The ACT / RFT tradition is committed to a high standard of empirical evaluation, including not just controlled assessment and evaluations of outcomes but also specification and evaluation of the putative processes of change, and linkage of these processes to a basic program of research that seeks to explain them in terms of functional behavioral principles, including those drawn from RFT.
The efficacy and effectiveness data on ACT are positive, but preliminary. A recent (July 2005) PowerPoint presentation of the evidence can be downloaded above. Also above is a table showing effect sizes for the ACT outcome literature. The most recent meta-analysis, Hayes, Luoma, Bond, Masuda, & Lillis, 2006, was published in Behaviour Research and Therapy in January 2006 and is available in the publications list or by clicking on the emboldened link.
ACT is not yet formally an empirically supported treatment on EST lists, though it is approaching or perhaps exceeding the standards for that status in some areas, such as smoking, pain, and psychosis, awaiting appearance of publications in press or under submission and on review by authorities responsible for such lists.
We recommend ACT on an experimental basis with any problem that fits the underlying model (e.g., the problem appears to involve cognitive fusion, or experiential avoidance, or a lack of clarity of values, and resulting inactivity, inflexibility, and ineffectiveness) provided it is used with systematic evaluation and there is a good reason not to use existing ESTs first (e.g., if they have already failed; client rejects their use). We think that approach is particularly appropriate for the problems in the following table, since at least some efficacy or effectiveness data are available. The stronger the data are in a given, the stronger we can make this recommendation.
This table lists only published data though if additional major studies are coming and we have actually seen the data in detail they may be mentioned as well. We have divided the data into randomized controlled trials and other types of studies – e.g., pre-post designs or single case designs. Only outcomes studies with real patients are included, not analogs. "Published" data include theses and dissertations. See the publications page for detailed information. This table is current as of late-2005 but the literature is moving quickly and it takes a while to update pages like this. You should download the "ACT Handout" as well, which is updated regularly:
| Depression | 3 RCTs; 1 other. Some indication that it is superior to CBT in some settings. Evidence of a distinct process. |
| Anxiety / Stress / OCD | 3 RCTs; 7 other. Some indication that it is superior to CBT in some settings, but also data that it can be beaten by traditional BT in minor anxiety problems. Evidence of changes in ACT processes. |
| Psychosis | 2 RCTs; 1 other. Not yet compared to other psychosocial methods beyond support but effects are good for amazingly small interventions. Done in addition to antipsychotic medication. Mediated by ACT processes. |
| Substance abuse | 1 RCT; 1 other. Some indication that it does better than existing pharmacotherapy methods, or supplements their effects. Other good studies done and under review |
| Smoking | 1 RCTs; one other. 2 other RCTs done and being written up with good outcomes. Indication that it does better than existing pharmacotherapy methods, or supplements their effects. |
| Chronic Pain | 1 RCT; 4 other, including two decent sized effectiveness trials. Good outcomes. No good head to head comparisons with empirically supported alternative methods yet. Works through ACT relevant processes. |
| Prejudice and burn out | 1 RCT; 1 crossover. Beats multicultural counseling and education alone. Works through ACT relevant processes. Helps in both stigma and burnout. Other good studies competed and on the way. |
| Marital problems | 1 other. Very limited data. |
| Eating disorder | 1 other. Very limited data. |
| Sexual deviation | 1 other. Very limited data. |
| Dually diagnosed | 1 RCT (sub-analysis). 1 other. Promising but limited data. |
| Self Harm / BPD | 1 RCT that mixed ACT with DBT. Extremely good outcomes but no follow up. Did move ACT relevant processes. |
| Epilepsy | 1 RCT. Very good outcomes on both seizures and quality of life. 1 year follow up. Mediated by ACT processes. |
| Diabetes management | 1 RCT. Good outcomes at follow up on self management and glucose control. Mediated by ACT processes. |
There are some data on effectiveness (see the "publications" section). Thus, we feel that we can recommend ACT to systems of care provided they use it under the limitation suggested above and will work with us to train it properly, and to evaluate its impact.
A number of instruments have been developed to measure ACT-specific processes. This section of the site will provide more information about these instruments, including downloads when available.
Measures are being developed very rapidly, and we encourage developers to contribute updates to this section of the site as often as possible. Interested parties are also encouraged to join the ACT listserv to learn of updated measures. Click on an instrument below to learn more about it.
ACBS Members: If you have an ACT-specific measure you would like listed here, click on the "add child page" link at the bottom of this page. When adding your content, remember that you can attach relevant files and documents.
Acceptance and Action Questionnaire – II (AAQ-II)
The AAQ-II was developed in order to establish an internally consistent measure of ACT’s model of mental health and behavioral effectiveness. Although the original AAQ (Hayes, Strosahl, Wilson, Bissett, Pistorello et al., 2004) has proved broadly useful (see Hayes, Luoma, Bond, Masuda and Lillis, 2006), obtaining sufficient alpha levels for it has at times been a problem. It appears that there are several reasons for this (e.g., scale brevity, item wording, item selection procedures), and they were addressed in developing the AAQ-II. As a result, it is recommended that researchers and practitioners use this newer scale instead of the original AAQ (which from here forward will be termed the AAQ-I). The AAQ-II was designed to assess the same construct as the AAQ-I and, indeed, the two scales correlate at .82. Thus, the AAQ-I can still be used, and findings based on it are still relevant, but it is perhaps psychometrically safer to use the AAQ-II.
The reference for the AAQ-II is:
Bond, F.W., Hayes, S.C., Baer, R.A., Carpenter, K.M., Orcutt, H.K., Waltz, T. & Zettle, R.D. (Submitted). Preliminary psychometric properties of the Acceptance and Action Questionnaire – II: A revised measure of psychological flexibility and acceptance.
(Note that authorship order was alphabetically determined for Carpenter, Orcutt, Waltz, and Zettle.)
What do we call ACT’s model of mental health and behavioral effectiveness? (Or, what does the AAQ-I and -II measure?)
[Taken from Bond et al. (Submitted)]
When ACT was originally developed, the overarching term for its underlying model was experiential avoidance – the attempt to alter the form, frequency, or situational sensitivity of negative private events (e.g., thoughts, feelings, and physiological sensations), even when doing so leads to behavioral difficulties (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Acceptance was the term used to positively describe this model; thus, it is defined as the willingness to experience (i.e., not alter the form, frequency, or sensitivity of) unwanted private events, in the pursuit of one’s values and goals.
The ACT model has matured over the years, with more emphasis on the dynamic and flexible fit between context, private experiences and valued action, which have always been inherent in the model. Such flexibility is seen when ACT therapists note that sometimes persisting in behavior is helpful, while at other times changing it is helpful: it depends upon the value- and goal-related opportunities that are available in a given context. Furthermore, as other parts of the ACT model are now given emphasis (e.g., cognitive defusion, contacting the present moment, mindfulness, and perspective-taking), experiential avoidance and, hence, acceptance are taking on a narrower meaning and are being used less often as terms for the overarching model (Hayes et al., 2006). Instead, the term psychological flexibility (or flexibility) is now being used to describe this model. It is defined as the ability to fully contact the present moment and the thoughts and feelings it contains without needless defense, and, depending upon what the situation affords, persisting or changing in behavior in the pursuit of goals and values (Hayes et al., 2006). While experiential avoidance and acceptance are still useful and acceptable ways to describe this construct, psychological flexibility is the more current and overarching term. In addition, it needs to be acknowledged that in some contexts (e.g., industrial-organizational psychology) it is important to speak of this domain positively (acceptance or flexibility) and in other contexts (e.g., psychopathology) it is easier to speak of it negatively (experiential avoidance or psychological inflexibility). These differences are terminological, not substantive.
The AAQ-II and key psychometric findings for the scale can be found here. Older versions of the AAQ (i.e., AAQ-9, AAQ-16 and AAQ-49) are also listed below.
There are more specific acceptance and defusion measures available. A good measure has been developed in the area of smoking (contact Elizabeth Gifford for more information: elizgifford@earthlink.net); a pain measure developed from the earliest versions of the AAQ called the Chronic Pain Acceptance Questionnaire (CPAQ; see attachments below) has been published and worked very well in this area (contact Lance McCracken for more information: Lance.McCracken@rnhrd-tr.swest.nhs.uk).
