Journal of Contextual Behavioral Science 3 (2014) 3844

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Original Article

Acceptance, mindfulness, and cognitive reappraisal as longitudinal

predictors of depression and quality of life in educators
Douglas M. Long n, Steven C. Hayes
University of Nevada, Reno, NV 89557-0062, USA

art ic l e i nf o

a b s t r a c t

Article history:
Received 16 March 2013
Received in revised form
19 August 2013
Accepted 24 October 2013

This longitudinal study used psychological process measures derived from Acceptance and Commitment
Therapy (ACT) and Cognitive Therapy (CT) models to prospectively predict depression and quality of life.
Participants included 93 K-12 education employees who repeatedly completed surveys over the course of
4 months. Both the ACT and CT regression models were predictive of depressive symptoms after controlling
for baseline depression. These models differed in their success at predicting life quality over time. In the CT
models, only automatic thought frequency had predictive value while dysfunctional attitudes and cognitive
reappraisal did not make unique contributions. In the ACT models, both psychological exibility and
present moment awareness made unique contributions while thought believability did not contribute. The
role of awareness was moderated by psychological exibility, suggesting that present moment sensitivity
can either be a strength or a weakness depending upon one's level of openness to experience. Strengths
and weaknesses of both the ACT and CT models are noted, as areas for future research.
& 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

Keywords:
Reappraisal
Mindfulness
Acceptance
Depression
ACT
CT

1. Introduction
Investigation of the intricate relationship between cognition
and mental health has long been important for the advancement
of cognitive behavioral therapies (CBTs). While CBTs have established effectiveness for a variety of disorders, attention has shifted
to the processes by which psychological health is impacted
(Hofmann, 2008). This is in part due to concerns about the
progressivity of technology-focused research (Wilson, 1997), as
well as the underutilization of complete CBT packages (Shafran
et al., 2009). By better understanding the processes involved in the
maintenance of psychological suffering and well-being, the efciency of interventions may be improved through more specic
targeting (Kazdin, 2007). Furthermore, this may expand psychology's public health impact by empowering transdiagnostic interventions outside of the traditional therapy setting (Kazdin & Blase,
2011). The models underlying Cognitive Therapy (CT; Beck, Rush,
Shaw, & Emery, 1979) and Acceptance and Commitment Therapy
(ACT; Hayes, Strosahl, & Wilson, 1999) are demonstrable of these
trends since both theories offer well-articulated accounts of
broadly applicable psychological processes.
The CT model emerged as an extension of a medical diagnostic
model in which health is identiable as an absence of signs and

n
Correspondence to: Department of Psychology, 298, University of Nevada, Reno,
NV 89557-0062, USA.
E-mail address: douglas.m.long@gmail.com (D.M. Long).

symptoms of underlying abnormalities. In the area of depression,

for example, CT aims to relieve emotional distress and other
symptoms of depression, (Beck et al., 1979, p. 35). It does so
through a variety of means such as empirical hypothesis testing
and cognitive reappraisal to restructure dysfunctional schemas. As
negative automatic thoughts and distorted interpretations of
events decline in frequency, depressive emotional and behavioral
symptoms are expected to be ameliorated.
In contrast, the ACT model is a variant of a behavioral developmental approach and is based on the idea that the psychological pain that is inherent in difcult life situations can be accepted
for what it is and learned from; attention can then be shifted
toward life enhancing behaviors. (Hayes, Strosahl, & Wilson, 2011,
p. 24). The ACT model focuses on how emotional, attentional, and
behavioral exibility can be reduced by the over-extension of
adaptive cognitive processes. The target of ACT in areas such as
depression is not merely the reduction of psychopathology but the
enhancement of quality of life. By promoting acceptance of
emotions and bodily sensations, and defusion from habitual
thoughts even those that are traditionally treated as undesirable
symptoms ACT seeks to create a situation in which thoughts
need neither to be believed nor challenged but can be noticed as
objects of awareness, learned from, and attention can then shift to
engagement with valued activities.
In addition to demonstrating utility through psychosocial
interventions across a variety of disorders (Butler, Chapman,
Forman, & Beck, 2006; Hayes, Luoma, Bond, Masuda, & Lillis,
2006), both the ACT and CT models have been inuential through

2212-1447/$ - see front matter & 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcbs.2013.10.004

