ACT work is dedicated to the scientific pursuit of understanding and positively influencing human behavior. As such, functional contextualists have committed to developing measures involved with the acceptance and commitment domains so that these factors are more readily understood and can be assessed for change. Many of the assessment tools discussed below are in development or have not had their psychometric properties completely evaluated. However, this is the beginning of a good list of tools and methods. To the extent possible, consider incorporating some of them into your practice.
Committed Action
Third-wave behavior therapy shares the same respect for ongoing measurement in a therapeutic endeavor as the first two waves. In fact, this particular section will describe methods very similar to the way first- and second-wave behavior therapists approach clinical measurement. Committed action is about executing behaviors in the direction of important life goals. The steps in this direction can be measured by the response dimen- sions. Human behavior can be assessed by its frequency, intensity, duration, latency, and perseverance. These measures belong in ACT.
Frequency is the measure of the number of times a behavior occurs in a given period.
For example, the obese individual can be asked to keep a weekly chart of how often he eats per day, how frequently he goes to the gym in a week, or how frequently he binges per month. Rate of response has always been a critical measure to behavior analysis, and Skinner even boasted that his most important scientific contributions were rate of
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response and the cumulative response recorder. Looking at how many times a response occurs over a period of time is an elegant measure of how much influence the environ- ment has on the operant. The method of assessment is amenable to checklists, wrist counters, and hash marks on calendars.
Intensity is a measure of the magnitude of force or energy of a behavior. This is
clearly a response dimension when talking about overt behavior. We might be interested in not only how many times a person lifts a barbell but also the weight of the barbell in kilograms. From a clinical point of view, we might assess how many drinks a person has (frequency) and also whether those are drinks of light beer with a low alcohol content or homemade gin with a high alcohol content (intensity). If we are interested in emo- tional variables, intensity may have to be self-reported on a subjective units of distress scale (SUDS). This is commonly heard when the therapist asks, “How angry/anxious/ depressed were you on a scale of 1 to 10?”
Duration is a measure of the continuance of a particular response class: once the
response starts, how long does it continue before it ceases? A person may be interested in measuring how long he meditates once he sits down to do so because he wants to work up from three minutes of meditation to fifteen minutes. More clinically, we may want to know how long a person can be exposed to aversive stimuli before making an incompatible experiential avoidance move. For instance, how long can your client maintain eye contact before looking away or talk about an uncomfortable issue before changing the subject? Duration of sobriety is significant to substance abuse treatment. Timing how long a man with a history of clergy abuse can be inside a church or how long a person with OCD and contamination fears can hold a doorknob are measures of duration. The ACT approach isn’t necessarily going to aim at reducing the duration
of private events—they are to be experienced, noteliminated. But timing how long a
person can engage in a life experience event (exposure exercises) can be key treatment data. It provides insight into how flexible client behavior is and can be a measure of commitment in the moment.
Much the same can be said for latency measures, which are assessments of how long it takes for a person to engage in a response once the response opportunity arises. A man with social phobia can self-monitor how long it takes him to leave the comfort of his car and go into his workplace. It is a measure of delay prior to an important response. It is also a matter of perspective. He may be in the car ruminating for a long time (a duration measure) or not at work when he could be (a latency measure).
Perseverance is slightly different from these dimensions in that the assessor is looking
for different environments or stimulus events that occasion certain responses. Clinicians interested in the contextual variables of a response class are looking for its perseverance. Asking a client with anger problems about what sets him off during the day is an assess- ment of perseverance: “Tell me what gets you angry in the morning/during your work commute/at work/at lunch/at home” and so on. Knowing what environments evoke the clinical problem can assist in developing better scenarios for exposure exercises and also help plan times to work on coping skills.
Values
In endeavoring to assist clients with values clarification, the ACT client may be asked to write down her summary of what personal value-directed living might look like. Hayes, Strosahl, and Wilson (1999) provided the Values Narrative Form, Values Assessment Rating Form, and the Goals, Actions, Barriers Form to assist clients in articulating what was personally important and vital to them.
The Valued Living Questionnaire (VLQ; Wilson & Groom, 2002) addresses the relative importance a person would place on each of ten personal life areas, and then asks how consistent the person’s recent behavior has been with respect to their values imbued in each life area. The Valued Living Questionnaire Working Manual (Wilson, 2006a) has a great deal of information for the use of the VLQ and values-based work in general for therapy.