Several AAQ measures for specific problems and populations are posted under Disease and disorder specific AAQ variations.
There are also a variety of translated versions of the AAQ and AAQ-II posted under ACT measures in Languages Other than English.
Other values measures are under development. Kelly Wilson (kwilson@olemiss.edu) or Matthew Smout (matthew.smout@saugov.sa.gov.au) are working on other approaches, and you may want to contact them.
This is a new approach developed by J. T. Blacklege and Joe Ciarocchi at the University of Wollongong.
In an August 2005 email J. T. said this
Joseph Ciarrochi & I (with invaluable suggestions from Steve) have just finished designing two new ACT values questionnaires that borrow elements from Sheldon's Personal Striving assessment form (Joseph discovered Kennon Sheldon's work a while back and it pointed us in a direction we felt might enhance ACT values assessment).
One is a full-length form called the Personal Values Questionnaire (which measures all 9 ACT values domains); the second is called the Social Values Survey (which measures only social, family, and couples relationships) that we tailored for a brief intervention with young adolescents.
There is currently no psychometric data for either (they are changed enough that Sheldon's Personal Striving data is largely irrelevant), though we will be validating the SVS on a sample of 8th graders in a few weeks, and validating the PVQ on a university student sample early next year. Please feel more than free to validate these questionnaires on any samply you see fit (just let us know--we'd love to see the data). The format of the questionnaire is close enough to Sheldon's for us to expect the measures to have similarly reasonable psychometric properties, but, of course, who knows until we see data.
We had two primary purposes in mind while we were designing these instruments. First, we wanted to describe each values domain in a way likely to influence subjects to write relatively ACT-consistent values--even if these subjects had not been exposed to ACT therapy. As we all know, ACT talks about values in a different way than the term is usually used--and it's thus hard to expect someone not familiar with ACT to state a value in an ACT-consistent way without interacting with a therapist.. We wanted to make it clear to subjects that by value, we are referring to unilateral actions that are likely to lead to increased vitality, meaning, purpose--not static end states that appear implicitly out of one's control. In other words, to avoid getting responses like "I value close friendships", we included prompts like, "What kinds of friendships would you most like to build? If you were able to be the best friend possible, how would you behave toward your friends? For example, you might value building friendships that are supportive, considerate, caring, accepting, loyal, or honest—but choose for yourself which qualities you would most like to bring to your friendships. " Some subtle changes from wording used on previous versions of values questionnaires, but we felt the 'build' theme, along with examples, seemed to provide the kind of prompts that might be more helpful.
Second, we wanted to include Likert-scale questions that assessed things like how much each stated value might be a function of things like pliance or experiential avoidance. Steve oriented us back toward RFT/rule governed behaviour terms that capture what we were trying to assess: as it stands now, question one under each values domain on the SVS and PVQ assesses pliance, question 2 assesses avoidant tracking, and questions 3 & 4 assess augmentals. There are also items that get at importance of each value, effectiveness in moving toward it, etc. As it stands (using Sheldon's scoring algorithms and common sense), subtracting the sum of items 1 & 2 from the sum of items 3 & 4 would yield a sort of 'value purity' score that tells us to what degree a subject/client values the stated value for the reasons we'd hope for from an ACT perspective (higher positive score = greater 'purity' of the value; negative score means the 'value' is actually a function of pliance and/or avoidance).
We've also similarly updated the SVS. Please use this version rather than the previously posted one.
We've tinkered with the instrument instructions a bit. Please use this version instead of the previously posted one.
This is an approach developed by Tobias Lundgren and JoAnne Dahl at the University of Uppsala and successful used in a recent study on reducing epileptic seizures with ACT.
see attachement - & feel free to change it as you like - one is a word doc. & then a jpeg
The Valued Living Questionnaire is a simple questionnaire originally developed as a clinical tool. It's categories map relatively closely to the categories in the original ACT book (no surprise, since I authored both). I have also added a short working guide to its use. We have a paper describing its basic psychometric properties. A preprint is available here on the ACBS site Download Manuscript. The manuscript contains a copy of the VLQ. Feel free to email me Kelly G. Wilson for any updates. Also, to get a better flavor of the values work, I would recommend reading my chapter with Amy Murrell in the Mindfulness and Acceptance book. The chapter is also available here on this site: Values Work in ACT.
peace all,
Kelly
The ACT daily diary and weekly report (see attachments below) can be clinically useful in monitoring progress.
Also here: http://www.contextualpsychology.org/questionnaire_dacceptation_et_daction
AAQ translated in Hebrew.
Liad Bareket-Bojmel
Department of Behavioral Sciences
Ben-Gurion University
liadbar@bgu.ac.il
Spanish version of the AAQ.
AAQ-II translated in Dutch.
Translated AAQ-II in Norwegian.
Translated by Trym N. Jacobsen and Ayna B.Johansen(can be reached at trym_n_jacobsen@yahoo.no)
AAQ-II translated in Portuguese.
German 22-item AAQ.
This German version of the AAQ was used in an upcoming study by these authors
The 22 item version (the one you can score all vaidated ways) of the AAQ-I in Swedish.
Translated by Rikard Calmbro and Henrik Torneskog. The translators can be reached at calmbro@hotmail.com.
This page contains a working list of child and adolescent specific measures related to ACT processes.
Avoidance and Fusion Questionnaire for Youth (AFQ-Y; Greco, Murrell, & Coyne, 2005; see attachments below): The AFQ is a 25-item measure that assesses: (a) experiential avoidance/control – i.e., attempts to escape, alter, or otherwise control negatively evaluated private events; and (b) cognitive and emotional fusion – i.e., attachment to private events and responding to internal experiences as if they were literally true. The AFQ has good internal consistency, with alphas ranging from .89-.93 in community and medical samples. Scores on the AFQ correlate with the Acceptance and Action Questionnaire (r = .65 to .68 assuming you have keyed the AAQ so that higher scores equal higher experiential avoidance) and general quality of life. The AFQ has also been found to correlate positively with child-reported anxiety and somatic complaints and teacher-reported internalizing symptoms (Greco & Lipani, in progress; Greco, Dew, & Baer, in progress).
Note on Development & Use of Measures
The WAM and AFQ were derived from an initial pool of 50 items developed to measure psychological acceptance, conceptualized as an active and multidimensional process involving high or low levels of: willingness to experience private events, values-oriented action, experiential avoidance, and cognitive and emotional fusion. Results of exploratory factor analysis on these initial 50 items supported a three-factor solution. Factor one consisted of 25 items, all negatively worded. Conceptually, this factor seems to tap into experiential avoidance and fusion and is now the Avoidance and Fusion Questionnaire for Youth (AFQ-Y). Factors two and three were combined into a single measure – the Willingness and Action Measure for Children and Adolescents (WAM-C/A). The WAM can be broken down into a 9-item Action Scale and a 5-item Willingness Scale. The WAM total and subscale scores correlate with each other but not with the AFQ-Y. Perhaps unsurprisingly, the Action Scale seems to be driving the results of the WAM. A validation study is currently underway and will help determine which version of the WAM is most useful and psychometrically sound. At this point, we suggest using the 25-item AFQ to measure experiential avoidance and fusion and the 14-item WAM to measure willingness and ability to take action.
We have used the WAM and AFQ with children and adolescents 9-17 years old. Based on results from school studies in middle Tennessee, children report good comprehension of items. Though preliminary, our findings suggest that the WAM may be a stronger predictor of positive outcomes such as quality of life and social effectiveness, whereas the AFQ may be a stronger predictor of negative outcomes such as physical and emotional symptoms. As noted above, the nine Action items seem to be driving the predictive utility of the WAM (Greco, Dew, & Baer, in progress). If you’d like more information regarding these scales, please contact Laurie.Greco@Vanderbilt.Edu.
WAM-C/A and AFQ-Y References:
Greco, L. A., Murrell, A. R., & Coyne, L. W. (2004). The Willingness and Action Measure for Children and Adolescents. Available from the first author at the Division of Adolescent Medicine and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN.
