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Cited by 70Mindfulness and Compassion InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder

Open access
Eustis, Elizabeth H., Hayes-Skelton, Sarah A., Roemer, Lizabeth, Orsillo, Susan M.·2016·Behaviour Research and Therapy
DOI 10.1016/j.brat.2016.09.012PMC PMC5127767
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Abstract

As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007). Identifying these mechanisms would help streamline evidence-based approaches, increase treatment response rates, and aid in the dissemination and implementation of evidence-based approaches in diverse contexts. The current study examined reductions in experiential avoidance (EA; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, as a potential mechanism of change in participants with a principal diagnosis of generalized anxiety disorder (GAD) receiving either acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Participants' EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions. Greater change in EA across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches. © 2016 Elsevier Ltd

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Crossref · 10.1016/j.brat.2016.09.012

Cites

55 of 55 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

16 of 54 cited sources checked · 8 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    The field lacks knowledge about specific mechanisms responsible for changes during anxiety disorder treatment.

    “As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007).”
    • Also stated in: § Introduction · plain
      “As a field, we have a wealth of information about the efficacy of various treatments for anxiety disorders; however, we lack information about specific mechanisms that are responsible for the changes that occur over the course of treatment (Kazdin, 2007; Levin, Luoma, & Haeger, 2015).”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites Kazdin, 2007 source
    • cites Levin, Luoma, & Haeger, 2015 source

      The paper’s introductory text (indexed under Abstract; page unavailable) says that growing outcome research creates a need for a more refined examination of mechanisms of change in acceptance and mindfulness-based therapies. That supports a gap in mechanism research, but it does not establish the claim for anxiety-disorder treatments as a whole. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
  • Premisecitation

    EA is uniquely associated with GAD symptoms.

    “Moreover, there is evidence that EA is uniquely associated with GAD symptoms (Lee, Orsillo, Roemer, & Allen, 2010; Roemer, Salters, Raffa, & Orsillo, 2005).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Lee, Orsillo, Roemer, & Allen, 2010 source

      The Results (GAD versus Non-GAD Comparisons; page not provided) report greater experiential avoidance in the GAD group than in non-anxious controls after controlling for depressive symptoms. But the Discussion (page not provided) says that secondary diagnoses and the lack of another clinical comparison group prevent conclusions about whether experiential avoidance is specific to GAD, so the claimed unique association is not established. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites Roemer, Salters, Raffa, & Orsillo, 2005 source
  • Premisecitation

    Research shows EA decreases from pre- to post-treatment in acceptance-based treatments for anxiety.

    “Although research with clinical and non-clinical samples demonstrates that EA is reduced from pre to post-treatment (or that experiential acceptance, that opposite of EA, increases) over the course of acceptance-based treatments for anxiety (Ciarrochi, Bilich, & Godsell, 2010; Roemer et al., 2008)”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Ciarrochi, Bilich, & Godsell, 2010
    • cites Roemer et al., 2008 source
  • Premisecitation

    Over time, experiential avoidance can impair psychosocial functioning.

    “While EA may appear to be effective in the short term, it can greatly interfere with psychosocial functioning in the long term.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Hayes et al., 1996 source
    • cites Lee et al., 2010 source

      The paper’s model (section labeled Abstract; page not provided) describes avoidance efforts intended to reduce distress and links struggling with internal experiences to behavioral restriction and dissatisfaction. It also reports a short-term reduction in physiological reactivity from worry. These passages support the general contrast, but the paper does not establish that experiential avoidance itself greatly impairs psychosocial functioning over the long term. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites Wegner, 2011 source
  • Interpretationcitation

    AR can promote non-avoidance through cue detection, requiring participants to turn toward their experiences.

    “While it may seem like AR could encourage EA, it can actually promote non-avoidance through cue detection, which requires participants to turn toward their experiences and notice them, instead of turning away from them or engaging in EA.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Hayes-Skelton et al., 2012 source
  • Classified as probably not a substantial claim. 39
  • May combine two claims. 36

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Some data suggest that conventional CBT and ABBT produce comparable decreases in EA.

