A preliminary test of the role of experiential avoidance in post-event functioning

Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability

BACKGROUND

Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress.

AIM

The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability.

METHODS

Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Disability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity.

RESULTS

The results of the correlation revealed that a significant relationship exists between multidimensional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoidance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multidimensional pain and pain anxiety with pain disability.

CONCLUSION

In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively.

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Coping Mechanisms during the War in Ukraine: A Cross-Sectional Assessment among Romanian Population

On 24 February 2022, the Russian Federation invaded Ukraine, starting a military conflict that soon turned into a full-scale war. The Romanians have been actively involved in helping their neighbors, causing the accumulation of emotional and mental pressure upon the Romanian population exposed to such a close military conflict. This cross-sectional study assessed, through an online survey (1586 adult Romanian residents), the primary coping mechanisms, quality of life and anxiety levels in response to the psychological trauma associated with the Russo-Ukrainian war. Based on the results, focusing on and venting emotions along with behavioral disengagement were the coping strategies that had the strongest negative impact on anxiety and well-being. On the other hand, positive reinterpretation and growth were associated with less anxiety, a higher degree of overall health and better quality of life. To the best of our knowledge, this study is the first of its kind to be performed among the Romanian population so far. Thus, we equip mental health practitioners with the tools (real-life evidence data) that will allow them to establish a more meaningful doctor-patient relationship, maximizing therapy results.

A prospective examination of the role of psychological (in)flexibility in posttraumatic stress: A cross-lagged panel design

Functional contextualist models of psychopathology suggest that psychological inflexibility and psychological flexibility are of central importance for understanding the development and maintenance of posttraumatic stress (PTS) symptomatology. To our knowledge, these two constructs and their domain-specific factors (e.g., cognitive fusion, experiential avoidance) have not been assessed in their entirety and examined in relation to PTS symptoms using a longitudinal study design. As such, the primary aim of the present study was to use cross-lagged panel analysis, an analytic approach that allows stronger causal inferences to be made regarding the nature of temporal relations among study variables, to determine the directional relations among PTS symptoms and psychological flexibility and inflexibility over an eight-month time period. Trauma-exposed adults (N = 810), recruited online via Amazon's Mechanical Turk (MTurk), completed a battery of self-report measures via a secure online platform at three time points, spanning eight months. Results suggest that the relationship between psychological inflexibility and PTS symptoms is bidirectional and mutually reinforcing. In contrast, significant prospective relations were not observed between psychological flexibility and PTS symptoms. Results of a follow-up exploratory path analysis showed that cognitive fusion was the only psychological inflexibility subfactor that partially mediated the relationship between PTS symptoms from baseline to the eight-month follow-up assessment. Taken together, these results suggest that psychological inflexibility, and primarily the domain of cognitive fusion, maintains PTS symptoms following trauma exposure. As such, it may important to integrate cognitive defusion techniques into evidence-based treatments for Posttraumatic Stress Disorder (PTSD).

Posttraumatic Stress Symptoms and Parenting Competence among Israeli Male Veterans: The Mediating Roles of Experiential Avoidance and Parental Reflective Functioning

Although empirical studies have documented associations between posttraumatic stress symptoms (PTSS) and parenting among various high-risk populations, there is a relatively limited amount of research on paternal parenting among veterans. Moreover, the understanding of possible mechanisms which may account for this effect is severely lacking. This study examined associations between military related PTSS and parenting sense of competence (PSOC) among veteran fathers. Furthermore, we examined the mediating role of experiential avoidance (EA) and parental reflective functioning (PRF) in the association between PTSS and PSOC. Participants were 189 Israel Defense Forces (IDF) male combat veterans (mean age = 30.03) who completed a set of validated self-report questionnaires in a cross-sectional design study. Results showed negative associations between PTSS and PSOC-parental satisfaction but not parental efficacy. Furthermore, EA mediated the association between PTSS and parental satisfaction and efficacy; PRF- Pre mentalizing modes mediated the association between PTSS and parental satisfaction. Our findings imply that EA and PRF may serve as mechanisms of the association between PTSS and PSOC among veteran fathers. These findings are discussed in light of a psychological trauma perspective, and clinical implications to increase fathers' mentalization and psychological flexibility are suggested.

Longitudinal relationships among posttraumatic stress disorder symptom clusters in response to positive memory processing

BACKGROUND AND OBJECTIVES

Avoidance, inherent to posttraumatic stress disorder (PTSD) symptomatology, is theoretically and empirically linked to the maintenance of PTSD symptom severity. While research indicates traumatized individuals avoid positive and trauma memories, several PTSD treatments focus exclusively on traumatic memories. We examined the mediating role of PTSD's avoidance in the relationship between processing positive memories and PTSD cluster severity (intrusion, mood/cognitions, arousal).

METHODS

Sixty-five trauma-exposed college students (M_age = 22.52; 86.10% female) were randomly assigned to 3 conditions: narrating/processing, writing/processing, or control (same task across baseline [T0] and follow-up [T1]).

RESULTS

Half-longitudinal mediation models indicated participation in the narrating vs. writing and control conditions predicted decreases in T1 intrusion severity via reduction in T1 avoidance severity. Similarly, participation in the narrating vs. writing and control conditions predicted decreases in T1 mood/cognitions' severity via reduction in T1 avoidance severity. Participation in the narrating vs. writing condition predicted decreases in T1 arousal severity via reduction in T1 avoidance severity.