"The CAMM is a 25-item measure of mindfulness and assesses the degree to which children and adolescents observe internal experiences, act with awareness, and accept internal experiences without judging them.
Scoring: Respondents are asked to indicate how true each item reflects their experience using a 5-point scale ranging from 0 (Never true) to 4 (Always true). A total acceptance-mindfulness score can be generated by reverse scoring negatively worded items (see below) and summing the item total, yielding a possible range in scores from 0-100. Higher scores indicate higher levels of acceptance and mindfulness.
Reverse-scored items: 2, 4, 5, 7, 8, 10, 11, 15, 16, 17, 18, 19, 20, 21, 25
Reliability: The CAMM demonstrates good internal consistency, with Cronbach’s alpha = .87.
Validity: Research using the CAMM suggests the measure has good concurrent validity.
Reference:
Greco, L. A., Dew, S. E., & Ball, S. (2005). Acceptance, mindfulness, and related processes in childhood: Measurement issues, clinical relevance, and future directions. In S.E. Dew & R. Baer (Chairs), Measuring Acceptance, Mindfulness, and Related Processes: Empirical Findings and Clinical Applications across Child, Adolescent, and Adult Samples. Symposium presented at the Association for Behavior and Cognitive Therapies, Washington, DC."
Information quoted from Ciarrochi, J. & Bilich, L. (2006). Process measures of potential relevance to ACT. Unpublished manuscript, University of Wollongong, Australia.
"Authors: L. A. Greco & Hart
The Diabetes Acceptance and Action Scale for Children and Adolescents is a 42-item measure that is being used to indicate levels of psychological flexibility in youth with Type 1 diabetes.
Scoring: To score the DAAS, first reverse score negatively worded items (see below), then sum all items. Higher scores on the DAAS should reflect higher levels of diabetes-related acceptance and action.
Reverse score key: 2, 4, 5, 6, 7, 8, 11, 13, 14, 17, 18, 19, 21, 22, 24, 25, 26, 27, 28, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42.
The authors are still in the process of collecting data. Preliminary data obtained thus far reveals statistically significant correlations:
Diabetes-related quality of life = .36 (higher acceptance correlates with higher Quality of Life)
Diabetes-related worry = -.41
Social anxiety = -.36
Adherence to medical regimen = .30"
Information quoted from Ciarrochi, J. & Bilich, L. (2006). Process measures of potential relevance to ACT. Unpublished manuscript, University of Wollongong, Australia.
The Avoidance and Fusion Questionnaire for Youth (AFQ-Y; Greco, Murrell, & Coyne, 2005) is a 17-item measure that asks respondents to rate how true each item is for them (0 = Not at All True; 4 = Very True). Items are tied to ACT’s model of human suffering and were generated to represent a theoretically cohesive conceptualization of psychological inflexibility fostered by: (1) Cognitive fusion (e.g., “My thoughts and feelings mess up my life,” “The bad things I think about myself must be true”); (2) Experiential avoidance (e.g., “I push away thoughts and feelings that I don’t like”); and (3) Inaction or behavioral ineffectiveness in the presence of unwanted internal experiences (e.g., “I can’t be a good friend when I feel upset”).
Consistent with theoretical underpinnings of ACT, support has been found for a one-factor scale comprised of items that seem to converge in a coherent manner. Results of classical test theory, factor analysis, and item response theory support the psychometric properties of the 17-item version of the AFQ-Y. Overall, research suggests that the AFQ-Y may be a useful and child-friendly measure of core ACT processes.
We describe the development and validation of the Avoidance and Fusion Questionnaire for Youth (AFQ-Y), a child-report measure of psychological inflexibility engendered by cognitive fusion, experiential avoidance, and behavioral ineffectiveness in the presence of negatively evaluated private events such as thoughts, feelings, and physical-bodily sensations. Consistent with underpinnings of Acceptance and Commitment Therapy (ACT), items on the AFQ-Y converged into a single, theoretically coherent scale. Results of classical test theory, exploratory factor analysis, and Rasch modeling provided preliminary support for the psychometric properties of a 17-item version of the AFQ-Y. Support was found for convergent and construct validity, as scores on this measure correlated in expected directions with behavioral-health outcomes and overlapping processes such as acceptance, mindfulness, and thought suppression. Overall, findings suggest that the AFQ-Y may be a useful child-friendly measure of core ACT processes.
There are many measures of ACT concepts that have been developed for specific disorders, syndromes, and types of chronic disease.
Diabetes specific AAQ
Trauma specific AAQ
Acceptance and Action Questionnaire for Weight-Related Difficulties.
Reference: Lillis, J. & Hayes, S.C. (under review). Measuring avoidance and inflexibility in weight related problems.
The Avoidance and Inflexibility Scale (AIS) assesses ACT processes in the context of cigarette smoking.
Reference:
Gifford, E. V., Antonuccio, D.O, Kohlenberg, B.S., Hayes, S.C., & Piasecki, M.M. (2002). Combining Bupropion SR with acceptance and commitment-based behavioral therapy for smoking cessation: Preliminary results from a randomized controlled trial. Paper presented at the annual meeting of the Association for Advancement of Behavioral Therapy, Reno, NV.
Sandoz, E. K. & Wilson, K. G. (2006). Body Image - Acceptance and Action Questionnaire: Embracing "Normative Discontent". Unpublished Manuscript. University of Mississippi.
Negative thoughts and feelings about body shape and/or weight have frequently been associated with rigid and disordered eating behavior (Bruch, 1973; Fairburn & Cooper, 1984). Commonly referred to as negative body image, these thoughts and feelings have even been proposed to have a causal role in the development of disordered eating (Polivy & Herman, 2002), resulting in the focusing of interventions on the manipulation of these thoughts and feelings ( Wilson, 2005). Another possibility is that negative body image is an extremely common and unsurprising, if not expected, outcome of being alive in Western culture. After all, Rodin, Silberstein, and Streigel-Moore (1985) identified body dissatisfaction twenty years ago as a "normative discontent." Further, it may be that the problem is not negative body image, but the pursuit of positive body image. If this is the case, than acceptance of thoughts and feelings regarding body and weight should be associated with healthier, more flexible patterns of eating and improved quality of life. Thus, body image Acceptance can be defined as actively contacting perceptions, thoughts and feelings regarding body shape and/or weight directly, fully, and without defense, while behaving effectively.
The Body Image - Acceptance and Action Questionnaire (BI-AAQ) is designed to measure the extent to which an individual exhibits an accepting posture toward negative thoughts and feelings about his or her body shape and/or weight. It is a 29-item self-report scale to which an individual responds on a 7-point scale from ‘Never True’ to ‘Always True.’ Initial psychometric data is promising. The scale is internally consistent with Cronbach’s alpha = .93. Construct validity is also good. Scores are significantly negatively correlated with well-established measures of theoretically related constructs such as body dissatisfaction, bulimia, general eating pathology, and general distress, and significantly positively correlated withwell-established measures of theoretically related constructs such as mindfulness skills, and general acceptance. Scores also predict performance on an Implicit Relational Assessment Procedure with body- and self-related stimuli. Regression analyses suggest that the BI-AAQ remains a significant predictor even after accounting for variance related to measures of general acceptance and measures of negative body image.
Scale is linked in Word format below and is downloadable for members.
Contact Emily Sandoz with questions or requests for the working manuscript: eksandoz@olemiss.edu
Chronic Pain version of the AAQ
The Voices Acceptance and Action Questionnaire.
Reference: Shawyer, F., Ratcliff, K., Mackinnon, A., Farhall, J., Hayes, S.C. & Copolov, D. (2007). The
voices acceptance and action scale (VAAS): Pilot data. Journal of Clinical Psychology, 63(6), 593–606.
Partial list of fusion measures.
Automatic Thoughts-Believability measure.
Reference: Zettle, R. D. & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context
of reason giving. The Analysis of Verbal Behavior, 4, 30 38.
Assesses believability of negative thoughts towards clients.
Reference: Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., Masuda, A.,
Pistorello, J., Rye, A. K., Berry, K. & Niccolls, R. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-835.
Partial list of available mindfulness measures.
The Five Facet Mindfulness Questionnaire is a 39 item measure consisting of five subscales (observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience).
Reference:
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27-45.