    “On the other hand, there is some evidence that traditional CBT is as effective as ABBT in reducing EA (Arch et al., 2012b; Twohig et al., 2010), which suggests that EA could be considered as a common mechanism.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Arch et al., 2012b

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Twohig et al., 2010 source

      The Method’s Process Results report significant improvement on the Acceptance and Action Questionnaire in both groups and no significant difference between them from pretreatment to follow-up. But this trial compared ACT with progressive relaxation training, not traditional CBT; ACT also improved significantly more than relaxation training immediately after treatment. It therefore does not establish comparable reductions in experiential avoidance with CBT and ABBT. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a secondary analysis of the same RCT, decentering was a common mechanism of change across ABBT and AR.

    “A recent secondary data analysis from the same RCT as the current study, comparing ABBT and Applied Relaxation (AR) in a sample with GAD found decentering to be a common mechanism of change across both treatment conditions (Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015 source

      The Present Study section identifies this as an analysis of data from an RCT comparing ABBT and AR in people with GAD. The Results and Discussion report a similar relationship between decentering and later anxiety symptoms across both treatments, but describe this as support for a *potential* common mechanism, not a definitive finding that the mechanism was established. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Avoidance efforts can paradoxically increase distress and restrict lives.

    “Avoidance efforts can both paradoxically increase distress and also restrict lives (Hayes et al., 1996; Lee et al., 2010; Wegner, 2011).”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Hayes et al., 1996 source
    • cites Lee et al., 2010 source
    • cites Wegner, 2011 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Understanding how treatments work requires measuring mediator variables across the whole treatment, not just before and after.

    “In order to understand mechanisms of change, or how change occurs throughout the course of treatment, mechanism variables need to be measured throughout treatment, not only with outcome variables at pre- and post-treatment (Kazdin, 2007; Kraemer, Wilson, Fairburn, & Agras, 2002).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Kazdin, 2007 source
    • cites Kraemer, Wilson, Fairburn, & Agras, 2002 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    CBT and ABBT are effective treatments for GAD.

    “Both Cognitive Behavioral (CBT) and Acceptance-based behavior therapies (ABBTs) have been found to be effective treatments for GAD (Borkovec & Ruscio, 2001; Covin, Ouimet, Seeds, & Dozois, 2008; Hayes-Skelton, Roemer, & Orsillo, 2013; Roemer, Orsillo, & Salters-Pedneault, 2008).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Borkovec & Ruscio, 2001

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Covin, Ouimet, Seeds, & Dozois, 2008 source
    • cites Hayes-Skelton, Roemer, & Orsillo, 2013 source

  • May combine two claims.

    Premisecitation

    In Twohig et al. (2010), ACT had greater pre-post EA reductions than PRT, but groups were equivalent at 3-month follow-up.

    “ACT participants reported significantly greater reductions in EA from pre-treatment to post-treatment compared with PRT participants, however the two groups were equivalent when examining reductions in EA from pre-treatment to 3-month follow-up.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Twohig et al., 2010 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Low internal consistency is a common problem with several AAQ versions.

    “This is a common problem with several versions of the AAQ (Bond et al., 2011; Gámez et al., 2011; 2014).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Bond et al., 2011 source

      In “The Achilles heel of the AAQ-I: Comprehension and reliability” (page unavailable), the paper says the AAQ-I’s internal consistency has often been a problem, with alpha sometimes below .70. It does not establish that low internal consistency is common across several AAQ versions; the General Discussion instead reports good reliability for the AAQ-II. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites Gámez et al., 2011 source
    • cites [2014]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The ABBT and AR in this RCT were adherent and competent, with no procedural breaks.

    “The ABBT and AR provided in this RCT were adherent and competent, and there were no procedural breaks (Hayes-Skelton et al., 2013).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hayes-Skelton et al., 2013 source

      The Methods section, “Adherence and Competency,” reports that ABBT and AR components were typically delivered in detail and skillfully, supporting the adherence and competence claim. It also reports one ABBT session with a forbidden strategy, so the assertion that there were no procedural breaks is not supported. (LLM, conf=0.91)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The AR in this trial was delivered adherently and competently, with no procedural breaks.