LIMITATIONS

Data was obtained from an analogue small-size sample of university students. In addition, sessions were only 6-8 days apart, with the processing component of each session lasting ∼30 min.

CONCLUSIONS

Processing positive memories may relate to lower PTSD severity via a reduction in PTSD's avoidance, paralleling effects of processing trauma memories. Our findings support future investigations of the mechanisms underlying impacts of positive memory processing in the context of PTSD treatments.

The longitudinal association between Perceived Stress, PTSD Symptoms, and Post-Traumatic Growth during the COVID-19 Pandemic: the role of coping strategies and psychological inflexibility

The present study investigates the mediating roles of psychological inflexibility and differential coping strategies on perceived stress and post-traumatic symptoms and growth in the context of COVID-19. Study one recruited 662 participants (54.8% women; Mage = 40.64 years, SD = 13.04) who completed a cross-sectional questionnaire. It was proposed that orientation to the problem, avoidance strategies, psychological inflexibility, and positive attitude were mediators for the positive association between perceived stress and PTSD symptoms. The fit indices for the path model were excellent: CFI = 0.977, TLI = 0.950, RMSEA = 0.057 [90%CI = 0.043-0.081], and SRMS = 0.042. Gender and stressful events encountered had indirect effects on the endogenous variables. In study two, 128 participants (57.8% women; Mage = 42.30, SD = 12.08) were assessed for post-traumatic growth one year later. Psychological inflexibility and orientation acted as mediators between perceived stress and PTSD symptoms. Furthermore, a novel path model was constructed in which psychological inflexibility and orientation to the problem as mediators for perceived stress and PTSD symptoms. The indices for the path model were excellent: CFI = 0.99, TLI = 0.97, RMSEA = 0.055 [90%CI = 0.001-0.144], and SRMS = 0.49. Furthermore, PTSD symptoms, psychological inflexibility, and orientation to the problem predicted post-traumatic growth. Specifically, both orientation to the problem (β = .06 [90%CI: .01;.13]) and psychological inflexibility (β = .14 [90%CI: .08;.26]) had an indirect effect on post-traumatic growth. Overall, these results significantly contribute to the literature as orientation to the problem positively predicted PTSD symptoms and post-traumatic growth one year later while psychological inflexibility predicted PTSD symptoms and less post-traumatic growth one year later. These results underline the importance of assessing both symptomology and psychological growth to determine adaptive coping strategies in specific contexts.

Group-based Compassion-focused Therapy on Experiential Avoidance, Meaning-in-life, and Sense of Coherence in Female Survivors of Intimate Partner Violence with PTSD: A Randomized Controlled Trial

The current study was carried out to investigate the effects of compassion-focused therapy (CFT) on experiential avoidance, meaning-in-life, and sense of coherence (SoC) in women suffering from post-traumatic stress disorder (PTSD) due to the intimate partner violence (IPV).42 women suffering from PTSD due to the IPV exposure were randomized to the two groups of experimental and control (21 per group). All participants completed the questionnaires of experiential avoidance, meaning-in-life, and SoC as pre-test measures. The experimental group received eight sessions of CFT, while the controls did not receive any treatment. After that, all subjects responded to the questionnaires of experiential avoidance, meaning-in-life, and SoC as the post-test measures. Data were analyzed using one-way repeated measures MANOVA.Subjects of the experimental group indicated a greater reduction in post-test scores of experiential avoidance, and a significant rise in the level of meaning-in-life and its subscales including the presence of meaning-in-life and search for meaning-in-life when compared to the controls. Nevertheless, there was no change in the level of SoC as a function of CFT.Applying CFT can result in reducing experiential avoidance and raising the meaning of life in women with PTSD due to IPV exposure. CFT is highly recommended to strengthen the well-being of patients with PTSD and reduce the PTSD symptoms.

The role of experiential avoidance in the relation between racial discrimination and negative mental health outcomes

Objective Racial discrimination has been shown to be associated with negative mental health outcomes among people of color (POC), and students of color (SOC) specifically. The current study examines experiential avoidance (EA) as a potential moderator in the relation between discrimination and mental health outcomes. Sample: Two-hundred students of color at a large, public university in Northeastern United States. Methods: We evaluated the associations between racial discrimination frequency and stress appraisal (GEDS and GEDS-A), EA (AAQ), and the Depression, Anxiety, and Stress Scales (DASS). Results: Discrimination frequency and appraised stress were associated with each DASS subscale. EA moderated the relation between GEDS and depression, and between GEDS-A and the stress subscale. Conclusions: Discrimination frequency and appraised stress were positively associated with DASS subscales, and at low EA scores, frequency and appraised stress of discrimination were no longer associated with depressive or stress symptoms, respectively.