The scale and measure development article are included below.
The Mindful Attention Awareness Scale (MAAS) is a 15 item measure assessing mindfulness of moment to moment experience.
Reference:
Brown, K. W. & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822-848.
The Philadelphia Mindfulness Scale is a 20 item measure consisting of 2 sub-scales (acceptance and present moment awareness).
Reference:
Cardaciotto, L. (2005). Assessing mindfulness: The development of a bi-dimensional measure of awareness and acceptance. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 66(6-B) , 3399.
This page is a working list of other measures related to ACT processes.
Reference: Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56(2), 267-283.
Description from abstract of original paper:
"We developed a multidimensional coping inventory to assess the different ways in which people respond to stress. Five scales (of four items each) measure conceptually distinct aspects of problem-focused coping (active coping, planning, suppression of competing activities, restraint coping, seeking of instrumental social support); five scales measure aspects of what might be viewed as emotion-focused coping (seeking of emotional social support, positive reinterpretation, acceptance, denial, turning to religion); and three scales measure coping responses that arguably are less useful (focus on and venting of emotions, behavioral disengagement, mental disengagement). Study 1 reports the development of scale items. Study 2 reports correlations between the various coping scales and several theoretically relevant personality measures in an effort to provide preliminary information about the inventory's convergent and discriminant validity. Study 3 uses the inventory to assess coping responses among a group of undergraduates who were attempting to cope with a specific stressful episode. This study also allowed an initial examination of associations between dispositional and situational coping tendencies."
Internalized Shame Scale.
Reference:
Rosario, P.M. & White, R.M. (2006). The Internalized Shame Scale: Temporal stability, internal
consistency, and principal components analysis. Personality and Individual Differences, 41, 95–103.
The Psychological Inflexibility in Pain Scale (PIPS) assesses both avoidance of pain and cognitive fusion with pain.
Reference:
Wicksell, R. K., Renöfält, J., Olsson, G. L., Bond, F.W. & Melin, L. (2008). Avoidance and cognitive fusion - central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS). European Journal of Pain, 12, 491-500.
Scale for personality rigidity.
Reference: Rehfisch, J.M. (1958). A scale for personality rigidity. Journal of Consulting Psychology, 22, 11-15.
This scale has been found to relate to rule governed behavior in laboratory studies.
Wulfert, E., Greenway, D. E., Farkas, P., Hayes, S. C., & Dougher, M. J. (1994). Correlation between a personality test for rigidity and rule-governed insensitivity to operant contingencies. Journal of Applied Behavior Analysis, 27, 659-671.
From abstract:
"Adults were selected on the basis of their scores on the Scale for Personality Rigidity (Rehfisch, 1958). Their scores served as a measure of hypothesized rule governance in the natural environment. Experiment 1 studied the effects of accurate versus minimal instructions and high versus low rigitidy on performance on a multiple differential-reinforcement-of-low-rate (DRL) 4-s fixed-ratio (FR) 18 schedule. When the schedule was switched to extinction, accurate instructions and high rigidity were associated with greater perseveration in the response pattern subjects developed during the reinforcement phase. In Experiment 2, the effects of rigidity and of accurate versus inaccurate instructions were studied. Initially, all subjects received accurate instructions about an FR schedule. The schedule was then switched to DRL, but only half of the subjects received instructions about the DRL contingency, and the other half received FR instructions as before. Accurate instructions minimized individual differences because both high and low scorers on the rigidity scale earned points in DRL. However, when inaccurate instructions were provided, all high-rigidity subjects follow them although they did not earn points on the schedule, whereas most low-rigidity subjects abandoned them and responded appropriately to DRL. The experiments demonstrate a correlation between performances observed in the human operant laboratory and a paper-and-pencil test of rigidity that purportedly reflects important response styles that differentiate individuals in the natural environment. Implications for applied research and intervention are discussed."
Reference:
Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223-250.
Coding Key:
Self-Kindness Items: 5, 12, 19, 23, 26
Self-Judgment Items: 1, 8, 11, 16, 21
Common Humanity Items: 3, 7, 10, 15
Isolation Items: 4, 13, 18, 25
Mindfulness Items: 9, 14, 17, 22
Over-identified Items: 2, 6, 20, 24
Subscale scores are computed by calculating the mean of subscale item responses. To compute a total self-compassion score, reverse score the negative subscale items - self-judgment, isolation, and over-identification - then compute a total mean.
(This method of calculating the total score is slightly different than that used in the article referenced above, in which each subscale was added together. However, I find it is easier to interpret the scores if the total mean is used.)
"Authors: R. Michael Bagby, James D. A. Parker and Graeme J. Taylor
The TAS is a 20-item instrument that is one of the most commonly used measures of alexithymia. Alexithymia refers to people who have trouble identifying and describing emotions and who tend to minimise emotional experience and focus attention externally.
The TAS-20 has 3 subscales:
• Difficulty Describing Feelings subscale is used to measure difficulty describing emotions. 5 items – 2, 4, 7, 12, 17.
• Difficulty Identifying Feeling subscale is used to measure difficulty identifying emotions. 7 items – 1, 3, 6, 11, 9, 13, 14.
• Externally-Oriented Thinking subscale is used to measure the tendency of individuals to focus their attention externally. 8 items – 5, 8, 10, 15, 16, 18, 19, 20.
Scoring: The TAS-20 is a self-report scale that is comprised of 20 items. Items are rated using a 5-point Likert scale whereby 1 = strongly disagree and 5 = strongly agree. There are 5 items that are negatively keyed (items 4, 5, 10, 18 and 19). The total alexithymia score is the sum of responses to all 20 items, while the score for each subscale factor is the sum of the responses to that subscale.
The TAS-20 uses cutoff scoring: equal to or less than 51 = non-alexithymia, equal to or greater than 61 = alexithymia. Scores of 52 to 60 = possible alexithymia.
Reliability: Demonstrates good internal consistency (Cronbach’s alpha = .81) and test-retest reliability (.77, p<.01).
Validity: Research using the TAS-20 demonstrates adequate levels of convergent and concurrent validity. The 3 factor structure was found to be theoretically congruent with the alexithymia construct. In addition, it has been found to be stable and replicable across clinical and nonclinical populations.
Reference:
Bagby, R. M., Parker, J. D. A. & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23-32."
Information quoted from Ciarrochi, J. & Bilich, L. (2006). Process measures of potential relevance to ACT. Unpublished manuscript, University of Wollongong, Australia.
"Authors: Daniel M. Wegner & Sophia Zanakos
The WBSI is a 15-item questionnaire that is designed to measure thought suppression. Chronic thoughts suppression is a variable that is related to obsessive thinking and negative affect associated with depression and anxiety. The WBSI can help to identify individuals who are more prone to develop chronic thought suppression as well as individuals who express wishing they were not depressed, but are in fact depressed. The measure can also be used by practitioners to evaluate changer over time.
Scoring: The scoring of the WBSI is based on a 5 point scale from Strongly disagree (1) to Strongly agree (5). The total score is obtained by summing up the responses that are provided by respondents. The total score can range from 15 to 75. Higher scores on the WBSI indicate greater tendencies to suppress thoughts.
Reliability: The WBSI has very good internal consistency, with alphas ranging from .87 to .89. The WBSI has also been found to have good stability with a 1 week test-retest correlation of .92, and a 3 week to 3 month test-retest correlation of .69.
Validity: Demonstrates excellent convergent validity with significant correlations between the WBSI and several measures including Beck’s Depression Inventory (BDI), the Maudsley Obsessive-Compulsive Inventory, and the State-Trait Anxiety Inventory (STAI). It has also been found that the WBSI correlates negatively with repression, thus suggesting that the WBSI measures a characteristic that is different to traditional concepts of repression.
Reference:
Wegner, D. M. & Zanakos, S. (1994). Chronic thought suppression. Journal of Personality, 62, 615-640."
Information quoted from Ciarrochi, J. & Bilich, L. (2006). Process measures of potential relevance to ACT. Unpublished manuscript, University of Wollongong, Australia.
Ciarrochi, J. & Bilich, L. (2006). Process measures of potential relevance to ACT. Unpublished manuscript, University of Wollongong, Australia.
