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Validation of a Spanish version of the Brief Experiential Avoidance Questionnaire (BEAQ) in clinical population.

Experiential avoidance has been defined as "the phenomenon that occurs when a person does not want to remain in contact with particular private experiences (e.g. bodily sensations, emotions, thoughts, memories, images, behavioral predispositions) and takes steps to alter the form or frequency of those experiences or the contexts that produce them" (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, p. 1154).

The importance of this construct is supported by research finding experiential avoidance to be a major factor in the development and maintenance of psychopathology. Several studies have pointed to the association between more experiential avoidance and greater interpersonal problems, as well as more severe psychopathology (Garcia Montes, Luciano Soriano, Hernandez Lopez, & Zaldivar Basurto, 2004; Gerhart, Baker, Hoerger, & Ronan, 2014; Hershenberg, Mavandadi, Wright, & Thase, 2017; Kroska, Miller, Roche, Kroska, & O'Hara, 2018; Mellick, Vanwoerden, & Sharp, 2017; Skinner, Rojas, & Veilleux, 2017; Spinhoven, Drost, de Rooij, van Hemert, & Penninx, 2015; Wagener, Baeyens, & Blairy, 2016). In addition, less experiential avoidance is associated with better well-being and quality of life (Alvarez Diaz & Esteve Zarazaga, 2009; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Jacob, Ower, & Buchholz, 2013; Kashdan, Barrios, Forsyth, & Steger, 2006).

The first instrument developed to measure experiential avoidance was the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004). A second version of this questionnaire, the Acceptance and Action Questionnaire II (AAQII; Bond et al., 2011), was developed after the AAQ received criticism, especially concerning its low internal consistency (Cronbach's alpha <70), inadequate distinction between process and result (Chawla & Ostafin, 2007), and poor discriminant validity with measures of negative affect and neuroticism.

However, this second version has also been criticized for insufficient discriminant validity withmeasures of negative affect and neuroticism, especially in clinical samples (Gamez, Chmielewski, Kotov, Ruggero, Suzuki, & Watson, 2014). Thus, the AAQII is more correlated with measures of neuroticism and negative affect than with the AAQ or other avoidance measures (Gamez, Chmielewski, Kotov, Ruggero, & Watson, 2011). According to these authors, this is observed in the item content, which focuses, for example, on failed attempts at controlling discomfort and its consequences (e.g., "emotions cause problems in my life"; "worries get in the way of my success"). This can lead to criterion contamination (Gamez et al., 2011), since it confuses process with result.

Another criticism of both scales (AAQ and AAQII) is that the authors initially conceptualized them as measures of experiential avoidance, but later redefined their scope as psychological inflexibility. This construct includes some aspects of experiential avoidance, but also other concepts, such as cognitive fusion, lack of contact with values, lack of committed action and attention to the present (Bond et al., 2011), thereby exceeding the content of the experiential avoidance variable (Gamez et al., 2011).

The Multidimensional Experiential Avoidance Questionnaire (MEAQ; Gamez et al., 2011) was designed to overcome the limitations of both versions of the AAQ. It was intended as a comprehensible and reliable measure of experiential avoidance, differentiated from neuroticism. However, its length (62 items) made its applicability difficult in contexts where time is limited. The Brief Experiential Avoidance Questionnaire (BEAQ; Gamez et al., 2014) emerged as a brief, but still effective questionnaire. Its authors pointed out that this instrument manages to reduce the application time from 12 minutes on the full scale (MEAQ) to 3 minutes. In addition, it covers content similar to the MEAQ and both scales show practically the same convergent and discriminant association. Because of the limitations of those already mentioned above (AAQ, AAQII and MEAQ), it has been suggested that this brief version, the BEAQ, is the most appropriate instrument for measuring experiential avoidance (Wolgast, 2014). However, no Spanish validation has yet been published.

Due to the relevance of the experiential avoidance construct and its negative association with wellbeing and health measures, we consider the validation of this instrument in Spanish population to be of great importance. The purpose of the present research was to analyze the psychometric properties of a Spanish version of the BEAQ in a clinical sample.

Method

Participants

The sample consisted of 332 patients treated in a community mental health unit. It included 228 women (69%) and 104 men (31%). All the participants were Caucasian and were aged between 18 and 78 years (M = 45.97, SD = 12.44). The inclusion criteria were: 1) have been diagnosed with a mental disorder according to ICD-10 (World Health Organization, 1992), specifically those corresponding to Depressive Disorder (F32.0, F32.1, F33.0 and F33.1), Dysthymia (F34.1), Anxiety Disorder (F40 and F41), Obsessive-Compulsive Disorder (F42), Adjustment disorders (F43), Eating Disorder (F50) and Personality Disorder (F60); 2) be of legal age; 3) have no cognitive impairment; 4) give their voluntary consent to participation in the study. Other sociodemographic and clinical data appear in Table 1.

Instruments

Brief Experiential Avoidance Questionnaire (Gamez et al., 2014). This is a self-report questionnaire with 15 items that measure experiential avoidance. The items are rated on a 6-point Likert scale (l="strongly disagree" to 6="strongly agree"). The scores range from 15 to 90 points (item 6 must be inverted), with higher scores showing greater experiential avoidance. In its original version, the BEAQ shows association with measures of avoidance, psychopathology and quality of life, as well as it shows strong convergence with each of the six dimensions of the MEAQ (Gamez et al., 2011), the original scale which the items for this short version were extracted from. The English version has good reliability, with a Cronbach's alpha of .80 to .89 for the various samples.