The integrated constructionist approach to emotions: A theoretical model for explaining alterations to positive emotional experiences in the aftermath of trauma

Prior research has assumed that individuals with PTSD find positive emotions enjoyable and rewarding. While intuitive, this assumption is problematic for a number of reasons. A growing body of literature suggests that positive emotions can be unwanted and uncomfortable experiences for many people, particularly individuals with PTSD. Yet our empirical and theoretical models of PTSD do not adequately account for this complexity. Throughout the following pages, we argue that the same behavioral processes that have been heavily researched and associated with fear and avoidance of negative emotions and PTSD can be extended to positive emotions as well. We propose the integrated constructionist approach to emotions, which integrates learning theory principles with a constructionist approach and suggest that trauma experiences lead to a shift in the evaluation, interpretation, and labeling of an individual's internal experiences. This evaluative shift results in generalized patterns of emotional responding characterized by efforts to downregulate internal stimuli that were previously defined as positive and may have been appetitive pre-trauma. We subsequently highlight the theoretical, empirical, and clinical importance of taking an idiographic approach to understanding and working with emotions among individuals with PTSD.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

OBJECTIVE

The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes.

METHOD

Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.

RESULTS

Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30).

SIGNIFICANCE OF RESULTS

Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Trauma-related guilt and posttraumatic stress disorder symptoms in military veterans: The role of psychological inflexibility

A growing body of evidence has shown consistent support for the association between trauma-related guilt and posttraumatic stress disorder (PTSD). However, factors that account for this association are not well understood. The present study examined psychological inflexibility as a potential mediator between trauma-related guilt and PTSD symptoms in a sample of U.S. military veterans. Secondary data analyses from a larger randomized control trial were conducted. Specifically, three separate mediation models were used to test if psychological inflexibility mediated the association between trauma-related guilt (guilt cognitions, guilt distress, overall guilt) and PTSD symptoms in 85 treatment-seeking veterans diagnosed with PTSD and alcohol use disorder. All three components of trauma-related guilt were positively associated with both psychological inflexibility and PTSD symptoms; psychological inflexibility was also positively associated with PTSD symptoms. Furthermore, psychological inflexibility partially mediated the association between all facets of trauma-related guilt and PTSD severity. These findings provide further support for the association between trauma-related guilt and PTSD and also provide insight into one mechanism linking trauma-related guilt to PTSD symptoms. Thus, psychological inflexibility may serve as an important intervention target for veterans with comorbid PTSD and alcohol use disorder struggling with trauma-related guilt.

Islamic Trauma Healing: Integrating Faith and Empirically Supported Principles in a Community-Based Program

Access to adequate, much less state-of-the-art, mental health care is a global problem. Natural disasters, civil war, and terrorist conflict have forcibly displaced millions of Muslims and have resulted in a remarkable level of individual and communitywide trauma exposure. As a result, many are at risk for posttraumatic stress and other trauma-related disorders. Many religiously oriented Muslims traditionally rely on Islamic principles and teachings, as well as their community, to cope with and address trauma-related distress. Islamic Trauma Healing is a six-session, lay-led group intervention developed within a Somali Muslim community that integrates evidence-based trauma-focused cognitive-behavioral therapy principles with cultural and religious practices aimed to enhance uptake and create an easily up-scalable intervention for a wide range of trauma. In sessions, narratives of prophets who have undergone trauma (e.g., Prophet Ayyub, faith during hard times) present Islamic principles and facilitate cognitive shifts. Group members spend individual time turning to Allah in dua (i.e., informal prayer), focused on exposure to trauma memories. Program themes arc across suffering to healing to growth following trauma. This paper describes the core theoretical principles and methods in the Islamic Trauma Healing program. We also describe leader perspectives and the program's train-the-trainer model, in which lay leaders are trained to further disseminate the program and allow Islamic Trauma Healing to be owned and sustained by the Muslim community.

Ethnic-racial identity and posttraumatic stress disorder: The role of emotional avoidance among trauma-exposed community individuals

OBJECTIVE

There are ethnic-racial differences in the prevalence of posttraumatic stress disorder (PTSD). However, the factors underlying these differences are not well studied or understood. The goal of this study was to explore the relation of strength of ethnic-racial identity to PTSD. Specifically, we examined whether strength of ethnic-racial identity was indirectly related to PTSD symptom severity through positive and negative emotional avoidance.

METHOD

Participants were 401 trauma-exposed community individuals (M_age = 43.86 years; 70.1% female; 23.4% Asian, 23.7% Black, 25.1% Hispanic, 25.4% White).

RESULTS

Within the overall sample of ethnic-racial minorities, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathways of both positive and negative emotional avoidance was significant. However, these findings were not replicated within each of the specific racial-ethnic subsamples. Specifically, while strength of ethnic-racial identity was indirectly associated with PTSD symptom severity through both positive and negative emotional avoidance in the Black subsample, this indirect effect was only significant through the pathway of positive emotional avoidance in the Hispanic subsample, and was nonsignificant in the Asian and White subsamples.