This document contains a large collection of ACT-relevant measures
Attached, please find a copy of self-monitoring forms I use with a wide range of patients. I direct patients to monitor those self-care behaviors relevant to their treatment (hygiene, eating, going to sleep at reasonable hour, exercise, meditation/centering, alcohol use). There is ample room for adding other behaviors or to permit some journaling/notes. *I recently replaced the GIF formatted forms with forms converted to PDF format (using free PDF writer at www.gohtm.com).
As healthcare delivery continues to move towards and integrated care model, the connections between biological, psychological, and social processes affecting health remain minimally understood. Researchers have been exploring the role of acceptance, mindfulness, and values in producing positive health outcomes, while examining the negative role of experiential avoidance in the development and maintenance of health problems. ACT studies have been conducted in the areas of chronic pain, smoking, stress, burnout, diabetes management, and epilepsy with more studies in progress. In this section you will find links to researchers, studies, and applications of ACT in the areas of Wellness, Behavioral Health, Health Psychology, and Behavioral Medicine.
A number of researchers are working on weight control issues from an ACT/ RFT perspective. Here is where you will find the relevant research and conceptual issues.
From an ACT perspective, many of the psychological factors related to weight control that were discussed previously can be grouped into three categories:
Persistence: Individuals who have difficulty maintaining weight loss typically report or have been found to eat in response to stress and other negative affective states, such as hopelessness, helplessness, anger, anxiety, or boredom. From an ACT perspective, this can be seen as a problem with persistence or distress tolerance. The ACT theory of psychopathology suggests that attempts to change or eliminate unwanted private experiences (experiential avoidance) result in a narrow set of behavioral responses. In this case, the presence of uncomfortable or undesirable emotions consistently occasions eating for comfort. The problem is that the short-term effects of reducing negative affect have little or no impact on an individual’s long-term ability to face discomfort and lead a healthy, vital life. Each instance strengthens the relationship between uncomfortable emotion and avoidance. In a sense, the individual becomes less able to deal with uncomfortable emotions over time and eating is required more and more as a coping response.
Rigidity: Individuals who have difficulty maintaining weight loss typically report or have been found to adhere to rigid thinking patterns and rigid control of eating behaviors. Unsuccessful maintainers frequently adhere to dichotomous “all or nothing” thinking, viewing a minor misstep as a total failure or discounting any gains that fall short of some imagined ideal as meaningless. These individuals are prone to alternating between total restriction of desirable foods and a complete lack of weight controls all together. From and ACT perspective, this can be viewed as cognitive fusion. Cognitive fusion refers to situations in which behavior is excessively regulated by verbal rules and is insensitive to direct experiences. Individuals may be responding to verbal formulations, such as, “I had cake therefore I blew it, so what’s the point” or, “I only lost 15 pounds. I’ll never get to where I want to be.” These private events are experienced as literal truth, not as experiences that can be noticed while not being believed nor disbelieved. Individuals respond as though this is a true state of affairs and engage in behaviors that are inconsistent with a healthy, vital life.
Motivational factors: Individuals who have difficulty maintaining weight loss typically report attempting to lose weight in response to pressure from friends, family members, or health professionals as opposed to personal reasons, such as caring for oneself, wanting to be more healthy, or less activity restriction. From an ACT perspective, this can be seen as a form of rule-governance called pliance. Pliance occurs when individuals engage in behaviors in an attempt to please others or “be good” (Hayes, Strosahl et al., 1999). When this function dominates over direct, personal experiences of what works, problems can occur. These externally based contingencies are often not enough to maintain behavior outside the presence of the contextual variables (e.g. family member telling them they are doing a good job). Given the lifelong nature of maintaining weight, it is unlikely that excessive pliance could be a successful long-term behavioral approach. From an ACT perspective, individuals do not need to engage in behaviors consistent with weight maintenance in order to be praised by others; they can do them as an expression of chosen personal values (also called augmenting) and doing what works in regard to those values (also called tracking). In this respect, weight maintenance behaviors are less rigid and are more likely to be tied to the direct contingencies necessary for success.
Motivation, then, can be viewed primarily as a values issue. People are often not connected to their values. It is possible that there is frequently a disparity between what people want in their lives and what they are actually doing. This disparity can be painful to contact, thus relegating the issue of values to the background. Acceptance and defusion can help create a context where this disparity can be noticed without attachment to the painful private events that can accompany this connection. From an ACT perspective, then, values work involves goal setting/ attainment and the willingness to say/ know what is truly wanted. This involves the ability to recognize and be in contact with the disparity between what is desired and what is currently being done.
The ability to cope with stress has been associated with weight maintenance. Individuals who were described as having poor coping skills, or a poor ability to manage internal or external demands that are appraised as stressful, have been show to regain weight when confronted with stressful life events (S. Byrne, Cooper, & Fairburn, 2003; Gormally & Rardin, 1981; Gormally, Rardin, & Black, 1980; Grilo, Shiffman, & Wing, 1989).
People who regain lost weight tend to eat in response to the presence of negative emotional states or use food to regulate their mood; a phenomenon often referred to as emotional eating (S. Byrne et al., 2003; Ganley, 1989). Obese people who have difficulty losing or keeping off weight have been shown to use food as a source of comfort and satisfaction (Castelnuovo-Tedesco & Schiebel, 1975), eat after difficult interpersonal situations (Hockley, 1979), and eat in response to hopelessness, helplessness, anger, anxiety, or boredom (Hudson & Williams, 1981; Rotmann & Becker, 1970).
Motivational factors have also been associated with weight maintenance. Successful weight maintainers have been found to be motivated to lose weight for more personal reasons as opposed to pressures from family, friends, or medical professionals (Ogden, 2000). It appears that when a person is intrinsically motivated, and weight loss is tied to meaningful outcomes other than just losing weight, patients tend to be more successful in keeping weight off.
Self-efficacy has been also been associated with weight maintenance. Self-efficacy can be described as a belief in one’s capability to produce desired outcomes in one’s life. Related, individuals who respond to overeating episodes passively tend to regain weight more than those who respond actively (Jeffery et al., 1984). The key difference seems to be that active responders somehow do not get stuck when confronted with adversity.
Rigid versus flexible control of eating behavior has been associated with weight regain. Rigid control is characterized by dichotomous ‘all or nothing’ thinking and alternating periods of severe restriction and no weight control efforts. Flexible control is characterized by a ‘more or less’ approach, a long-term outlook, and the inclusion of desired foods at moderate amounts (Westenhoefer, 2001).
Despite the literature findings, potentially important psychological variables are rarely targeted in clinical trials of comprehensive weight loss programs or program components. Many interventions lack a psychological component altogether (for a review, see Avenell et al., 2004).
Obesity has been referred to as a dangerous epidemic and one of the most important public health challenges of the 21st century. The sharp increase in obesity has contributed to increases in related conditions, causing a sizeable economic cost burden for health providers and funding agencies. The 2002 estimated U.S. cost burden for obesity was $92.6 billion (Finkelstein, Fiebelkorn, & Wang, 2003).
It has been shown that marketplace food portions have increased in size since the 1970’s(Young & Nestle, 2002). People have been eating out more (K. Ball, Brown, & Crawford, 2002), food industry marketing has increased, and larger numbers of new products are being introduced (Gallo, 1990). Most Americans are sedentary. Technological advances have led to an increase in use of computers, cars, elevators, and televisions, with subsequent decreases in athletic activities including walking and bicycling.
Obese people also face discrimination resulting in external consequences. A recent review of the literature found evidence of obesity discrimination at every stage of the employment cycle (Roehling, 1999). Negative attitudes regarding obesity are widespread, socially acceptable, and develop as early as three years of age (Falkner et al., 1999; Puhl & Brownell, 2003a).
Well controlled, comprehensive weight loss programs often achieve substantial weight loss results with low rates of attrition. However weight maintenance has been a significant problem in the literature. Typically, half the weight lost is regained in the first year following treatment, and by 3-5 years posttreatment, 80% of patients have returned to or exceeded their pretreatment weight (Perri, 1998; Wadden et al., 1989; Wing, 1998).