Ciarrochi and Blackledge (in Ciarrochi & Bilich, 2006) forwarded the Personal Values Questionnaire (PVQ) targeting values clarification. The authors “wanted to describe each value’s domain in a way likely to influence subjects to write relatively ACT-consistent values—even if these subjects had not been exposed to ACT therapy” (Ciarrochi & Blackledge, 2005). The tool assesses nine areas of a person’s life (family, friends, work, and so on) in a qualitative fashion, and then attempts to quantify the motivations for each value. The Social Values Survey (Ciarrochi & Blackledge, 2005) is an abbreviated version usable with adolescents.
Targeting values during assessment is made very practical using Dahl and Lundgren’s (2006) Values Bull’s-Eye. Using the figure of an archery bull’s-eye target, clients are asked to rate how closely their recent behavior “hit the mark” with respect to valued living. The tool was used in Dahl and Lundgren’s clinical research program with indi- viduals with seizure disorders and is available in their book. It is also available at www .contextualpsychology.org, the website of the Association of Contextual Behavioral Science in Ciarrochi and Bilich’s (2006) collection of ACT related assessment instruments.
Acceptance
A linchpin assessment tool in ACT work has been the Acceptance and Action Questionnaire (AAQ; Bond, 2006). The first AAQ emerged from collaborative efforts (Hayes, Strosahl, Wilson, et al., 2004) aimed at developing a brief general measure of experiential avoidance applicable to population research. This seven-point Likert scale self-report questionnaire aims to appraise a person’s need to avoid negative private content, to have cognitive and emotional control, and to be able to take important action in the face of these private events. There are several versions of the AAQ, varied slightly in the number of questions (AAQ-9, AAQ-16, and AAQ-22), and some of the overlapping questions on each have been slightly altered on the other assessments. A revised version, the AAQ-II, has also been published (Hayes, 2007) and continues to be developed and put through validation studies.
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Greco, Murrell, and Coyne (2005) developed a related measure for youngsters. The Avoidance and Fusion Questionnaire for Youth (AFQ-Y) includes seventeen Likert scale items aimed at fusion and experiential avoidance. According to the authors, the “research suggests that the AFQ-Y may be a useful and child-friendly measure of core ACT processes” (Greco, 2006). Sandoz and Wilson (2006) have also constructed the Body Image Acceptance Questionnaire (BIAQ), which is a twenty-nine-item, seven- point Likert scale to assess the extent to which an individual shows acceptance toward negative feelings and thoughts about body shape and/or weight.
The Chronic Pain Acceptance Questionnaire (CPAQ; Geiser, 1992) is a staple assessment in ACT-based treatment research with individuals dealing with pain prob- lems (McCracken, 1998; McCracken, Vowles, & Eccleston, 2004). The latest version of the CPAQ is a twenty-item Likert scale yielding scores for two subscales: activity engagement and pain willingness. The idea behind the assessment is to see if clients can move forward in their important life goals in the presence of their pain, so it lends itself well to ACT work (McCracken & Eccleston, 2006). By the time you read this book, there may be still newer measures. One source for ACT-related measures, including reliability and validation data, is www.contextualpsychology.org.
Defusion
Properly measuring the extent to which a client is disentangled from her private verbal behavior would be a boon to an ACT therapist’s work. Of course, given the privacy of these events, clinicians must rely on self-report to get close to this kind of information. The White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994) attempts to take a crack at this bear of a task. The WBSI assesses an individual’s inclina- tion to squelch aversive cognitive content. The ten-item Likert scale can be interpreted with norms, and has been correlated with treatment effects for folks with anxiety con- cerns (Smari & Holmsteinssen, 2001). Keep in mind that the aforementioned AFQ-Y also has a component of defusion measurement.
Defusion measures can be developed idiographically. While symptom- or disorder- specific measures are still in their infancy (and depending on the disorder, perhaps have not been developed yet), general assessment procedures, such as self-report measures of relative influence of thoughts and feelings, will serve to assess how much impact they are having. Subjective units of distress scales and individualized Likert scales may be practical tools. Bach and Hayes (2002) demonstrate the use of idiosyncratic measures for the frequency, distress, and believability of psychosis symptoms, and provide a good model for your own development of clinical measures. Eifert and Forsyth (2005) propose using established measures, such as the Automatic Thoughts Questionnaire-B (ATQ-B; Hollon & Kendall, 1980) and the Thought-Action Fusion Scale (TAF; Shafran, Thordarson, & Rachman, 1996), and enhancing the queries with a simple believability scale (for example, 0 = completely unbelievable to 6 = completely believable) in order to assess defusion.