CONCLUSIONS

Results underscore ethnic-racial differences in the way in which strength of ethnic-racial identity impacts PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychological flexibility in the context of COVID-19 adversity: Associations with distress

The COVID-19 pandemic has led to hardship for individuals across the globe, and research to-date has indicated a significant impact of the pandemic on mental health functioning. In order to promote psychological resilience during this time, it is important to understand modifiable targets for clinical intervention. The current study examined demographic characteristics, pandemic-related adversity, and psychological flexibility in relation to general and peritraumatic distress in a sample of United States survey respondents during May of 2020. Participants were recruited from Amazon Mechanical Turk (MTurk), N = 485. Participants completed measures of pandemic-related adversity, psychological flexibility components (openness to experience, behavioral awareness, and valued action), peritraumatic distress, and general distress. Hierarchical regression analyses examined whether demographic characteristics, pandemic-related adversity, and components of psychological flexibility were associated with general and peritraumatic distress. Results indicated that higher pandemic-related adversity, lower openness to experience, and lower behavioral awareness were significantly associated with higher general distress. Greater pandemic-related adversity, lower openness to experience, lower behavioral awareness, and higher valued action were significantly associated with higher peritraumatic distress. Adding the components of psychological flexibility to the model increased the amount of variance accounted for in both measures of distress. The results indicated that psychological flexibility components may be particularly important targets for prevention and intervention efforts in the midst of the COVID-19 pandemic. Transdiagnostic interventions, such as Acceptance and Commitment Therapy, that target psychological flexibility may be useful as the impact of the pandemic continues to unfold.

Coping with childhood maltreatment: Avoidance and eating disorder symptoms

Childhood maltreatment is associated with eating disorder symptoms; however, the nature of this association is unclear. We found those who experienced childhood maltreatment had higher avoidant coping and eating disorder symptoms. We also found an additive effect for maltreatment, such that with more types of maltreatment experienced, avoidant coping and eating disorder symptoms were greater. We also found evidence of an indirect effect such that childhood maltreatment was related to eating disorder symptoms through avoidant coping. Future research is needed to better understand factors that may promote development of adaptive coping patterns and prevention of eating disorder symptoms.

The role of emotion dysregulation in negative affect reactivity to a trauma cue: Differential associations through elicited posttraumatic stress disorder symptoms

BACKGROUND

Recent research has linked emotion dysregulation with increases in subjective ratings of negative affect (NA reactivity) to trauma reminders, a central symptom of posttraumatic stress disorder (PTSD). The current study adds to this burgeoning line of research by exploring elicited PTSD symptoms as a mechanism explicating the relation between emotion dysregulation and NA reactivity following trauma cue exposure.

METHODS

Participants were 60 treatment-seeking marijuana users with insomnia symptoms who reported exposure to a traumatic event. Participants were administered questionnaires assessing emotion dysregulation, PTSD symptoms, and NA prior to and/or after listening to a personalized trauma script, and subsequently completed a diagnostic interview.

RESULTS

Results demonstrated that greater emotion dysregulation was associated with heightened NA reactivity through re-experiencing symptoms, but not avoidance or dissociation symptoms, even after accounting for past 30-day PTSD symptom severity and pre-trauma script NA. These effects were driven by the dimensions of emotion dysregulation characterized by nonacceptance of negative emotions and limited access to effective emotion regulation strategies.

LIMITATIONS

This study requires replication among other clinical samples, and is limited by use of self-report measures.

CONCLUSIONS

Findings provide novel empirical support for one mechanism through which emotion dysregulation may confer vulnerability to PTSD symptomology, and offer implications for refining PTSD treatments.

Post-traumatic stress disorder's relation with positive and negative emotional avoidance: The moderating role of gender

Post-traumatic stress disorder (PTSD) is characterized by avoidance of trauma-related emotions. Research indicates that this avoidance may extend to any emotional experience that elicits distress, including those that are unrelated to the trauma. Literature in this area has been limited in its exclusive focus on negative emotions. Despite evidence of gender differences in PTSD and emotional avoidance separately, no studies to date have examined gender as a moderator of their association. The goal of the current study was to extend research by exploring the moderating role of gender in the relation between PTSD symptom severity and positive and negative emotional avoidance. Participants were 276 trauma-exposed individuals (65.9% female, 65.6% White, M_age = 19.24) from a university in the north-eastern United States. Moderation results indicated a main effect for PTSD symptom severity on both positive (b = 0.07, p < .001) and negative (b = 0.04, p = .03) emotional avoidance. The interaction of gender and PTSD symptom severity was significant for positive emotion avoidance (b = 0.97, p = .01). Analysis of simple slopes revealed that PTSD symptom severity was significantly associated with positive emotional avoidance for males (b = 0.13, p < .001) but not females (b = 0.03, p = .08). Results suggest the importance of gender-sensitive recommendations for assessment and treatment of emotional avoidance in PTSD.

Emotional avoidance and social support interact to predict depression symptom severity one year after traumatic exposure

Individuals exposed to a traumatic event commonly develop symptoms of depression, a psychiatric disorder associated with a number of negative clinical and public health consequences. Both intrapersonal and interpersonal risk factors have been associated with heightened risk for depression following traumatic event exposure; however, less is known about how these risk factors may interact to predict trauma-exposed individuals' risk of subsequently developing depression symptoms. This study examined the interactive influence of emotional avoidance (an intrapersonal risk factor) and perceived social support (an interpersonal risk factor) on the development of depression symptoms over a one-year period among N = 46 individuals recruited shortly after visiting a hospital emergency department for treatment following exposure to a traumatic event. Results revealed a significant main effect of emotional avoidance on 12-month depression symptoms. The main effect was qualified by an emotional avoidance by perceived social support interaction: the relation of emotional avoidance to 12-month depression symptoms was positive and significant only for individuals with low levels of perceived social support. Results highlight the need to consider both intrapersonal and interpersonal risk factors, as well as their interaction, when predicting which individuals may be most at risk to develop depression following traumatic event exposure.