Part of the ACT/ RFT movement is a "grand vision" to affect positive change on the culture more generally. Groups and organizations engage in practices that harm individuals, families, and the environment, yet there is little scientific understanding of how to bring about changes in these practices. A number of professionals throughout the world are conducting research on such topics as stigma, prejudice, prevention, advertising, child rearing, and environmental preservation among other important issues. Here is where you will find information on specific applications of ACT to cultural issues with links to relevant researchers and studies.
Despite decades of social concern, racial, ethnic, and religious prejudice persists. Few cultural issues seem more important than figuring out why people hate and how to reduce discriminatory and violent behavior due to prejudice. It seems our survival may depend on our ability as human beings to solve this issue. ACT/ RFT is relevant not just to the needs of the victims of prejudice, discrimination, and terrorism, but also to the understanding and modification of psychological processes that lead to the perpetration of hateful and discriminatory acts.
From an ACT/ RFT perspective, prejudice can be defined as the objectification and dehumanization of human beings because of their participation in verbal evaluative categories. Prejudice, defined this way, is a kind of verbal entanglement. It is difficult to avoid because some of the same cognitive processes that permit problem-solving also seem to foster prejudice. In addition, may of the things humans do to try and change or eliminate prejudice are either inert or prone to making these processes more resistant to change. Indeed, validated methods for reducing prejudice are very limited.
In this section are links to two papers. One is a conceptual paper describing prejudice/ terrorism from an ACT/ RFT perspective. The other is a link to a pilot study using ACT to reduce prejudice among college students.
Updates will soon follow.
A number of studies have been conducted examining the impact of small, ACT-based interventions in analogue settings. This page will include a list of studies with available intervention scripts or sections of articles that specifically state how the intervention was conducted. In addition, we will include scripts for studies that have not yet been completed in order to provide additional examples of the interventions that are being tested. These scripts can help inform the design of future analogue/component studies as well as provide a resource for those reviewing these studies.
If there are any additional study intervention scripts that are not listed here, you can add it by creating a new page using the instructions below.
To Add Content
1. Log in to your ACBS member account (you cannot create content as a guest).
2. Find your way to this parent page.
3. Click [add child page] at bottom.
4. Provide a concise, descriptive title.
5. Either attach a text file or a link to the content.
6. Remember to click [submit].
We are in the process of testing the effects of a self-as-context intervention on two measures of task persistence (breath holding and a difficult math task). We used an active control condition involving the same metaphor and exercise, but emphasizing self-as-content and emotion control strategies throughout. The results of the intervention will be analyzed soon and included on this page.
We would really appreciate any feedback regarding the intervention scripts. If you have any comments or suggestions please contact Mike Levin at levinm2@gmail.com.
Data to be presented at
Levin, M., Waltz, T.J., Yadavaia, J.E. & Hayes, S.C. (2008). Examining the effect of a self as context intervention on multiple measures of task persistence. Paper presented at the 34th Annual Convention of the Association for Behavior Analysis International, Chicago, IL.
We are currently testing the effects of a brief values intervention on study behavior with college students. The intervention includes a week of self monitoring and is being compared to self monitoring alone without the values intervention. The study is being conducted by Jennifer Plumb, Michael Twohig, Michael Levin, Kate Morrison and Steven Hayes.
The values condition protocol script is included below. We would really appreciate any feedback regarding the intervention scripts. If you have any comments or suggestions please contact Jen Plumb at jcplumb@gmail.com.
Campell-Sills, L., Barlow, B.H., Brown, T.A. & Hofmann, S.G. (2006). Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44, 1251-1263.
Abstract
The present investigation compared the subjective and physiological effects of emotional suppression and acceptance in a sample of individuals with anxiety and mood disorders. Sixty participants diagnosed with anxiety and mood disorders were randomly assigned to one of two groups. One group listened to a rationale for suppressing emotions, and the other group listened to a rationale for accepting emotions. Participants then watched an emotion-provoking film and applied the instructions. Subjective distress, heart rate, skin conductance level, and respiratory sinus arrhythmia were measured before, during, and after the film. Although both groups reported similar levels of subjective distress during the film, the acceptance group displayed less negative affect during the post-film recovery period. Furthermore, the suppression group showed increased heart rate and the acceptance group decreased heart rate in response to the film. There were no differences between the two groups in skin conductance or respiratory sinus arrhythmia. These findings are discussed in the context of the existing body of research on emotion regulation and current treatment approaches for anxiety and mood disorders.
Protocol included below
Eifert, G. H. & Heffner, M. (2003). The effects of acceptance versus control contexts on avoidance of panic-related symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 34, 293-312.
Abstract
The present study compared the effects of creating an acceptance versus a control treatment context on the avoidance of aversive interoceptive stimulation. Sixty high anxiety sensitive females were exposed to two 10-min periods of 10% carbon dioxide enriched air, an anxiogenic stimulus. Before each inhalation period, participants underwent a training procedure aimed at encouraging them either to mindfully observe (acceptance context) or to control symptoms via diaphragmatic breathing (control context). A third group was given no particular training or instructions. We hypothesized that an acceptance rather than control context would be more useful in the reduction of anxious avoidance. Compared to control context and no-instruction participants, acceptance context participants were less avoidant behaviorally and reported less intense fear and cognitive symptoms and fewer catastrophic thoughts during the CO2 inhalations. We discuss the implications of our findings for an acceptance-focused vs. control-focused context when conducting clinical interventions for panic and other anxiety disorders.
The intervention protocol is included below quoted from Heffner (2000).
Feldner, M. T., Zvolensky, M. J., Eifert, G. H., & Spira, A. P. (2003). Emotional avoidance: An experimental tests of individual differences and response suppression during biological challenge. Behaviour Research and Therapy, 41, 403-411.
Abstract
The present study examined the affective consequences of response inhibition during a state of anxietyrelated
physical stress. Forty-eight non-clinical participants were selected on the basis of pre-experimental
differences in emotional avoidance (high versus low) and subjected to four inhalations of 20% carbon
dioxide-enriched air. Half of the participants were instructed to inhibit the challenge-induced aversive
emotional state, whereas the other half was instructed to simply observe their emotional response. Participants
high in emotional avoidance compared to those low in emotional avoidance responded with greater
levels of anxiety and affective distress but not physiological arousal. Individuals high in emotional avoidance
also reported greater levels of anxiety relative to the low emotional avoidance group when suppressing
compared to observing bodily sensations. These findings are discussed in terms of the significance of
emotional avoidance processes during physical stress, with implications for better understanding the nature
of panic disorder.
The intervention protocol is included below quoted from Feldner (2003).
Forman, E.M., Hoffman, K.L., McGrath, K.B., Herbert, J.D., Brandsma, L.L. & Lowe, M.R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45, 2372-2386.
Abstract
The present study utilized an analog paradigm to investigate the effectiveness of two strategies for coping with food cravings, which was theorized to be critical to the maintenance of weight loss. Ninety-eight undergraduate students were given transparent boxes of chocolate Hershey’s Kisses and instructed to keep the chocolates with them, but not to eat them, for 48 h. Before receiving the Kisses, participants were randomized to receive either (a) no intervention, (b) instruction in control-based coping strategies such as distraction and cognitive restructuring, or (c) instruction in acceptance-based strategies such as experiential acceptance and defusion techniques. Measures included the Power of Food Scale (PFS; a measure of psychological sensitivity to the food environment), self-report ratings of chocolate cravings and surreptitiously recorded chocolate consumption. Results suggested that the effect of the intervention depended on baseline PFS levels, such that acceptance-based strategies were associated with better outcomes (cravings, consumption) among those reporting the highest susceptibility to the presence of food, but greater cravings among those who scored lowest on the PFS. It was observed that craving self-report measures predicted chocolate consumption, and baseline PFS levels predicted both cravings and consumption. Results are discussed in terms of the implications for weight loss maintenance strategies.
Protocol included below
Kehoe, A., Barnes-Holmes, Y., Barnes-Holmes, D., Cochrane, A. & Stewart, I. (2007). Breaking the pain barrier: Understanding and treating human suffering. The Irish Psychologist, 33(11), 288-297.
This article (see link above to download) describes the intervention components in detail starting on page 292.