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

the development of measures intended to assess their distinctive

component processes (Hayes et al., 2004; Segal & Swallow, 1994).
For example, the CT model's emphasis on the form and frequency
of cognitions as primary factors sustaining depression guided the
development of the Automatic Thoughts Questionnaire (ATQ),
which assesses depressive thought frequency (Hollon & Kendall,
1980). By contrast, the ACT model views one's degree of attachment to cognition as being more fundamentally important than
thought content itself, and this guided a modication of the ATQ
whereby depressive thought believability was assessed (Zettle &
Hayes, 1986).
The development of such theoretically distinct measures has
been important as it allows for more clear differentiation between
interventions (O'Donohue & Yeater, 2003). ACT's focus upon the
ability to relate to cognition more exibly and CT's focus upon the
ability to rationally modify cognitive content has been highlighted
as a key difference between ACT and CT (Hayes, 2004). Mediation
analyses using theory-guided measures in preliminary randomized controlled trials comparing ACT and CT have suggested that
these interventions work through different processes that are
broadly consistent with their respective models (Forman,
Herbert, Moitra, Yeomans, & Geller, 2007; Zettle & Hayes, 1986;
Zettle, Rains, & Hayes, 2011). Though quite useful, randomized
control trials are costly to perform and require quality process
measures that meet a variety of criteria. For example, in order to
be maximally useful, process measures must predict future outcomes of interest and yet not be so strongly associated with
outcomes or other processes so as to be indistinguishable from
them (Kazdin, 2007).
Since treatment evaluation requires high-quality measures, and
since predictive power can be valuable in its own right, longitudinal studies have been employed as a means of rening ACT
and CT measurement models. CT process measures of dysfunctional attitudes and automatic negative thoughts have been
successful in prospective predictions of depressive symptoms
and disorders (Alloy, Abramson, Whitehouse, & Hogan, 2006;
Chioqueta & Stiles, 2007). Likewise, ACT process measures of
psychological exibility have successfully predicted depression,
mental health, and life functioning in various areas such as job
satisfaction or quality of life (Bond & Bunce, 2003; Landstra,
Ciarrochi, Deane, & Hillman, 2013; McCracken & Eccleston, 2003).
While longitudinal studies have been conducted with measures
of cognitive reappraisal and acceptance as general coping strategies (e.g., Kraaij, Pruymboom, & Garnefski, 2002), more research is
needed that uses theory-specic predictions to compare the
relative strengths of ACT and CT longitudinal assessment models.
ACT and CT have specied different primary outcomes of interest,
as well as multiple processes that may interact in different ways.
Thus, studies of ACT and CT measurement models will ideally be
conducted in a manner that allows for the predictive utility of this
conceptual precision to be evaluated. For example, a recent study
using experience sampling methods in a group of individuals
struggling with psychosis found acceptance to be more strongly
predictive of quality of life relative to cognitive reappraisal
(Vilardaga, Hayes, Atkins, Bresee, & Kambiz, 2013). This is consistent with the ACT model's emphasis on experiential acceptance
as a coping strategy with particular relevance to quality of life
outcomes.
The present study applied ACT and CT process measures to
longitudinal prediction of depression and quality of life data from
a sample of K-12 education staff. It is known that public education
employees are vulnerable to the effects of job stress (Watts &
Short, 1990) and can benet from cognitive behavioral interventions such as ACT (Jeffcoat & Hayes, 2012). Evidence of model
distinctiveness is examined in the present study by looking for
differential performance of ACT and CT process measures in

39

predicting depression and quality of life. The precision and

breadth of each model is examined by considering whether
theoretically distinct process measures make unique predictive
contributions and whether expected interactions between model
processes are obtained.