Psychopathology among adult survivors of child pornography

BACKGROUND

The majority of studies investigating child pornography have focused on conceptualizing the problem and the harm of the crime, evaluating the risk for child pornography offending, or discuss preventive measures. Little is known about survivors of this type of crime.

OBJECTIVE

This research explores the relationship between child pornography victimization and psychopathology in adulthood. Specifically, we examined the contribution of emotional reactions at the time of the crime and shortly after (guilt, embarrassment and avoidance) on psychopathology among adult survivors of child pornography.

PARTICIPANTS AND SETTING

The study was conducted among 107 child pornography adult survivors, aged 18-63 (M = 39.48, SD = 12.31). All participants were sexually molested during the crime.

METHODS

An online survey was completed by a convenience sample of adult survivors of child pornography.

RESULTS

Findings indicate survivor's current age predicted current psychopathology symptoms. Survivor's emotional reactions of guilt and embarrassment at the time of the crime and shortly after were significantly associated with elevated psychopathology, above and beyond demographic characteristics and features of the crime.

CONCLUSIONS

The present results suggest the way survivors of child pornography react to the crime might shape their mental health in the long term.

Measuring Experiential Avoidance and Posttraumatic Stress in Families

Experiential avoidance (EA) is receiving attention as an emotion regulation strategy and critical factor in the development and maintenance of posttraumatic stress disorder (PTSD) Evidence suggests that EA explains co-varying relationships among topographically dissimilar problem behaviors. The transmission of emotion regulatory strategies is important to understanding the development of these problems. EA may be a learned response style. This conceptual framework was used to test parent EA as a predictor of young adult/older adolescent (offspring) EA, posttraumatic stress symptoms (PTSS), and problem behaviors in a university context as well as to test the best predictors of these outcomes individually for parents and offspring. Two measures of experiential avoidance, the unwillingness to be in contact with distressing emotions, thoughts, and memories were used to predict the outcomes of interest. The Acceptance and Action Questionnaire-II (AAQ-II) was the strongest and only statistically significant predictor of PTSS and problem behaviors for parents and offspring above and beyond trauma history, while the Multidimensional Experiential Avoidance Questionnaire (MEAQ) remained non-significant. Implications regarding measurement discrepancies, PTSS, and harmful behavior trajectories are discussed.

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.

The mediating role of the metacognition, time perspectives and experiential avoidance on the relationship between childhood trauma and post-traumatic stress disorder symptoms

Background: The current study was designed to investigate the direct and indirect effects of the childhood trauma, metacognition, time perspectives and experiential avoidance in prediction of post-traumatic stress disorder (PTSD) symptoms. Methods: Participants included 432 adult patients referred for treatment to psychological, psychiatric disorders clinics and medical clinics of Shiraz, Iran. They were exposed to a traumatic event according to criterion A in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V). Childhood Trauma Questionnaire (CTQ), Post-traumatic Checklist for DSM-5 (PCL-5), Zimbardo Time Perspective Inventory (ZTPI), Acceptance and Action Questionnaire - II (AAQ-II) and metacognitions questionnaire-30 (MCQ-30) all were applied for data collection. Results: The results indicated that childhood trauma has a direct correlation with symptoms of PTSD, metacognition, and time perspectives, while it has an indirect correlation with experiential avoidance as well as symptoms of PTSD. Thus, metacognition and time perspectives play a mediating role between childhood trauma and experiential avoidance. In the same way, all three variables (metacognition, time perspectives, and experiential avoidance) play the same role between childhood trauma and symptoms of PTSD. Conclusions: Altogether, results of this study were consistent with the metacognitive model as well as Time Perspective Theory for PTSD and emphasizes that childhood trauma, metacognition, time perspectives and experiential Avoidance are important in explanation of PTSD symptoms.

Childhood trauma and problem behavior: Examining the mediating roles of experiential avoidance and mindfulness processes

OBJECTIVE

Childhood trauma is associated with a variety of risky, unhealthy, or problem behaviors. The current study aimed to explore experiential avoidance and mindfulness processes as mechanisms through which childhood trauma and problem behavior are linked in a college sample.

PARTICIPANTS

The sample consisted of college-aged young adults recruited November-December, 2016 (N = 414).

METHODS

Participants completed self-report measures of childhood trauma, current problem behavior, experiential avoidance, and mindfulness processes. Bootstrapped mediation analyses examined the mechanistic associations of interest.

RESULTS

Mediation analyses indicated that experiential avoidance was a significant mediator of the association between childhood trauma and problem behavior. Additionally, multiple mediation analyses indicated that specific mindfulness facets-act with awareness and nonjudgment of inner experience-significantly mediated the same association.

CONCLUSIONS

Interventions for college students who have experienced childhood trauma might profitably target mechanisms such as avoidance and mindfulness in order to minimize engagement in problem behavior.