Keogh, E., Bond, F. W., Hanmer, R. & Tilston, J. (2005). Comparing acceptance and control-based coping instructions on the cold-pressor pain experiences of healthy men and women. European Journal of Pain, 9, 591-598.
Abstract
The current study reflects recent developments in psychotherapy by examining the effect of acceptance-based coping instructions, when compared to the opposite, more control/distraction-based instructions, on cold-pressor pain. Since previous research indicates gender differences in how people cope with pain, we also sought to determine whether differences would be found between healthy men and women. As predicted, results indicated that women reported lower pain threshold and tolerance level than did men. Furthermore, the acceptance-based instruction resulted in lower sensory pain reports when compared to the opposite instructions. Finally, for affective pain, acceptance instructions only benefited women. These results suggest that acceptance-based coping may be particular useful in moderating the way in which individuals, especially women, cope with pain.
The intervention protocol is included below quoted from Keogh et al. (2005).
Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747-766.
Abstract
The effects of acceptance versus suppression of emotion were examined in 60 patients with panic disorder. Prior to undergoing a 15-minute 5.5% carbon dioxide challenge, participants were randomly assigned to 1 of 3 conditions: a 10-minute audiotape describing 1 of 2 emotion-regulation strategies (acceptance or suppression) or a neutral narrative (control group). The acceptance group was significantly less anxious and less avoidant than the suppression or control groups in terms of subjective anxiety and willingness to participate in a second challenge, but not in terms of self-report panic symptoms or physiological measures. No differences were found between suppression and control groups on any measures. Use of suppression was related to more subjective anxiety during the challenge, and use of acceptance was related to more willingness to participate in a second challenge. The results suggest that acceptance may be a useful intervention for reducing subjective anxiety and avoidance in patients with panic disorder.
Protocol included below
Masedo, A.I. & Esteve, M.R. (2007). Effects of suppression, acceptance and spontaneous coping on pain tolerance, pain intensity and distress. Behaviour Research and Therapy, 45, 199-209.
Abstract
Wegner’s Theory of Ironic Processes has been applied to study the effects of cognitive strategies to control pain. Research suggests that suppression contributes to a more distressing pain experience. Recently, the acceptance-based approach has been proposed as an alternative to cognitive control. This study assessed the tolerance time, the distress and the perceived pain intensity in three groups (suppression, acceptance and spontaneous coping groups) when the participants were exposed to a cold pressor procedure. Two hundred and nineteen undergraduates volunteered to participate. The suppression group showed the shortest tolerance time and the acceptance group showed the longest tolerance time. The acceptance group showed pain and distress immersion ratings that were significantly lower than in the other two groups, between which the differences were not significant. In the first recovery period, the suppression group showed pain and distress ratings that were higher than in the other two groups. In the second recovery period, although the acceptance group showed pain and distress ratings that were significantly lower than in the other two groups, the suppression and the spontaneous coping groups did not differ. The presence of a ‘rebound’ of physical discomfort and the effects of suppression on behavioural avoidance are discussed. These results support the acceptance approach in the management of pain.
The full intervention protocol is included below in Spanish as well as a quoted section from the article describing the intervention in English.
Páez-Blarrina M., Luciano C., Gutiérrez-Martínez O, Valdivia S., Ortega J. and Rodríguez-Valverde M. (2008). The role of values with personal examples in altering the functions of pain: Comparison between acceptance-based and cognitive-control-based protocols. Behaviour Research and Therapy, 46 , 84-97.
Abstract
The purpose of the present study was twofold. First, to compare the effect of establishing a motivational context of values on pain tolerance, believability, and reported pain, with three experimental conditions: pain acceptance (ACT condition), pain control (CONT condition), or no values (untrained condition). Second, the study aimed to isolate the impact of adding the corresponding coping strategies to both the ACT and the CONT conditions. Thirty adults were randomly assigned to one of the three experimental conditions. The participants went through the pain task in two occasions (Test I and Test II). In Test I, the effects of the ACT-values protocol (which established pain as part of valued action), the CONT-values protocol (which established high pain as opposed to valued action), and the no-values protocol, were compared. In Test II, the effect of adding the corresponding coping strategy to each condition (defusion for ACT vs. suppression for CONT) was examined. Test I showed a clear superiority of the ACT-values protocol in increasing tolerance and lowering pain believability. In Test II, the superiority of the ACT protocol was replicated, while the CONT protocol proved useful to reduce reported pain, in accordance with previous studies.
Protocol included below
Roche, B., Forsyth, J.P. & Maher, E. (2007). The impact of demand characteristics on brief
acceptance- and control-based interventions for pain tolerance. Cognitive and Behavioral Practice, 14, 381-393.
Abstract
The present analog study compared the effectiveness of an acceptance- and control-based intervention on pain tolerance using a cold pressor task, and is a partial replication and extension of the Hayes, Bissett et al. (Hayes, S. C., Bissett, R.T., Korn, Z., Zettle, R. D., Rosenfarb, I. S., Cooper, L. D., & Grundt, A. M. (1999). The impact of acceptance versus control rationales on pain tolerance. The Psychological Record, 49, 33-47) study. Our aim was to test the effects of a nonspecific source of therapeutic change within the context of ACT therapy. Otherwise healthy undergraduates (N=20) were exposed to a cold pressor task before, immediately after, and 10 min following one of the two interventions. Half of the participants also were assigned to a high demand characteristic condition in which the experimenter maintained close physical proximity, eye contact, and placed subtle social pressure on participants to please the experimenter. The results showed that the most important factor influencing latency to withstand the cold pressor task was social pressure. The acceptance-based intervention was more subject to demand than the control strategy. Evaluative ratings of pain were unaffected by the demand manipulation. The current data suggest that demand characteristics can exert a significant positive impact on the outcome of therapeutic protocols. The implications of this view for acceptance- and control-based psychosocial interventions are discussed.
Intervention script quoted from article below
Vowles, K., McNeil, D.W., Bates, M., Gallimore, P. & McCall, C. (2007). Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behavior Therapy, 38, 412-425.
Abstract
Psychosocial treatments for chronic pain are effective. There is a need, however, to understand the processes involved in determining how these treatments contribute to behavior change. Control and acceptance strategies represent two potentially important processes involved in treatment, although they differ significantly in approach. Results from laboratory-based studies suggest that acceptance-oriented strategies significantly enhance pain tolerance and behavioral persistence, compared with control-oriented strategies. There is a need, however, to investigate processes of acceptance and control directly in clinical settings. The present study investigated the effects of three brief instructional sets (pain control, pain acceptance, continued practice) on demonstrated physical impairment in 74 individuals with chronic low back pain using an analogue experimental design. After controlling for baseline performance, the pain acceptance group demonstrated greater overall functioning on a set of 7 standardized physical tasks relative to the other two groups, which did not differ from one another. Further, the acceptance group exhibited a 16.3% improvement in impairment, whereas the pain control group worsened by 8.3% and the continued practice group improved by 2.5%. These results suggest that acceptance may be a key process involved in behavior change in individuals with chronic pain.
Protocol included below
For suggestions on doing ACT research, check out the attached talk Steve gave at the ACT SI II in Philadelphia, July 2005
This part of the site maintains a summary of publications (journal articles, chapters, theses, dissertations, books) but for an more complete indexed list also click on the publications link in the Features menu on the left side of the screen, or the books & tapes there. The file at the bottom of the page (the ACT handout) lists most ACT publications as of March 2007.
The subsections divide the empirical ACT literature into several categories. If you have a study that should be added you can upload the actual publication into the publications section (click on the word "publications" at the top of any page of the site and then go to "create content" on the left and say it is a publication you want to add). You can't add the reference to the publication here directly ... you have to email that information to the site editor and we will add it ... but if the publication itself is already uploaded we can link the reference here to that file so that people can find it and download it.
Case Studies by Year (Controlled Time Series Studies are covered in the RCT page)
2008
2007
2006
2005
Case study. Shows improvement with a dually diagnosed patient.
A case study that examines a combination of ACT and FAP in the successful treatment of a case of Schizotypal Personality Disorder.
Discussion article and case study showing how to apply ACT to the treatment of PTSD.
2004
Case study. An ACT protocol with an emphasis on mindfulness helps with sports outcomes.