2. Method
2.1. Recruitment and procedures
This longitudinal assessment study was conducted as part of a
correspondence in-service course for Nevada K-12 education
employees titled, Working and Living Resiliently Under Stress,
(WALRUS). The program aimed to, promote healthier living and
working under stressful conditions by teaching emotional intelligence skills to faculty and staff via exposure to a workbook.
Recruitment was conducted through a combination of emails by
school administrators, yers, and newsletter articles that advertised continuing education credits, nancial lotteries, and free
emotional intelligence workbooks as incentives. Participation
required that individuals be over 18 years old, be able to read
English, have regular internet access.
Participants were informed that they may be randomly
assigned to waiting period wherein they would complete a series
of baseline assessments over 4 months before receiving the
workbook. Thus, the in-service program as a whole operated as
a randomized controlled trial with a total of 93 participants
randomized to the 4-month waiting period arm. These participants make up the sample used in the current analyses; they had
no exposure to the workbooks in the time-period of interest.
Online assessments containing outcome and process measures
were delivered three times once at the beginning of the study,
once 2 months later, and then again following an additional
2 months. All surveys were administered online using Survey
Monkey (www.surveymonkey.com) and were distributed through
individualized emails containing coded links.
2.2. Outcome measures
Depression was measured using the seven-item depression
subscale of the Depression Anxiety Stress Scales (DASS; Lovibond
& Lovibond, 1995; depression in the current study .90). The
DASS consists of a series of self-report items scored on a four-point
Likert scale with regard to the participant's experiences over the
last week. The DASS has been used in many studies involving
general populations and has demonstrated good psychometric
characteristics across settings (Crawford & Henry, 2003). The
depression subscale focuses on depressive symptoms with items
such as, I felt down-hearted and blue and I felt that I had
nothing to look forward to. Scores range from zero to 42 with
higher scores indicating greater distress. This scale was treated as
the primary outcome of interest from a CT point of view as it
emphasizes symptoms of depression.
Psychological quality of life was measured with the six-item
psychological subscale from the World Health Organization Quality of Life scale (WHOQOL-P; Harper & Power, 1998; in the
current study .84). In the WHOQOL-P, participants rate their
quality of life over the past 4 weeks in a variety of areas of life
engagement using a ve-point Likert scale and items such as, To
what extent do you feel your life to be meaningful and How
much do you enjoy life? Scores on this WHOQOL-P subscale range
from ve to 30 with higher scores indicating better psychological
quality of life. This scale was treated as the primary outcome of
interest from the ACT point of view as it tends to focus on a sense
of satisfaction and meaningful engagement with life.

40

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

in these thoughts. Score range from 30 to 150 with higher scores

indicating greater frequency or greater believability.
Tendency to use cognitive reappraisal as a coping skill was
assessed with the six items of the reappraisal subscale taken from
the Thought Control Questionnaire (TCQ-R; Wells & Davies, 1994;
in the current study .78). Reappraisal is conceptualized as a
core process of change in CT and is measured in the TCQ by asking
participants to reect upon their strategies for controlling unpleasant and unwanted thoughts. Participants then indicate their
agreement on a four-point Likert scale with items like, I question
the reasons for having the thought, and I try a different way of
thinking about it. Scores on the TCQ reappraisal subscale range
from six to 24 with higher scores indicating greater use of
reappraisal as a coping skill. The present study explores the
potential mitigating role of reappraisal upon distressing thoughts
by examining the TCQ-R in relation to outcomes both directly and
in interaction with the ATQ-F.
Dysfunctional cognitions were measured with the nine-item
version of the Dysfunctional Attitudes Scale (DAS; Oliver &
Baumgart, 1985; in the current study .80). The DAS was
developed to measure enduring cognitive schemas that make
individuals susceptible to mental illness and depression a core
process in the CT model. It asks participants to indicate their level
of agreement on a ve-point Likert scale with items like, My life is
wasted unless I am a success, and I should be happy all the time.
Scores on the DAS range from nine to 45, with higher scores
indicating stronger dysfunctional attitudes.

2.3. Process measures

The Acceptance and Action Questionnaire (AAQ-II; Bond et al.,
2011; in the current study .86) was developed as a measure of
psychological exibility which is conceptualized as the core
process of change in ACT. Its items focus upon a sense of openness
to experience and behavioral exibility in the presence of experience, asking participants to rate their agreement on seven-point
Likert scales with statements like It's OK if I remember something
unpleasant, and I am afraid of my feelings. Scores range from
seven to 70 with higher values indicating greater exibility and
openness to one's experiences.
The ten items of the Philadelphia Mindfulness Scale's awareness sub-scale were used to measure present moment awareness,
which is also seen as an essential process in the ACT model
(PHLMS-A; Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008;
in the current study .86). While mindfulness can be dened to
contain a variety of components (Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006), the PHLMS focuses a general tendency to be aware and observing of one's environment and
experience. Completion of this scale involves ve-point Likert
scale ratings of agreement with statements such as, I notice
changes inside my body, like my heart beating faster or my
muscles getting tense, and When I shower, I am aware of how
the water is running over my body. Scores on the PHLMS
awareness subscale range from 10 to 50 with higher scores
indicating greater present moment awareness. Previous research
has shown that self-focused attention can be predictive of higher
anxiety and other negative outcomes (Wells, 1985). In particular
contexts, however, such as in meditative treatments, self-focused
attention is associated with positive outcomes (Baer, 2009). The
current study explores this dual role of self-attention from an ACT
viewpoint by examining the PHLMS-A in relation to outcomes
both directly and in interaction with the AAQ.
The Automatic Thoughts Questionnaire (ATQ) was used to
assess both the frequency (ATQ-F; Hollon & Kendall, 1980; in
the current study .97) and the believability (ATQ-B; Zettle &
Hayes, 1986; in the current study .98) of automatic negative
statements about oneself. The frequency with which negative
thoughts occur is taken to be indicative of the level of dysfunction
in underlying attitudes a core focus of the CT model. The
believability of such thoughts is relevant to both models but has
been especially emphasized from an ACT point of view since the
ability to have a thought but not believe it is seen as indicating a
exible, defused stance. The ATQ presents participants with a list
of thirty thoughts that pop into people's heads. Participants were
asked to rate each thought on two ve-point Likert scales: one
indicating the frequency with which the thought occurred for
them in the last week, and another indicating their degree of belief