Acceptance and Commitment Therapy for People Experiencing Appearance-Related Distress Associated With a Visible Difference: A Rationale and Review of Relevant Research

People may have a visibly different appearance due to various causes, such as congenital conditions, injury, disease, or medical treatment. Some individuals with a visible difference experience social anxiety and isolation, body image dissatisfaction, shame and self-stigma, psychological trauma, and challenges managing their condition. In this article, we synthesize the relevant literature and present the theoretical rationale for the application of Acceptance and Commitment Therapy (ACT), a third-wave behavioral therapy combining mindfulness skills and value-driven action, to those experiencing distress relating to an unusual or altered appearance. We also outline how ACT may be tailored to the specific considerations of this population and recommend next steps in researching its acceptability and clinical effectiveness.

Developing professional caregivers' empathy and emotional competencies through mindfulness-based stress reduction (MBSR): results of two proof-of-concept studies

OBJECTIVES

To assess the feasibility and acceptability of a mindfulness-based stress reduction (MBSR)-based intervention and determine if the intervention is associated with a significant signal on empathy and emotional competencies.

DESIGN

Two pre-post proof-of-concept studies.

SETTING

Participants were recruited at the University of Montreal's Psychology Department (Study 1) and the CHU Sainte-Justine Department of Hematology-Oncology (Study 2).

PARTICIPANTS

Study 1: 12 students completed the 8-week programme (mean age 24, range 18-34). Study 2: 25 professionals completed the 8-week programme (mean age 48, range 27-63).

INTERVENTION

Standard MBSR programme including 8-week mindfulness programme consisting of 8 consecutive weekly 2-hour sessions and a full-day silent retreat.

OUTCOMES MEASURES

Mindfulness as measured by the Mindful Attention Awareness Scale; empathy as measured by the Interpersonal Reactivity Index (IRI)'s Perspective Taking and Empathic Concern subscales; identification of one's own emotions and those of others as measured by the Profile of Emotional Competence (PEC)'s Identify my Emotions and Identify Others' Emotions subscales; emotional acceptance as measured by the Acceptance and Action Questionnaire-II (AAQ-II) and the Emotion Regulation Scale (ERQ)'s Expressive Suppression subscale; and recognition of emotions in others as measured by the Geneva Emotion Recognition Test (GERT).

RESULTS

In both studies, retention rates (80%-81%) were acceptable. Participants who completed the programme improved on all measures except the PEC's Identify Others' Emotions and the IRI's Empathic Concern (Cohen's d median=0.92, range 45-1.72). In Study 2, favourable effects associated with the programme were maintained over 3 months on the PEC's Identify my Emotions, the AAQ-II, the ERQ's Expressive Suppression and the GERT.

CONCLUSIONS

The programme was feasible and acceptable. It was associated with a significant signal on the following outcomes: perspective taking, the identification of one's own emotions and emotional acceptance, thus, justifying moving towards efficacy trials using these outcomes.

The reciprocal relations between experiential avoidance, school stressor, and psychological stress response among Japanese adolescents

The present study aimed to investigate the reciprocal relations between experiential avoidance, stressor, and psychological stress response (which consist of anger, depression, anxiety, helplessness, and physical complaints). In this study, 688 Japanese junior high school students (353 boys, 334 girls, 1 unidentified; mean age 13.28 years) completed three waves of questionnaires on experiential avoidance, stressor, and psychological stress response, with one-week intervals between measurement waves. Results from cross-lagged panel analyses showed that experiential avoidance predicted subsequent stressor and psychological stress response. Furthermore, the stressor and psychological stress response influenced by prior experiential avoidance affected subsequent occurrence of experiential avoidance. The findings suggest that reciprocal relations exist among the variables, and that the interaction between experiential avoidance and psychological stress was possible in adolescents.

Avoidance in posttraumatic stress among refugee survivors of violent conflict and atrocities: Testing trans-cultural risk processes and candidate intervention targets

BACKGROUND

A fast-growing population of refugees and survivors of violent conflict and atrocities are at risk for trauma-related mental health problems. Experimental clinical research key to the development of interventions tailored to this population is limited.

AIMS

In an experimental psychopathology laboratory paradigm, we tested the expression and function of avoidance in posttraumatic stress (PTS) among a highly traumatized community sample of forcibly displaced refugees seeking asylum.

METHOD

We measured behavioral avoidance and emotional reactivity to repeated exposure to threatening stimuli (trauma-, war-, and geographically-relevant natural threat) in 110 Sudanese male asylum seekers (M(SD)_age = 32.7(6.5)) recruited from the community in Israel.

RESULTS

First, we found evidence of sensitization - traumatized refugees expressed increasing levels of behavioral avoidance and emotional reactivity in response to repeated exposure to threatening stimuli. Second, as predicted, refugees suffering from more severe PTS were more likely to exhibit greater behavioral avoidance and emotional reactivity reflexively or immediately upon exposure to threat stimuli. Finally, as predicted, behavioral avoidance mediated the effect of PTS severity on emotional reactivity to threat exposure.

CONCLUSIONS

Findings are consistent with theorizing that avoidance may function as a trans-cultural malleable risk process sub-serving PTS and thereby a promising intervention target among highly traumatized refugees from E. Africa.