2003
This case study describes a heavily values focused ACT treatment of a case of alcohol dependence within an Acceptance and Commitment Therapy model. Identifying valued directions seemed to help the client achieve sobriety and put a plan into action to "start living."
A successful application of ACT to a 30-year-old male with difficulties in accepting his bisexual orientation and with an erectile dysfunction is presented.
Case study with a retarded psychotic person experiencing command hallucinations and multiple delusions. Believability drops dramatically over treatment but not frequency. Good functional improvement.
2002
Describes the use of ACT in anorexia and shows resulting data. Case study. The case study is followed by discussion articles:
- Wilson, K. G. & Roberts, M. (2002). Core principles in Acceptance and Commitment Therapy: An application to anorexia. Cognitive and Behavioral Practice, 9, 237-243.
- Hayes, S. C. & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9, 243-247.
- Orsillo, S. M. & Batten, S. J. (2002). ACT as treatment of a disorder of excessive control: Anorexia. Cognitive and Behavioral Practice, 9, 253-259.
- There is also a cognitive paper that is nominally a response to the case, but it mentions ACT only in passing, focusing instead on the traditional CBT model.
Presents data on ACT with a patient who failed a course of cognitive therapy.
2001
Describes the use of ACT in the treatment of psychotic disorders and shows resulting data. Case study.
Describes the use of ACT in the treatment of complicated bereavement and shows resulting data. Case study.
Describes the use of ACT in the treatment of alcoholism and shows resulting data. Case study.
Describes the use of ACT in the treatment of anxiety problems and shows resulting data. Case study.
Describes the use of ACT in the treatment of chronic pain and shows resulting data. Case study.
Describes the use of ACT in the treatment of alcoholism and shows resulting data. Case study.
Describes the use of ACT in the treatment of agoraphobia and shows resulting data. Case study.
2000
1999 and Earlier (First ACT Book Appears in 1999)
Uncontrolled. Presents case data on the use of ACT components with families.
Shows a series of uncontrolled case evaluations on ACT with anxiety problems.
Correlational studies on ACT-Related Processes by Year
See also the experimental psychopathology page
2008
2007
In a sample of 187 elderly those higher in psychological acceptance had higher quality of life in the areas of health, safety, community participation and emotional well-being; and had less adverse psychological reactions to decreasing productivity.
This correlational study examined the hypothesis that experiential avoidance mediates associations between excessively materialistic values and diminished emotional well-being, meaning in life, self-determination, and gratitude. Results indicated that people with high materialistic values reported more negative emotions and less relatedness, autonomy, competence, gratitude, positive emotions, and sense of meaning – all of these relations were mediated by experiential avoidance mediated all of these relations. Emotional disturbances such as social anxiety and depressive symptoms failed to account for these findings after accounting for shared variance with experiential avoidance.
Correlational study with 730+ folks suffering from trichotillomania. Experiential avoidance as measured by the AAQ fully mediated the rela¬tionship between hair-pulling and both fears of negative evaluation and feelings of shame and partially mediated the relationship between hair-pulling severity and dysfunctional beliefs about appearance.
2006
Found that the impact of skin picking on depression and anxiety was partially mediated by the AAQ in a non-referred sample of chronic skin pickers.
two studies, one correlational and one longitudinal, show that experiential avoidance as measured by the AAQ fully or partially mediated the relationships between coping and emotion regulation strategies on anxiety-related pathology, (Sutdy 1) and psychological distress and hedonic functioning over the course of a 21-day monitoring period (Study 2). The variables examined included maladaptive coping, emotional responses styles, and uncontrollability on anxiety-related distress (e.g., anxiety sensitivity, trait anxiety, suffocation fears, and body sensation fears), and suppression and cognitive reappraisal on daily negative and positive experiences. The data showed that cognitive reappraisal, a primary process of traditional cognitive-behavior therapy, was much less predictive of the quality of psychological experiences and events in everyday life compared with EA.
In a 21-day experience sampling study, dispositional social anxiety, emotional suppression, and cognitive reappraisal was compared daily measures of social anxiety. Socially anxious individuals reported the lowest rate of positive events on days when they were more socially anxious and tended to suppress emotions, and the highest rate of positive events on days when they were less socially anxious and more accepting of emotional experiences. Irrespective of dispositional social anxiety, participants reported the most intense positive emotions on days when they were less socially anxious and more accepting of emotional experiences.
2005
Experiential avoidance as measured by the AAQ correlated positively with post-discharge parental stress and traumatic stress symptoms surrounding preterm birth. Moreover, it partially mediated the association between stress during delivery and later traumatic stress symptoms. This process was not moderated by parent reports of child temperament or perceived social support, suggesting that experiential avoidance plays a mediating role irrespective of child characteristics or perceived support from family members and close friends.
185 trauma survivors were assessed for peritraumatic dissociation, experiential avoidance (using the AAQ), and PTSD symptom severity. Both peritraumatic dissociation and experiential avoidance were significantly related to PTSD symptoms at baseline. After the initial levels of PTSD was taken into account, only experiential avoidance was related to PTSD symptoms both 4- and 8-weeks later.
Correlational study. Shows that the AAQ is associated with GAD symptoms in both clinical and non-clinical populations.
2004
In a large sample of adults suffering from trichotillomania, experiential avoidance as measured by the 9 item AAQ correlated with more frequent and intense urges to pull, less ability to control urges, and more pulling-related distress than persons who were not experientially avoidant. Actual pulling did not differ.
Study compared experiential avoidance (as measures by the AAQ) and emotional intelligence in terms of their ability to predict general mental health, physical well-being, and job satisfaction in workers (controlling for the effects of job control since this work organisation variable is consistently associated with occupational health and performance). Results from 290 United Kingdom workers showed that emotional intelligence did not significantly predict any of the well-being outcomes, after accounting for acceptance and job control. Acceptance predicted general mental health and physical well-being but not job satisfaction, Job control was associated with job satisfaction, only. Not controlling one’s thoughts and feelings (as advocated by acceptance) may have greater benefits for mental well-being than attempting consciously to regulate them (as emotional intelligence suggests).
Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54, 553-578. The AAQ validation study. Over 2000 subjects. Validates both a 9 and 16 item version, both single factor.
See McCracken 1998
Correlational study. Showed that experiential avoidance was correlated with post-traumatic symptomatology over and above other measures of psychological functioning.
Correlational study. Among a sample of individuals exposed to multiple potentially traumatic events, general experiential avoidance (but not thought suppression in particular), predicted symptoms of depression, anxiety, and somatization when controlling for posttraumatic stress symptom severity. Thought suppression (but not experiential avoidance) was associated with severity of posttraumatic stress symptoms when controlling for their shared relationship with general psychiatric symptom severity.
2003
Shows that AAQ predicts positive work outcomes (mental health, satisfaction, performance) even one year later, especially in combination with job control. Re-factors the AAQ and shows that a two factor solution can work on a slightly different 16 item version.
2002
Correlational study showing that childhood sexual abuse (CSA), experiential avoidance and emotional expressivity were significantly related to psychological distress. However, only experiential avoidance mediated the relationship between CSA and current distress.
2001
This is a correlational study (N = 283) showing that generalized experiential avoidance accounted for 67% of the variance in distress in a sexually abused population.
1999 and earlier
This study is based on a pain related early version of the AAQ. Greater acceptance of pain was associated with reports of lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily uptime, and better work status. A relatively low correlation between acceptance and pain intensity showed that acceptance is not simply a function of having a low level of pain. Regression analyses showed that acceptance of pain predicted better adjustment on all other measures of patient function, independent of perceived pain intensity. This work is replicated, refined and extended in McCracken, L. M. & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain. Pain, 105, 197-204. and McCracken, L. M. , Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain: Component analysis and a revised assessment method. Pain, 107, 159-166.
101 heterogeneous outpatients reporting moderate to severe levels of anxiety or depression were randomly assigned either to traditional CT or to ACT. 23 junior therapists were used. Participants receiving CT and ACT evidenced large and equivalent improvements in depression, anxiety, functioning difficulties, quality of life, life satisfaction and clinician-rated functioning. “Observing” and “describing” one’s experiences mediated outcome