3. Results
3.1. Sample characteristics
The total sample at baseline consisted of 93 participants, with
91 following-through to the 2-month follow-up assessment, and
90 following-through to the 4-month follow-up assessment. Most
were female (N 83, 90%), Caucasian (N 89, 96%) and between
the ages of 30 and 60 (N 78, 82%). This was a highly educated
sample with most having obtained a master's degree or higher
(N 68, 74%). The majority of the participants were teachers
(N 74, 80%), while the remaining participants were administrators, secretaries, counselors, nurses, or other school employees.
Means, standard deviations, and bivariate correlations for all
measurements taken at baseline are shown in Table 1. These
measurements indicate that this was a non-depressed sample
according to standard cut-off scores (Lovibond & Lovibond, 1995),
and the sample additionally demonstrated a fairly high quality of
life. Bivariate correlations showed that both depression and
psychological quality of life were signicantly associated with

Table 1
Means, standard deviations, and bivariate correlations at baseline (N 93).
Variable
1. Depression
2. Life Quality
3. AAQ
4. PHLMS-A
5. DAS
6. TCQ-R
7. ATQ-F
8. ATQ-B

M
7.07
21.23
50.79
37.35
20.34
15.38
53.25
26.65

SD
9.19
4.01
9.32
6.23
6.45
3.31
23.32
54.31

3
nn

 .72

4
nn

 .62
.71nn

 .15
.24n
.29nn

6
nn

.38
 .44nn
 .47nn
 .30nn

 .02
.08
.17
.38nn
 .18t

8
nn

.84
 .71nn
 .69nn
 .17
.47nn
 .02

.63nn
 .61nn
 .54nn
 .04
.29nn
.00
.71nn

Note: Depression DASS depression subscale; Life Quality WHOQOL Psychological Quality of Life subscale; AAQ Acceptance and Action Questionnaire; PHLMSA Philadelphia Mindfulness Scale awareness subscale; DAS Dysfunctional Attitudes Scale; TCQ-R Thought Control Questionnaire reappraisal subscale; ATQ-F Automatic
Thoughts Questionnaire frequency subscale; ATQ-B Automatic Thoughts Questionnaire believability subscale.
t
p o .10., n p o .05, nn p o.01.

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

psychological exibility (AAQ), believability of depressogenic

thoughts (ATQ-B), frequency of depressogenic thoughts (ATQ-F),
and presence of dysfunctional attitudes (DAS), but not cognitive
reappraisal (TCQ-R). Awareness (PHLMS-A) did not correlate with
depression but correlated weakly and positively with quality
of life.
To explore the possibility that the sample's characteristics
may have changed over time, a series of paired-sample t-tests
were conducted comparing baseline with values from 2 and
4 months later. With two exceptions, all of these comparisons
were non-signicant. The 4-month follow-up mean for the DAS
was 19.19 (SD 6.36), and this was a statistically signicant
decrease from baseline with a small effect size (t(90) 1.20,
p r .05, d .18). Additionally, the 4-month follow-up mean
for the TCQ-R was 16.23 (SD 4.04), and this was a statistically signicant increase from baseline with a small effect size
(t(90)  2.91, p r .01, d  .24).
3.2. Regression analyses
Data screening procedures identied one outlier for removal
a participant who failed to complete all the ACT measures and
who appeared with a residual score greater than three standard
deviations away from the residual mean in the CT model
regressions. The relations between baseline and follow-up measures were assessed in this study using hierarchical multiple
regression. In total, eight regressions were conducted, with
variables representing the ACT and CT models functioning as
predictors of both depression and quality of life. Step 1 in each
regression controlled for the baseline level of the outcome
variable of interest either depression or quality of life. Step 2
then entered the three psychological process variables particularly representing either ACT or CT. The nal step entered an
interaction term between two process variables from the previous step, to explore the possibility that factors within each
model might interact. Each regression demonstrated variance
ination factor scores below ve, and tolerance statistics above
.1, indicating that multicolinearity was not a concern (Mertler &
Vannatta, 2010). Furthermore, inspection of residual histograms
and scatter plots suggested that the assumption of homogeneity
was satised.