    “the AR provided in this trial was adherent and competent, and there were no procedural breaks (Hayes-Skelton et al., 2013)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hayes-Skelton et al., 2013 source

      The Methods section (“Adherence and Competency”) reports that rated AR sessions addressed permitted components skillfully, received high competency ratings, and had no forbidden strategies. But adherence was assessed in 102 sampled AR sessions, so the paper does not establish that there were no procedural breaks anywhere in the trial. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Across analyses, there was no significant main effect of treatment condition and no significant interaction of AAQ slope with treatment.

    “There was neither a significant main effect of treatment condition nor a significant interaction effect of AAQ slope by treatment in any analyses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    AAQ slope and intercept were both significant predictors of change in worry (PSWQ).

    “Results indicated that AAQ slope and AAQ intercept were both significant predictors of change in worry, and that there was no main effect of treatment nor interaction with treatment condition.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Four individuals completed 5-7 sessions before dropping out, but none showed meaningful change on weekly GAD symptoms, distress, and interference.

    “Four individuals completed 5–7 sessions before dropping out, but none of them showed meaningful change on the weekly measure of GAD symptoms, distress, and interference.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Treatment condition showed neither a main effect nor an interaction effect on worry change.

    “there was no main effect of treatment nor interaction with treatment condition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    AAQ slope and intercept were both significant predictors of change in quality of life (QOLI).

    “Results indicated that AAQ slope and AAQ intercept were both significant predictors of change in quality of life.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • May combine two claims.

    Findingown data

    The AAQ slope was significant across the whole sample, with a mean of −4.01.

    “we first confirmed that the AAQ slope was significant across the sample (mean = −4.01, p <.001)”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • May combine two claims.

    Findingown data

    The AAQ slope was significant in the ABBT condition, with a mean of −4.68.

    “ABBT mean = −4.68 (SD = 2.02), t(30) = −12.90, p < .001”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • May combine two claims.

    Findingown data

    The AAQ slope was significant in the AR condition, with a mean of −3.39.

    “AR mean = −3.39 (SD = 1.99), t(32) = −9.79, p < .001”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • May combine two claims.

    Findingown data

    AAQ slope explained significant unique variance in both the PSWQ and QOLI regressions above decentering.

    “Results indicated that AAQ slope accounted for significant unique variance in both regressions, indicating that EA is uniquely related to changes in these outcomes above and beyond decentering.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • Classified as probably not a substantial claim.

    Premisereasoning

    The literature remains mixed on whether EA acts as a shared or treatment-specific mediator in mindfulness and acceptance therapies.

    “Further, findings to date are inconsistent regarding whether EA is a distinct or common mechanism of change in mindfulness and acceptance-based behavioral therapies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Forman et al. (2012) found acceptance of thoughts and emotions associated with improvements in ACT but not CT.

    “Forman and colleagues (2012) found acceptance of thoughts and emotions (versus “cognitive and affective change strategies”) was associated with improvements in outcomes in the ACT, but not the CT, condition”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Forman et al., 2012 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Some studies found that earlier changes in EA predicted later symptom changes.

    “Exceptions are a small number of studies that have demonstrated that changes in EA, or psychological flexibility, earlier in treatment predicted changes on symptom measures later in treatment (Dalrymple & Hebert, 2007; Kocovski, Fleming, & Rector, 2009).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Dalrymple & Hebert, 2007

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Kocovski, Fleming, & Rector, 2009 source

  • Classified as probably not a substantial claim.

    Premisereasoning

    These exploratory analyses come from open trial designs.

    “While these exploratory analyses identifying EA as a potential mechanism of change are promising, they come from open trial designs.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In an RCT of ACT versus CBT for mixed anxiety disorders, the cognitive defusion slope statistically accounted for later changes in worry, avoidance behavior, and life quality in both arms.

    “the slope of change in cognitive defusion for each participant was entered into linear regressions, which indicated that changes in cognitive defusion mediated changes in worry, behavioral avoidance, and quality of life outcomes across both conditions.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Arch, Wolitzky-Taylor, Eifert, & Craske (2012a)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisereasoning

    A comparison of early versus late change ignores the slope across the whole treatment.

