS, the AAQ-II was found to have an identical pattern of correlations to the measures of negative and positive emotionality as the constructed Distress scale had, whereas the correlation was significantly weaker for the constructed Acceptance scale. In conjunction with the above, this strengthens the suggestion that the discriminant validity of the AAQ-II is highly questionable. There are important limitations to the present study that should be noted. First, the study is based on only one sample from a nonclinical population. In future studies it is important to study more samples and other populations—for example, using clinical samples to see if the results replicate or whether parts of the identified factor structure is due to method effects. In addition, the items constructed for the item-pool on which the factor analysis was made were rationally developed as a part of the present study, and though efforts were taken to separate process or strategy from distress and negative affectivity (which the empirical tests performed suggest that this effort was at least partially successful), it is hard to completely achieve this
Table 5
Bivariate Correlations Between the Factors (N = 406)
Factor 1 Factor 2 Factor 3
Factor 1 (AAQ + Distress)
Factor 2 (Control/avoidance)
1.00 .24 -.27
1.00 -.41
Factor 3 (Behavioral flexibility)
1.00
⁎ p b .01. Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
8
wolgast
distinction in a static and global self-report measure. Hence, parts of the criticism directed at the AAQ-II are probably valid for some of the items constructed in this study as well. The validation procedure used to handle this problem, where the content of the items were assessed by ACT therapists, however, strengthens the assumption that the constructed items have adequate content validity. Despite these limitations, the results of the study are interesting and important in light of the widespread use of the AAQ in both clinical and scientific contexts (Bond et al., 2011), and given the centrality of the measure in empirically validating the ACT model of psychopathology and treatment (e.g., Boulanger et al., 2010; Hayes et al., 2006). Indeed, the present study builds upon previous research (e.g., Chawla & Ostafin, 2007; Gámez et al., 2011) and suggests that the extent to which the relatively strong associations often found between psychological inflexibility/experiential avoidance— particularly when operationalized with the AAQ or AAQ-II—and measures related to psychological well-being are due to the psychological processes assumed in the theoretical models, or merely a consequence of measurement and operationalization (i.e., that they to a large extent measure the same thing), remains to be determined. Hence, based upon the findings of the study, one might question the appropriateness of using the AAQ-II in clinical research and stress the importance of the development of new measures of acceptance or psychological flexibility. In this context, the MEAQ, developed by Gámez et al. (2011), seems to be a more promising measure of experiential avoidance/psychological inflexibility than the AAQ-II, but might also suffer from some of the same limitations, such as strong correlations with neuroticism and an uncertainty as to what some items really measure. In addition, the risk of measuring confounding constructs has been even further reduced in the brief version of the MEAQ that was recently published (Gámez et al., 2014). Indeed, when taking into account the results of the present study, the brief version of the MEAQ (Gámez et al., 2014) seems to be the most appropriate measure for assessing experiential avoidance/ psychological flexibility, and clearly preferable to the AAQ-II. Finally, however, it is my opinion that a central part of the problem discussed in this article is that one tries to capture a dynamic and shifting psychological process with a static and global self-report measure. Instead, in light of the results from the present study, and as suggested by Kashdan and Rottenberg (2010), future studies should aim at developing alternative and more dynamic and contextually situated approaches to measuring psychological flexibility/
experiential avoidance and see how they relate to psychological well-being and functioning. Conflict of Interest Statement The author declares that there are no conflicts of interest.