Table 2
Beta coefcients from hierarchical regression analyses of the baseline ACT model
predicting 2-month follow-up depression scores (N 91).
Predictors from baseline

Regression step
1

Depression
ATQ-B
AAQ
PHLMS-A
AAQxPHLMS-A
R2

2
nn

.67

3
nn

.48
.01
 .28nn
.06

.51nn

.06n

.48nn
.01
 .30nn
.08
 .01
.01

Note: DepressionDASS depression subscale; ATQ-B Automatic Thoughts Questionnaire believability subscale; AAQ Acceptance and Action Questionnaire;
PHLMS-A Philadelphia Mindfulness Scale mindfulness subscale.
t
p o.10, n p o .05, nn p o .01.

Table 3
Beta coefcients from hierarchical regression analyses of the baseline ACT model
predicting 4-month follow-up depression scores (N 90).
Predictors from baseline

Depression
ATQ-B
AAQ
PHLMS-A
AAQxPHLMS-A
R2

Regression step
1

.56nn

.33nn
.06t
 .24n
.32nn

.36nn

.11nn

.33nn
.06
 .26n
.34nn
 .01
.01

Note: DepressionDASS depression subscale; ATQ-B Automatic Thoughts Questionnaire believability subscale; AAQ Acceptance and Action Questionnaire;
PHLMS-A Philadelphia Mindfulness Scale mindfulness subscale.
t
p o .10, np o .05, nnp o .01.

Table 4
Beta coefcients from hierarchical regression analyses of the baseline CT model
predicting 2-month follow-up depression scores (N 91).
Predictors from baseline

3.3. Depression regressions

Results from depression regressions are shown in Tables 25
below. When controlling for baseline depression, the baseline ACT
model in Step 2 accounted for an additional 6% of the variance in
2-month follow-up depression (p r.01), and 11% of the variance in
4-month follow-up depression (p r.01). The interaction between
the PHLMS-A and the AAQ was explored because of the possibility
that awareness in the absence of psychological exibility might
indicate excessive self-focus, whereas awareness and psychological exibility together might be a more reliably positive indication.
In Step 2, the PHLMS-A correlated positively with 4-month outcomes but had no association with 2-month outcomes, and the
interaction of awareness and psychological exibility showed a
non-signicant positive increment of 1% of the variance in both
2 and 4-month follow-up depression.
The baseline CT model in Step 2 accounted for an additional
11% (p r.01) of 2-month follow-up depression and 8% (pr .01) of
4-month follow-up depression, after accounting for baseline
depression. The added effect of the interaction of the ATQ-F and
TCQ-R was explored because the need for and amount of reappraisal might interact with the level of cognitive dysfunction, but
this term did not account for additional variance in either 2 or
4-month follow-up scores.

41

Depression
ATQ-F
DAS
TCQ-R
TCQ-RxATQ-F
R2

Regression step
1

.67nn

.23n
.22nn
 .12
 .31 t

.51nn

.11nn

.22 t
.23nn
 .13
 .32 t
.01
.00

Note: DepressionDASS depression subscale; ATQ-F Automatic Thoughts Questionnaire frequency subscale; DAS Dysfunctional Attitudes Scale; TCQ-R
Thought Control Questionnaire reappraisal subscale.
t
p o .10, n p o .05, nn p o.01.