    “Moreover, comparing early change to late change does not take into account the course of change (i.e., the slope) over the entire period of treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In this sample, the 16-item single-factor AAQ had internal consistency values from .72 to .84 across assessment points.

    “Internal consistency for the current sample with the 16-item single factor version was .75 at pre-, .72 at week 4, .78 at week 8, .76 at week 12, and .84 at post-treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PSWQ is a 16-item self-report instrument for trait worry with established reliability.

    “The PSWQ is a reliable 16-item self-report measure used to examine trait levels of worry.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Meyer, Miller, Metzger, & Borkovec, 1990 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Findings are mixed on whether improvements in AR are due to decreases in muscle tension.

    “However, the findings are mixed on whether or not improvements in AR are actually due to decreases in muscle tension (for a review, see Conrad & Roth, 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Conrad & Roth, 2007 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    There was no significant difference in pre-treatment GAD severity between participants who dropped out before session 8 and those who completed 8 or more sessions.

    “nor a significant difference in GAD severity at pre-treatment in participants who dropped out before session 8 or completed 8 or more sessions (dropped before session 8 mean GAD pre CSR= 5.47, completed session 8 or more mean GAD pre CSR = 5.48, X2(3) = 3.42, p =.33).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Decentering subscale has shown good internal consistency in non-clinical and clinical samples.

    “The Decentering subscale has demonstrated good internal consistency in non-clinical and clinical samples (α = .83, α = .84; Fresco et al., 2007a; Fresco et al., 2007b).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Fresco et al., 2007a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Fresco et al., 2007b

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductreasoning

    The study does not fully establish temporal precedence because outcomes were measured at post-treatment while controlling for pre-treatment scores, and rate of change over time was not modeled.

    “it does not fully achieve temporal precedence since outcomes are examined at post treatment while accounting for pre-treatment scores, but they do not take into account the rate of change over time as some other approaches do”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The single-factor 16-item AAQ is more sensitive to change over time and is common in treatment outcome research.

    “The single-factor 16-item version was used for analyses, as it is more sensitive to change across time, and is common in the treatment outcome literature, allowing direct comparison to other studies (Hayes et al., 2004).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Niles et al. (2014) found that non-linear change in EA significantly mediated post-treatment social anxiety symptoms and anhedonic depression in ACT but not CBT.

    “Results demonstrated that the “curvature” or non-linear change in EA was a significant mediator of post-treatment social anxiety symptoms and anhedonic depression in the ACT group, but not the CBT group.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Niles and colleagues (2014)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    There was no significant difference across treatment conditions in dropout before session 8.

    “Chi-square tests indicated that there was not a significant difference across treatment conditions in drop out before session 8 (X2(1) = 0.11, p =.74)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The AAQ is a self-report instrument with a history of use for assessing experiential avoidance.

    “The AAQ is a self-report questionnaire that has historically been used to measure EA (Hayes et al., 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The QOLI has demonstrated good test-retest and internal validity.

    “It has demonstrated good test-retest and internal validity (Frisch et al., 2005).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Frisch et al., 2005 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In this sample, the PSWQ had internal reliability of .78 at pre-treatment and .90 at post-treatment.

    “Internal reliability in the current sample was .78 at pre, and .90 at post-treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In this sample, the QOLI had internal reliability of .80 at pre-treatment and .86 at post-treatment.

    “Internal reliability in the current sample was .80 at pre and .86 at post-treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    In this trial, therapists cultivated relaxation in a manner that reduced EA, and these reductions were linked to positive outcomes.

    “in this trial, therapists were able to cultivate relaxation in a way that decreased EA for participants, and these reductions were related to positive outcomes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    There was no evidence of moderation or moderated mediation.

    “In other words, there was no evidence of moderation or moderated mediation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    This study modeled linear change in EA and did not examine non-linear change because of limited sample size.

    “The current study examined linear change in EA, and did not consider non-linear change, due to the limited sample size.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Change in AAQ over the course of treatment was linear.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Four AAQ observations were missing in the analyzed sample.