The conceptualization of emotion regulation difficulties, and its association with posttraumatic stress symptoms in traumatized refugees

This study investigated the conceptualization of emotion regulation difficulties in a sample of refugees with varying levels of posttraumatic stress (PTS), and examined whether specific emotion regulation difficulties were associated with PTS severity. Refugees were administered an abbreviated version of the Difficulties in Emotion Regulation Scale, the PTSD Symptom Scale - Interview Version, and the Harvard Trauma Questionnaire. Confirmatory Factor Analysis was used to examine model fit for the 6-factor model originally proposed by the developers of the DERS and the more recently proposed 5-factor model that excludes the awareness subscale. Both models displayed adequate fit. After controlling for age, gender, time in Australia, and trauma exposure, the clarity and strategies subscales were significantly associated with PTS severity. The association between impaired emotional clarity and reduced agency related to accessing regulation strategies and PTS severity in this refugee sample highlights the need for further research to assess interventions that target these disruptions in refugees.

Constructive and Unproductive Processing of Traumatic Experiences in Trauma-Focused Cognitive-Behavioral Therapy for Youth

Although there is substantial evidence to support the efficacy of cognitive-behavioral treatments (CBT) for posttraumatic stress disorder (PTSD), there is some debate about how these treatments have their effects. Modern learning theory and cognitive and emotional processing theories highlight the importance of reducing avoidance, facilitating the constructive processing of feared experiences, and strengthening new inhibitory learning. We examined variables thought to be associated with unproductive and constructive processing of traumatic experiences in a sample of 81 youth with elevated PTSD symptoms, who received Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for abuse or traumatic interpersonal loss. Sessions during the trauma narrative phase of TF-CBT were coded for indicators of unproductive processing (overgeneralization, rumination, avoidance) and constructive processing (decentering, accommodation of corrective information), as well as levels of negative emotion. In previous analyses of this trial (Ready et al., 2015), more overgeneralization during the narrative phase predicted less improvement in internalizing symptoms at posttreatment and a worsening of externalizing symptoms over the 12-month follow-up. In contrast, more accommodation predicted improvement in internalizing symptoms and also moderated the negative effects of overgeneralization on internalizing and externalizing symptoms. The current study examined correlates of overgeneralization and accommodation. Overgeneralization was associated with more rumination, less decentering, and more negative emotion, suggesting immersion in trauma-related material. Accommodation was associated with less avoidance and more decentering, suggesting a healthy distance from trauma-related material that might allow for processing and cognitive change. Decentering also predicted improvement in externalizing symptoms at posttreatment. Rumination and avoidance showed important associations with overgeneralization and accommodation, respectively, but did not predict treatment outcomes. This study identifies correlates of overgeneralization and accommodation that might shed light on how these variables relate to unproductive and constructive processing of traumatic experiences.

Experiential Avoidance and Rumination in Parents of Children on Cancer Treatment: Relationships with Posttraumatic Stress Symptoms and Symptoms of Depression

We conducted a cross-sectional survey study to investigate whether there is a relationship between experiential avoidance (EA), rumination, post-traumatic stress symptoms (PTSS), and symptoms of depression, in parents of children on cancer treatment. Data from 79 parents (55 mothers) of 79 children with a median of three months since their cancer diagnosis were included in cross-sectional analyses. EA and rumination were positively correlated with PTSS and symptoms of depression. EA and rumination did not provide incremental explained variance in PTSS over and above that explained by symptoms of depression, while controlling for symptoms of anxiety and demographic characteristics. However, EA and rumination provided incremental explained variance in symptoms of depression over and above that explained by PTSS, while controlling for symptoms of anxiety and demographic characteristics. Rumination and EA are important constructs in the understanding of PTSS and symptoms of depression in parents of children on cancer treatment. Future research should delineate the temporal relationships between these constructs.

Mood, Disability, and Quality of Life among a Subgroup of Rheumatoid Arthritis Individuals with Experiential Avoidance and Anxiety Sensitivity

Objective. The current study aimed to identify and characterize distinct RA subgroups based on their level of EA and AS and compares the difference among the subgroups in mood, disability, and quality of life. Methods. Individuals with chronic pain for at least 3 months were recruited from an academic rheumatoid clinic. Participants were assessed for demographic, psychosocial, and personality measures. A two-step cluster analysis was conducted to identify distinct subgroups of patients. Differences in clinical outcomes were compared using the Multivariate ANOVA based on cluster membership. Results. From a total of 223 participants, three distinct subgroups were formed based on cluster analysis. Cluster 1 (N = 78) included those with low levels of both EA and AS. Cluster 2 (N = 81) consisted of individuals with moderate levels of EA and low levels AS. Cluster 3 (N = 64) included those with moderate levels of EA and high AS. Compared to those in Cluster 1, those in Cluster 3 had significantly higher levels of mood impairment and disability and lower quality of life (p < 0.05). Significantly lower levels of mood impairment were seen in Cluster 1 compared to Cluster 2 (p < 0.05). However, no significant difference in disability or quality of life was seen between the two groups. Conclusions. The three subgroups differed significantly in levels of impairment in mood, disability, and quality of life. However, levels of EA had a greater impact on disability and quality of life than AS.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

Acceptance and commitment therapy as a nonpathologizing intervention approach for survivors of trauma

Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) is proposed as a nonpathologizing approach to trauma-related problems. ACT has at its core a functional approach to understanding the human condition such that problems are maintained by functional processes, such as avoidance. Treatment focuses on these processes to institute change, stepping away from directly pursuing symptoms as an evaluative outcome. A collaborative, client-centered approach is used in defining valued life directions and committing to action based on those values. ACT presents a method of approaching trauma-related problems that is structured to support a client in finding a life beyond trauma that has value.