3.4. Quality of life regressions

Results from quality of life regressions are shown in Tables 69
below. When controlling for baseline psychological quality of life,
the baseline ACT model at Step 2 accounted for a non-signicant
2% of the variance at 2-month follow-up and 8% (pr.01) of the
variance at 4-month follow-up. As with depression, awareness was
not a signicant predictor at the 2-month follow-up but was a
signicant predictor at the 4-month follow-up. The interaction
between awareness and exibility did not account for any
additional variance at the 2-month follow-up. However, at the
4-month follow-up, the interaction was a signicant (pr .05)

42

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

positive predictor, and adding this to the model accounted for an

additional 2% of the variance (pr .05).
When controlling for baseline psychological quality of life,
the baseline CT model at Step 2 accounted for 3% (pr .01) of
the variance at the 2-month follow-up and a non-signicant 2%
of the variance at 4-month follow-up. Including the interaction
of the frequency of depressogenic thoughts and cognitive reappraisal skills added nothing to the model at either 2 or 4 month
follow-ups.

Table 5
Beta coefcients from hierarchical regression analyses of the baseline CT model
predicting 4-month follow-up depression scores (N 90).
Predictors from baseline

Depression
ATQ-F
DAS
TCQ-R
TCQ-RxATQ-F
R2

.56nn

.15
.21nn
 .13
.09

.14
.22nn
 .15
.07
.01
.00

.36nn

.08nn

Table 6
Beta coefcients from hierarchical regression analyses of the baseline ACT model
predicting 2-month follow-up psychological quality of life (N 91).

Life Quality
ATQ-B
AAQ
PHLMS-A
AAQxPHLMS-A
R2

Regression step
2

.83nn

.70nn
 .01
.08n
 .05

.73nn

.02t

.70nn
.00
.08n
 .05
.00
.00

Table 7
Beta coefcients from hierarchical regression analyses of the baseline ACT model
predicting 4-month follow-up psychological quality of life (N 90).

Life Quality
ATQ-B
AAQ
PHLMS-A
AAQxPHLMS-A
R2

Regression step
1

Life Quality
ATQ-F
DAS
TCQ-R
TCQ-RxATQ-F
R2

nn

.66
 .05nn
.03
.06

.73nn

.03nn

.83

nn

.66nn
 .05nn
.03
.05
.00
.00

Note: Life Quality WHOQOL Psychological Quality of Life subscale; ATQF Automatic Thoughts Questionnaire frequency subscale; DAS Dysfunctional
Attitudes Scale; TCQ-R Thought Control Questionnaire reappraisal subscale.
t
p o .10, n p o .05, nn po .01.

Table 9
Beta coefcients from hierarchical regression analyses of the baseline CT model
predicting 4-month follow-up psychological quality of life (N 90).
Predictors from baseline

Regression step
1

Life Quality
ATQ-F
DAS
TCQ-R
TCQ-RxATQ-F
R2

.74

2
nn

.59nn

3
nn

.65
 .03t
.04
.03
.02

.65nn
 .03t
.04
.03
.00
.00

Note: Life Quality WHOQOL Psychological Quality of Life subscale; ATQF Automatic Thoughts Questionnaire frequency subscale; DAS Dysfunctional
Attitudes Scale; TCQ-R Thought Control Questionnaire reappraisal subscale.
t
p o .10, np o .05, nn p o .01.

4. Discussion

Note: Life Quality WHOQOL Psychological Quality of Life subscale; ATQB Automatic Thoughts Questionnaire believability subscale; AAQ Acceptance
and Action Questionnaire; PHLMS-A Philadelphia Mindfulness Scale mindfulness
subscale.
t
p o .10, n p o.05, nn p o.01.

Predictors from baseline

Predictors from baseline

Regression step

Note: DepressionDASS depression subscale; ATQ-F Automatic Thoughts Questionnaire frequency subscale; DAS Dysfunctional Attitudes Scale; TCQ-R
Thought Control Questionnaire reappraisal subscale.
t
p o .10, n p o.05, nn p o.01.

Predictors from baseline

Table 8
Beta coefcients from hierarchical regression analyses of the baseline CT model
predicting 2-month follow-up psychological quality of life (N 91).

Regression step
1

.74nn

.60nn
.01
.15nn
 .14nn

.59nn

.08nn

.60nn
.01
.16nn
 .15nn
.01n
.02n

Note: Life Quality WHOQOL Psychological Quality of Life subscale; ATQB Automatic Thoughts Questionnaire believability subscale; AAQ Acceptance
and Action Questionnaire; PHLMS-A Philadelphia Mindfulness Scale mindfulness
subscale.
t
p o.10, n p o .05, nn p o .01.