    “There are four missing AAQ data points among participants included in these analyses; one participant is missing week 4, another participant is missing week 12, and one participant is missing weeks 8 and 12.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Scores on the 16-item single-factor AAQ correlate strongly with the 9-item version.

    “The single-factor 16-item version is highly correlated with the 9-item version (Hayes et al., 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Early withdrawers were proportionally more likely to identify as Latinx than the current sample.

    “proportionally more self-identified racially as Latinx compared with the current sample (X2(1) = 4.75, p =.03).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The study did not assess follow-up effects of EA and relied only on self-report measures.

    “We also did not look at the effects of EA on follow up outcomes, and used self-report measures only.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Hayes et al. (2004) suggest that higher EA may occur in marginalized individuals due to greater exposure to discrimination and challenging emotional content.

    “Hayes and colleagues (2004) indicate that higher levels of EA may be seen in individuals with marginalized identities, as they are more likely to be exposed to discrimination and therefore more challenging emotional content”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • May combine two claims.

    Premisecitation

    In Arch et al. (2012b), both CBT and ACT showed significant pre-post EA reductions with no significant between-condition differences.

    “Significant reductions in EA from pre-post, measured by the AAQ, were reported in both conditions, with no significant differences between conditions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Arch et al., 2012b

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Early withdrawers reported significantly lower education levels than the current sample.

    “participants who withdrew before session eight reported significantly lower levels of education (X2 (6) = 17.88, p = .007)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The QOLI is a 32-item self-report instrument covering importance and satisfaction in sixteen life domains.

    “The QOLI is a 32-item self-report measure that examines the importance and level of satisfaction across sixteen areas of life.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Frisch, Cornwell, Villanueva, & Retzlaff, 1992 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The Mplus model used to estimate AAQ slopes and intercepts converged normally.

    “The model to calculate slopes and intercepts ran in Mplus and terminated normally.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The 9-item AAQ has shown adequate internal consistency and test-retest reliability.

    “The 9-item version has demonstrated adequate internal consistency (alpha= .70), and test-retest reliability (r = .64 in an undergraduate sample over 4 months; Hayes et al., 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • May combine two claims.

    Premisecitation

    In Kocovski et al. (2015), the model comparing acceptance across treatment conditions did not converge, so differences across treatments are unknown.

    “However, the model comparing acceptance across the treatment conditions did not converge, and therefore results were not reported and it is unknown whether or not there were differences across these group treatments.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kocovski et al., 2015 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Prior work reports strong internal consistency and adequate-to-good test-retest reliability for the PSWQ.

    “The measure has demonstrated good to very good internal consistency (α’s from .86 to .93), as well as adequate to good test-retest reliability (r’s ranging from .74 to .93 across periods of time from 2–10 months; Molina & Borkovec, 1994).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Molina & Borkovec, 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisereasoning

    Neither Twohig et al. nor Arch et al. examined whether change in EA was associated with outcome across treatments.

    “Unfortunately, neither of these studies looked at potential differences across treatments in the extent to which change in EA may have been associated with outcome.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    One outlier was found on the AAQ at pre-treatment and week 4; analyses with and without this participant produced the same results.

    “One outlier was identified on the AAQ at pre and week 4 (pre z-score = −3.19, m4 z-score = −3.06). Subsequent analyses were run with and without this participant; because results did not differ, we report analyses with the participant included.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Early withdrawers (before session eight) and completers (at least eight sessions) were not significantly different on demographic characteristics in this sample.

    “Overall, the participants who withdrew before session eight did not differ significantly from the participants who completed at least 8 sessions demographically.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In this sample, the EQ-Decentering subscale had internal reliability from .85 to .93 across time points.

    “Internal reliability in the current sample was .85 at pre, .85 at week 4, .88 at week 8, .92 at week 12, and .93 at post-treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Kocovski et al. (2015) found a bidirectional model best fit acceptance and social anxiety symptoms.

