Psychological Flexibility: We Know Less Than We Think

Part 1: New research to measure a core element of resilience.

Posted Jul 06, 2020

Historically, mental health professionals treated client distress by trying to get rid of it. This approach appears sensible because most people begin therapy with the aim of reducing the amount of suffering in their lives. Hundreds of published scientific studies show that, following some variant of cognitive-behavioral therapy, people’s symptoms of distress drop significantly. There is an unintended consequence of this therapeutic approach.

If therapy trains people to reduce/avoid/get rid of their difficult thoughts and feelings, then people view the presence of difficult thoughts and feelings as the enemy. When difficult thoughts and feelings appear, this is the moment when psychological tools are to be used for eradicating them (with prejudice). Therapy trains people to engage in a never-ending internal battle with perfectly natural feelings of anxiety, sadness, anger, guilt, embarrassment, boredom, and loneliness. Many of these thoughts and emotions, albeit painful, offer useful information about what is the most useful strategy to adopt in a given situation.

Take anger, felt when you believe someone or something is obstructing personally important goals. A world without anger is a dangerous place for people at the lower rungs of the social hierarchy. Civil rights revolutions derive from anger directed outwards. Low-grade frustration and high-grade feelings of righteous indignation motivates someone on the margins to demand tolerance and respect. Science shows that when anger is deployed effectively, it works. When directed at another person, 76% of targets realized their own faults in a situation; 48% of relationships strengthened (whereas 35% of relationships weakened), and 44% of targets gained respect (whereas 29% lost respect) for the angry person. As for how to get better at using anger, know that anger is more effective when you can clarify the source. When people are unable to identify what is angering them with precision, anger is experienced as more intense, harder to control, harder to express outwardly to another person, and there is greater regret for inaction.

Perhaps distress reduction is the wrong treatment goal, especially if we want to help people become more resilient. In 1973, Ferster believed “the significance of a person's activities is understood by the way it operates on the environment, including, of course, both sides of his skin … behavioral significance is largely derived from the reinforcers maintaining them, rather than their overt form.” Many factors produce resilience. Upon pondering targets, we must choose those that are the most relevant and impactful. Only recently have alternative philosophies emerged, most strikingly with the advent of Acceptance and Commitment Therapy (ACT). ACT adopts the view that distress is an inevitable human experience that is not inherently problematic. Distress itself does not impair functioning and well-being. The culprit is unhealthy attempts to escape distress when time and effort can be spent elsewhere in meaningful activity. When we feel anxious about sharing insecurities with a romantic partner, we crack jokes. When we feel sad or lonely, we comfort ourselves with excessive food, alcohol, or other substances. When we feel regret, we spend hours burying ourselves in work. Too often, our strategies to cope with distress, while providing momentary relief, bring us further away from the life we want and from our values. According to the rich theory of ACT, the best way to respond to distress is whichever way best facilitates the pursuit of meaningful life aims. This is the core of psychological flexibility (PF).

Our team operationalizes PF as the ability to respond to distress in ways that facilitate valued goal pursuit. This definition captures the original definition of PF by the founders of Acceptance and Commitment Therapy, “the ability to change or persist with functional behavioral classes when doing so serves valued ends,” while focusing on the specific contexts in which flexibility is most important: challenging situations that would otherwise disrupt valued living. Reducing distress is only functional to the extent that doing so facilitates the pursuit of self-endorsed, meaningful, values-consistent goals.

Research on PF and related constructs has exploded in recent years pointing to the central role of PF in healthy human functioning.  Clinical outcome studies of ACT suggest an effective treatment for numerous presenting problems, including depression, chronic pain, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, trichtillomania, psychosis, and substance use. Several meta-analyses suggest that, across dozens of studies and hundreds of clients, ACT is more effective than waitlist and placebo conditions and at least as effective as gold-standard cognitive behavioral interventions (e.g., A-tjak, Davis, Morina, Powers, Smits, & Emmelkamp, 2015; Jiménez, 2012; Levin, Hildebrant, Lillis, & Hayes, 2012; Powers, Vörding, & Emmelkamp, 2009). Importantly, ACT and related mindfulness and acceptance-based interventions produce therapeutic change through PF, their theoretically proposed mechanism of action. Yet there is a not-so-hidden problem in this large body of work. Nearly the entire literature on the effectiveness of ACT interventions and the causes and consequences of PF hinge on the use of a single assessment: The Acceptance and Action-Questionnaire (AAQ-I and II). And this measure has flaws.

The AAQ-I (Hayes et al., 2004) was designed to measure experiential avoidance (EA), defined as an unwillingness to remain in contact with aversive internal experiences (e.g., thoughts, memories, bodily sensations). The AAQ-I items capture several constructs similar to and distinct from this definition of EA, including thought suppression (e.g., “I try to suppress thoughts and feelings that I don’t like by just not thinking about them”), functional impairment (e.g., “When I feel depressed or anxious, I am unable to take care of my responsibilities”), and beliefs about emotions (e.g., “anxiety is bad”). Given its many facets but use of a single total score, it is unsurprising that the AAQ-I has demonstrated only modest internal consistency (e.g., αs<.50; Zvolensky et al., 2005). The revised AAQ-II emerged in response to criticisms, but it has similar problems. Item content is still conflated with functional impairment (e.g., “Emotions cause problems in my life,” “It seems like most people are handling their lives better than I am”) and psychological distress (e.g., .70-.71 correlations between the AAQ-II and the BDI; Bond et al., 2011).

Several researchers have demonstrated the validity problems of the AAQ-II. Wolgast (2014) found that the AAQ-II was more strongly correlated with items assessing psychological distress compared to those measuring acceptance/non-acceptance. Rochefort, Baldwin, and Chmielewski (2018) showed that the AAQ-II was more strongly correlated with measures of negative emotionality than measures of EA and mindfulness. Tyndall and colleagues (2019) demonstrated that the AAQ-II was more strongly correlated with measures of depression, anxiety, and stress and “may primarily be a measure of psychological distress (i.e., the outcome rather than the process of psychological inflexibility).

Move on to Part II for a potential solution to the scientific problems in the psychological flexibility literature.

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