The primary focus of the present study was the ability of ACT
and CT process measures at baseline to predict depression and
psychological quality of life at follow-up assessments 2 and 4
months later. All of these analyses should be viewed in light of the
fact that the lengths of time between baseline and follow-up
assessments place varying constraints upon the explanatory possibilities available to measurement models once they have controlled for baseline outcome measures. This is most notable for
quality of life at the 2-month observation point, where 73% of the
variance is explained by baseline quality of life. For the 4-month
follow-up, 59% of the variance is explained by baseline life quality;
this is still a high level but allows for more contribution from the
baseline process measures. The depression scores offer somewhat
more room for the process measures to relate to outcomes with
baseline depression explaining 51% of the variance at the 2-month
follow-up, and 36% at the 4-month observation point.
One purpose of this study was to examine the scope of
relevance of the two theory-driven measurement models. Both
models successfully predicted depression at 2 and 4-month
follow-ups over and above baseline depression with similar effect
sizes. Quality of life predictions were more varied. At the 2-month
follow-up, the CT model successfully explained 3% of the variance
in life quality, while the ACT model only trended toward explaining 2% of the variance (p .09). Four-month predictions presented
quite a different picture however, as the ACT model successfully
explained 10% of the variance in quality of life, and the CT model
only trended toward explaining 2% of the variance (p .08). These
observations are fairly consistent with the developmental history
of the CT process measures, which were created with a focus on
cognitive characteristics of depression. In contrast, the ACT

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

measures were developed with a broader focus on quality of life

and a variety of health areas including depression, anxiety, PTSD
severity, trichotillomaina, parenting stress, and others (Hayes
et al., 2006; Hayes, 2008).
Another purpose of this study was to examine the predictive
utility of the conceptual distinctions drawn between the different
process measures employed. With respect to the CT model, unique
contributions from each measure would have been desirable, since
they have at least tentatively been identied with distinct levels of
cognitive systems (Segal & Swallow, 1994). While the frequency of
negative automatic thoughts performed well as measured by the
ATQ-F, no predictive utility was gained with measures of dysfunctional attitudes (DAS) or cognitive reappraisal (TCQ-R). These
mixed ndings contribute additional data to a long standing
debate regarding the primacy of dysfunctional cognitions in the
development of depressive symptoms (LaGrange et al., 2011;
Lewinsohn, Steinmetz, Larson, & Franklin, 1981). Nonetheless, the
ability of negative thought frequency to prospectively predict
depressive symptoms could be seen as supportive of the CT model.
While the reappraisal scale (TCQ-R) trended toward signicance
with regard to depression at the 2-month follow-up (p.08), the
overall performance of the measure here is similar to observations by
Wells and Davies (1994), as well as Sauer and Baer (2009), who
found no association between cognitive reappraisal and well-being in
non-clinical samples. In contrast, Reynolds and Wells (1999), found
reappraisal as measured by the TCQ to be associated with fewer
symptoms in a depressed sample. Thus, while the contents of its
items are not depression-specic it could be argued that the TCQ-R
was not very relevant to this non-clinical sample with its low
depression mean (see Table 1). There is some concern, however, that
cognitive reappraisal may actually be less effective in clinically
distressed individuals since it requires more effort than other coping
strategies (Reynolds & Wells, 1999; Vilardaga et al., 2013). The results
of the present study should not be taken to suggest that reappraisal is
not relevant to mental health, but they do suggest some constraints
on its relevance a topic of interest for future research.
Unique contributions from each of the ACT process measures
were not observed in the 2-month predictive models. However,
present moment awareness as measured by the PHLMS-A at times
demonstrated a complex relationship to mental health alongside
and in combination with psychological exibility as measured by
the AAQ. Present moment awareness could be interpreted as a
strength being positively associated with quality of life at
baseline, but it also showed itself to be a vulnerability since higher
awareness at baseline prospectively predicted lower quality of life
and higher depressive symptoms 4 months later. Examining the
content of the awareness assessment items (PHLMS-A) helps make
some sense of this from an ACT perspective. Agreement with items
such as, Whenever my emotions change, I am conscious of them
immediately, and When I am startled I notice what is going on
inside my body, could either indicate a problematic hypervigilance or skillful experiential engagement depending upon the
context of the behavior in question. This is reminiscent of the
phenomenon known to researchers of self-focused attention as
the self-absorption paradox (Trapnell & Campbell, 1999).
This possibility is strengthened by the interaction of the AAQ
and the PHLMS-A in predicting life quality at the 4-month follow-up.
The interaction shown in the present study suggests that increased
openness to experience transforms present moment sensitivity from a
vulnerability to a strength. Simultaneously, increased present moment
sensitivity enhances the positive relation between openness and life
quality. Said in another way, maximal life quality is associated not
simply with being open, or being present, but with being open and
being present. This nding is consistent with arguments that a useful
distinction is made between acceptance and awareness (Cardaciotto
et al., 2008; Hayes, Villatte, Levin, & Hildebrandt, 2011), as well as with