    “Results indicated a bidirectional model was the best fit for acceptance, measured by the social anxiety- acceptance and action questionnaire, and social anxiety symptoms, indicating changes in acceptance predicted subsequent changes in social anxiety symptoms and vice versa.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kocovski, Fleming, Hawley, Ho, and Antony (2015) source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In initial AAQ studies, women scored higher than men in clinical samples, and non-white individuals scored higher than white individuals.

    “In addition, in initial studies of the AAQ, women scored higher than men in clinical samples, and individuals who did not identify as white in terms of their race scored higher than individuals who identified as white (Hayes et al., 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source
58 of 58

  • The paper relies on this without support.

    The Acceptance and Action Questionnaire provides a valid measure of experiential avoidance.

    “Participants’ EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions.”

  • The paper relies on this without support.

    Generalized anxiety disorder is chronic and unlikely to remit without treatment.

    “There is a particular need to better understand mechanisms of change in the treatment of Generalized Anxiety Disorder (GAD), a chronic disorder unlikely to remit without treatment.”

  • The authors state this as an assumption.

    Change in AAQ over the course of treatment was linear.

    “All modeled slopes were linear.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • It is possible that because therapists were also trained in ABBT, they modeled experiential acceptance and decentering despite not explicitly discussing it; client reports of experiential acceptance predict outcomes across both therapies, and decentering increased and led to improved symptoms across both therapies.

    “It is also possible that because our therapists were also trained in ABBT, they modeled experiential acceptance and decentering despite the fact that it was not explicitly discussed; client reports of experiential acceptance do predict outcomes across both therapies in this trial (Eustis, Hayes-Skelton, Roemer, & Orsillo, 2016) and decentering increased and led to improved symtoms across both”

    From Do treatment responders maintain their gains following a randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder? (2025) · cites this paper as Eustis, Hayes-Skelton, Roemer, & Orsillo, 2016

  • Experiential avoidance and psychological flexibility mediated outcomes in AABT and applied relaxation for GAD.

    “Similarly, experiential avoidance and psychological flexibility mediated outcomes in AABT and applied relaxation for GAD.33”

    From Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression (2017) · cites this paper as [33]

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentχ²(1) = 0.11reported p = .74 · recomputed p = .740

    “X2(1) = 0.11, p = .74”

  • Consistentχ²(3) = 3.42reported p = .33 · recomputed p = .331

    “X2(3) = 3.42, p = .33”

  • Consistentχ²(6) = 17.88reported p = .007 · recomputed p = .007

    “X2 (6) = 17.88, p = .007”

  • Consistentχ²(1) = 4.75reported p = .03 · recomputed p = .029

    “X2(1) = 4.75, p = .03”

  • Consistentt(30) = -12.9reported p < .001 · recomputed p < .001

    “t(30) = −12.90, p < .001”

  • Consistentt(32) = -9.79reported p < .001 · recomputed p < .001

    “t(32) = −9.79, p < .001”

  • Consistentt(62) = 2.57reported p = .013 · recomputed p = .013

    “t(62) = 2.57, p = .013”

7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Self-check results appear here once an independent check has confirmed them.

Cites

Flagged first, then by citations

9 of the 64 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Eustis, E. H., Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M.
Affiliations
  • University of Massachusetts Boston (US)
  • Suffolk University (US)
Corresponding author
Eustis, Elizabeth H.
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2016-12
Volume
87
Pages
188-195
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2016.09.012
PMC
PMC5127767
OpenAlex
W185182777
Cited by
70
References
64
Citations by year
2026: 5 · 2025: 5 · 2024: 11 · 2023: 7 · 2022: 13 · 2021: 7 · 2020: 10 · 2019: 8 · 2018: 3 · 2017: 1
FWCI
5.35
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Behaviour Research and Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • Department of Biotechnology, Ministry of Science and Technology, India
  • National Institute of Mental Health (R01MH074589)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
experiential avoidance, mechanisms of change, generalized anxiety disorder, applied relaxation, worry, quality of life, Acceptance and Action Questionnaire, mindfulness, cognitive behavioral therapy, anxiety disorders
MeSH terms
Adult, Anxiety Disorders, Avoidance Learning, Female, Humans, Male, Quality of Life, Relaxation Therapy, Young Adult, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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