Psychological Flexibility as a Framework for Understanding and Improving Family Reintegration Following Military Deployment

Postdeployment reintegration may present an exceptional challenge to service members and their families; yet, overcoming this challenge seems to strengthen family relationships through a shared sense of purpose. Navigating family reintegration may be an important determinant of long-term psychological well-being. If the needs of military families are to be answered effectively, it is of critical importance to identify the skills that facilitate positive reintegration following deployment. This article proposes psychological flexibility as a group of interrelated skills that could be directly intervened on to facilitate not only resilience but also positive growth and development. This paper focuses on the conceptualization of family reintegration in terms of psychological flexibility, including common deficits observed in this population and potential goals of treatment. Video Abstract.

Psychometric properties of the Portuguese version of the Acceptance and Action Questionnaire-Trauma Specific (AAQ-TS): A study with Portuguese Colonial War Veterans

BACKGROUND

The Acceptance and Action Questionnaire-Trauma Specific (AAQ-TS) is a self-report measure designed to assess-trauma-related psychological (in)flexibility, as conceptualized in Acceptance and Commitment Therapy. However, there are no studies to date regarding its psychometric properties. This study explores such properties in the Portuguese version of the AAQ-TS, in Portuguese Colonial War Veterans.

METHOD

A Principal Components Analysis (PCA) was conducted in a sample from the general population of war Veterans (N=371). Confirmatory Factor Analysis (CFA) as well as reliability and convergent validity studies were performed in a different sample from the same population (N=312). For the discriminant validity a clinical sample with a war-related PTSD (N=42) and a non-clinical sample without PTSD (N=44) were used.

RESULTS

The CFA suggested a re-specified 15-item model with good global adjustment and factorial validity. The AAQ-TS showed internal consistency, a good temporal reliability, convergent validity with psychopathological symptoms (related to PTSD, anxiety, depression and stress) and peritraumatic dissociation (altered awareness and depersonalization/derealization). The questionnaire also discriminates between war Veterans with and without a PTSD diagnosis.

LIMITATIONS

The major limitation relates to the samples' characteristics and sampling methods, which can limit the generalization of results.

CONCLUSION

The Portuguese version of the AAQ-TS is a reliable and valid measure to assess experiential avoidance related to trauma in Portuguese Colonial War Veterans.

Further Investigation of the Association between Anxiety Sensitivity and Posttraumatic Stress Disorder: Examining the Influence of Emotional Avoidance

Anxiety sensitivity (AS) and the tendency to avoid emotions have both been identified as vulnerability factors for the development and maintenance of posttraumatic stress disorder (PTSD). Furthermore, both cross-sectional and prospective research have provided evidence that emotional avoidance and AS interact to predict anxiety symptoms, such that AS may only be associated with anxiety-related pathology among those who exhibit a tendency to avoid their emotions. The purpose of the present study was to determine if this moderator model extends to PTSD within a sample of substance dependent patients. Specifically, this study examined if AS is associated with PTSD only among individuals with high (vs. low) levels of negative emotional avoidance. As predicted, results of a logistic regression analysis revealed a significant interaction between negative emotional avoidance and AS in predicting PTSD status. Follow-up analyses revealed a significant positive association between AS and PTSD status for participants high in negative emotional avoidance; however, AS was not associated with PTSD for those low in negative emotional avoidance. This finding remained even when relevant covariates were included in the model. Results confirm hypotheses and are consistent with the extant anxiety-risk literature.

Paying less but harvesting more: the effect of unconscious acceptance in regulating frustrating emotion

Previous studies indicate that emotion regulation may occur unconsciously, without the cost of cognitive effort, while conscious acceptance may enhance negative experiences despite having potential long-term health benefits. Thus, it is important to overcome this weakness to boost the efficacy of the acceptance strategy in negative emotion regulation. As unconscious regulation occurs with little cost of cognitive resources, the current study hypothesizes that unconscious acceptance regulates the emotional consequence of negative events more effectively than does conscious acceptance. Subjects were randomly assigned to conscious acceptance, unconscious acceptance and no-regulation conditions. A frustrating arithmetic task was used to induce negative emotion. Emotional experiences were assessed on the Positive Affect and Negative Affect Scale while emotion- related physiological activation was assessed by heart-rate reactivity. Results showed that conscious acceptance had a significant negative affective consequence, which was absent during unconscious acceptance. That is, unconscious acceptance was linked with little reduction of positive affect during the experience of frustration, while this reduction was prominent in the control and conscious acceptance groups. Instructed, conscious acceptance resulted in a greater reduction of positive affect than found for the control group. In addition, both conscious and unconscious acceptance strategies significantly decreased emotion-related heart-rate activity (to a similar extent) in comparison with the control condition. Moreover, heart-rate reactivity was positively correlated with negative affect and negatively correlated with positive affect during the frustration phase relative to the baseline phase, in both the control and unconscious acceptance groups. Thus, unconscious acceptance not only reduces emotion-related physiological activity but also better protects mood stability compared with conscious acceptance. This suggests that the clinical practice of acceptance therapy may need to consider using the unconscious priming of an accepting attitude, instead of intentionally instructing people to implement such a strategy, to boost the efficacy of acceptance in emotion regulation.