43

research on the relationship between self-acceptance and self-focused

attention (Harrington & Loffredo, 2010).
While ATQ-B trended toward signicance in the ACT model's
4-month prediction of depression (p .09), its overall performance
is a disappointment for the ACT model since this is intended to
measure cognitive defusion that is, a more exible relationship
to thought content. Previous studies have found the distinction
between the ATQ-F and ATQ-B scales to be useful (Zettle et al.,
2011), and other data have supported the role of defusion in the
ACT model (Levin, Hildebrandt, Lillis, & Hayes, 2012). Thus, the
present ndings may be due to the non-depressed nature of the
sample. It could be that the believability of depressive cognition
assessed in the ATQ is not particularly relevant if such cognition is
not occurring at a high rate. Further development of cognitive
defusion measures may help to clarify this issue, and in fact new
measures have been arriving (Herzberg et al., 2012).
Since the majority of research informing ACT and CT has been
conducted with distressed samples, many of their process measures
have a focus on clinical content (i.e., the ATQ-F, ATQ-B, and the DAS).
This presented a challenge for the present study since these
measures may not be relevant to a non-clinical sample. The question
of relevance is an empirical one, however, and should be of interest
given the need for expanding psychological intervention into nontraditional settings and populations (Kazdin & Blase, 2011). These
analyses therefore function to some extent to test the breadth of
relevance of the measures used. At the same time, these analyses can
have some bearing upon the ACT and CT models particularly since
some of the measures (i.e., the AAQ, the PHLMS-A, and the TCQ-R)
are not tied to specic content areas.
One should be careful not to overstate the results of this study,
as there were several notable weaknesses. First of all, the homogeneous demographics of the sample precluded the analysis of
gender, education, ethnicity, and other cultural variables as possible moderators of the observed ndings. Secondly, the non-clinical
nature of the sample and the lack of more long-term follow-up
assessments both functioned to constrict the explanatory power
available to the measurement models. It is possible as well that a
larger sample size may have provided more clarity regarding the
handful of predictions that trended toward signicance. Thirdly,
although the sample's characteristics were largely unchanged over
the course of 4 months, small but signicant changes in dysfunctional cognitions (as measured by the DAS) and cognitive reappraisal (as measured by the TCQ-R) may have somehow altered the
performance of baseline predictive models. Of course, random
variations such as these are likely to be found in any longitudinal
study. Replications of the patterns of observations found in this
study will be essential to assess the long-term utility of the
suggested interpretations.
Since no independent variables were manipulated in this study,
it does not allow for attributions of causality or comparative claims
regarding ACT and CT interventions. Nonetheless, longitudinal
studies such as this one provide a way to identify and test common
and core processes related to mental health and quality of life.
Hopefully this on-going process will help to rene the extension of
psychosocial interventions outside of clinical contexts such as in
educational settings where job demands may make nding time
for traditional therapy difcult. Without proper support, educators
can turn to less effective means of coping (Watts & Short, 1990)
contributing to a high turn-over rate in the profession (Norton,
1999). While there is preliminary evidence that ACT can be
usefully extended in workbook form to this population (Jeffcoat
& Hayes, 2012), care must be taken with the targeting of
mental health processes in non-clinical samples. For example,
this study suggests that present moment sensitivity is one process
that can relate to mental health outcomes in dynamic and
unexpected ways.

44

D.M. Long, S.C. Hayes / Journal of Contextual Behavioral Science 3 (2014) 3844

Despite its limitations, this longitudinally assessed non-clinical

sample served to test the range of relevance of popularly administered process measures. Furthermore, these analyses served to
evaluate the utility of conceptual distinctions within the ACT and
CT models regarding their different outcomes of primary interest
and component processes. These data contain strengths and
weaknesses for each model, but they are generally supportive of
each when tested within each model's assumptions. Future
research should further explore the breadth of relevance of these
models as well as conditions under which their component
processes interact. In particular, the possibility that present
moment sensitivity can change from vulnerability into an asset
through interaction with experiential openness, as suggested in
these ndings, poses an exciting agenda for intervention and
longitudinal research in the area of mindfulness and acceptance.
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