Acknowledgment I would like to express my gratitude to professor Lars-Gunnar Lundh for valuable comments on an earlier version of this manuscript. References Aldo, A., Nolen-Hoeksema, S., & Schweizer, S. (2009). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30, 217–237. http://dx.doi.org/10.1016/j.cpr.2009.11.004. Batten, S. V., Follette, V. M., & Aban, I. (2001). Experiential Avoidance and high risk sexual behavior in survivors of child sexual abuse. Journal of Child Sexual Abuse, 10(2), 101–120. http://dx.doi.org/10.1300/J070v10n02_06 Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck Depression Inventory II manual. San Antonio, TX: Psychological Corporation. Blackledge, J. T., & Hayes, S. C. (2001). Emotion Regulation in Acceptance and Commitment Therapy.Journal of Clinical Psychology, 57, 243–255. http://dx.doi.org/10.1002/10974679(200102)57:2b243::AID-JCLP9N3.3.CO;2-O. Bond, F., & Bunce, D. (2000). Mediators of change in emotion-focused and problem focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156–163. http://dx.doi.org/10.1037/ 1076-8998.5.1.156. Bond, F. W., Flaxman, P. E., & Bunce, D. (2008). The influence of psychological flexibility on work redesign: Mediated moderation of a work reorganisation intervention. Journal of Applied Psychology, 93, 645–654. http://dx.doi.org/ 10.1037/0021-9010.93.3.645. Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary Psychometric Properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–688. http://dx.doi.org/10.1016/j.beth.2011.03.007. Boulanger, J. L., Hayes, S. C., & Pistorello, J. (2010). In Kring, A.M. & Sloan, D.M. (Eds.), Emotion Regulation and Psychopathology (pp. 107–136). New York: Guilford Press. Cao, J., Ji, Y., & Zou, Z. -H. (2013). Reliability and validity of the Chinese version of the Acceptance and Action Questionnaire-Second Edition (AAQ-II) in college students. Chinese Mental Health Journal, 27, 873–877. Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology, 63, 871–890. http://dx.doi.org/10.1002/jclp.20400 Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., & Watson, C. (2011). Development of a measure of experiential avoidance: The multidimensional experiential avoidance questionnaire. Psychological Assessment, 23, 692–713. http://dx.doi.org/10.1037/a0023242. Gámez, W., Chmielevski, M., Kotov, R., Ruggero, C., Suzuki, N., & Watson, C. (2014). The Brief Experiential Avoidance Questionnaire: Development and initial validation. Psychological Assessment, 26, 35–45. http://dx.doi.org/10.1037/ a0034473.
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
what does the aaq-ii really measure? Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336–343. http://dx.doi.org/10.1037/0022-006X.75.2.336. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25. http://dx.doi.org/10.1016/j.brat.2005.06.006. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Taormino, D., et al. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, 553–578. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. D. (1996). Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168. http://dx.doi.org/10.1037/0022006X.64.6.1152. Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behavior Research and Therapy, 9, 1301–1320. http://dx.doi.org/10.1016/j.brat.2005.10.003. Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–878. Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58–69. http://dx.doi.org/10.1007/ s12160-009-9083-x. Marsh, H. W., Lüdtke, O., Muthén, B., Asparouhov, T., Morin, A. J. S., Trautwein, U., & Nagengast, B. (2010). A new look at the big five factor structure through exploratory structural equation modeling. Psychological Assessment, 22, 471–491. http://dx.doi.org/10.1037/a0019227.
9
Marx, B. P., & Sloan, D. M. (2002). The role of emotion in the psychological functioning of adult survivors of childhood sexual abuse. Behavior Therapy, 33(4), 563–577. http://dx.doi.org/ 10.1016/S0005-7894(02)80017-X. Meyer, E. C., Morissette, S. B., Kimbrel, N. A., Kruse, M. I., & Gulliver, S. B. (2013). Acceptance and Action Questionnaire—II scores as a predictor of posttraumatic stress disorder symptoms among war veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 521–528. http://dx.doi.org/10.1037/ a0030178. Öst, L2G (2008). Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behaviour Research and Therapy, 46, 296–321. http://dx.doi.org/ 10.1016/j.brat.2007.12.005. Pennato, T., Berrocal, C., Bernini, O., & Rivas, T. (2013). Italian version of the acceptance and action questionnaire-II (AAQ-II): Dimensionality, reliability, convergent and criterion validity. Journal of Psychopathology and Behavioral Assessment, 35, 552–563. http://dx.doi.org/10.1007/s10862-013-9355-4. Roemer, L., Salters, K., Raffa, S., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research, 29, 71–88. http://dx.doi.org/10.1007/s10608-005-1650-2. Stewart, S. H., Zvolensky, M. J., & Eifert, G. H. (2002). The relations of anxiety sensitivity, experiential avoidance, and alexithymic coping to young adults’ motivations for drinking. Behavior Modification, 26, 274–296. http://dx.doi.org/ 10.1177/0145445502026002007. Thompson, B. (2004). Exploratory and confirmatory factor analysis. Washington DC: American Psychological Association. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of Positive and Negative Affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. http://dx.doi.org/10.1037/ 0022-3514.54.6.1063.
R E C E I V E D : August 26, 2013 A C C E P T E D : July 4, 2014 Available online xxxx
Please cite this article as: Martin Wolgast, What Does the Acceptance and Action Questionnaire (AAQ-II) Really Measure?, Behavior Therapy (2014), http://dx.doi.org/10.1016/j.beth.2014.07.002