Acceptance and Action Questionnaire II (Bond et al., 2011). This is a self-report scale with seven items measuring experiential avoidance. The items evaluate unwillingness to experience unwanted emotions, thoughts and feelings and the inability to act according to values on a 7-point Likert scale (l="never true" to 7="always true"). Scores range from 7 to 49, with higher scores showing higher experiential avoidance. The Spanish version used (Ruiz, Langer Herrera, Luciano, Cangas, & Beltran, 2013) has acceptable internal consistency, with a Cronbach's alpha of .75 for a sample of clinical patients.

Symptoms Checklist-90-Revised (SCL-90-R; Derogatis, 1977). This self-report scale is composed of 90 items covering a wide variety of psychopathological manifestations. The nine dimensions evaluated are somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. The results offer a symptomatic profile as well as three global indexes: global severity index, total positive symptoms and positive symptom distress index. The items are scored on a scale of 5-point Likert scale (0 ="not at all" to 4 ="very or extremely"), based on the intensity with which a series of symptoms were experienced during the previous week. The Spanish adaptation used (Gonzalez de Rivera, de las Cuevas, Rodriguez-Abuin, & Rodriguez-Pulido, 2002) has a Cronbach's alpha coefficient of .94 for the 90 elements included in the test.

Procedure

First, following guidelines for test validation (Muniz, Elosua, & Hambleton, 2013), authorization was requested from the main author of the BEAQ scale for its translation and validation in a Spanish sample. With his permission, it was translated into Spanish by the reverse translation method. This scale was applied to a pilot sample of six patients to make sure they understood it, and it was unnecessary to make any changes in the items. Due to the length of the questionnaire, the SCL-90-R was applied only to the first 112 participants. This research was approved by the Andalusian Biomedical Research Ethics Committee.

Data analysis

First, the Kaiser-Meyer-Olkin and the Barlett's sphericity test analysis were performed to find out whether the items were correlated and adequate for factor analysis. To determine the factor loadings, an analysis of principal component analysis was carried out, specifying a one-factor solution as proposed by the authors of the original scale.

Furthermore, a descriptive analysis of the items on this Spanish version of the BEAQ was carried out by calculating measures of central tendency and dispersion. Skewness and kurtosis were calculated as well to determine the behavior of the data found from the questionnaire. Next, the normal distribution of data was checked with the Kolmogorov-Smirnov test of normality. The Student's t test was also calculated for any possible gender differences in the scores.

Internal consistency of the BEAQ was then calculated using the Cronbach's alpha coefficient, and Omega coefficient was used to examine its factorial reliability (Dunn, Baguley, & Brunsden, 2014; Elosua & Zumbo, 2008; Ventura-Leon & Caycho-Rodriguez, 2017). In addition, temporal reliability was analyzed with the Pearson's r correlation of the measure at two different times four to six weeks apart. Finally, the instrument's sources of validity were analyzed (Muniz, 2018). First, the concurrent validity of the BEAQ with the AAQII was calculated, using the Pearson's r correlation coefficient. An analysis of convergent validity of experiential avoidance with the SCL-90-R, a general psychopathology measure, was performed using the Pearson's correlation. Specific correlation with the global severity index, as well as with five of its subscales (anxiety, depression, phobic anxiety, somatization and obsessive-compulsive), were also explored. Statistical analyses were performed using SPSS v.21.

Results

Sources of validity evidence of internal structure

The Kaiser-Meyer-Olkin test for sample adequacy (KMO = .83) and the Barlett's sphericity test ([X.sup.2] = 1251.87, p < .01) both confirmed adequacy of the sample data for factor analysis. A principal component analysis was done, forcing a one-factor solution, as proposed in the original scale. The first five eigenvalues were 4.52, 1.57, 1.11, 1.08 and .94 The component extracted explained 30.12% of the variance. Table 2 shows the saturation of each item on this single component.

Descriptive statistics

The descriptive characteristics of the BEAQ in the sample are presented in Table 3. The Kolmogorov-Smirnov normality test confirmed that the distribution of the BEAQ scores followed a normal distribution, at a significance level over .05 (Z= .864, p = .445).

The Student t test for independent samples showed absence of significant differences in the scores on experiential avoidance (t = .103, p = .92) between women (M = 55.54, SD = 13.40) and men (M= 55.72, SD = 15.04). The effect size, calculated by Cohen's d, was insignificant (d = 0.013).

Reliability of the scores

Internal consistency. The Cronbach's alpha was .82, which shows high internal consistency of the instrument. Table 4 shows the means and variance in the scale if the item was eliminated, as well as the corrected item-total correlation and Cronbach's alpha when each item of the scale is eliminated. The corrected item-total correlation was over .35 for 13 of the 15 items, which is adequate and significant according to Cohen and Manion (1989). The two exceptions were Items 3 and 6, which had a correlation with the total scale of r = .24 and r = .21, respectively. Because of these results, the Cronbach's alpha was calculated for the scale after eliminating these items. By eliminating Item 3, Cronbach's alpha remained at .82 and only rose slightly when Item 6 was eliminated, from .82 for the total items to .83. In no case would eliminating any of the remaining items improve the Cronbach's alpha for the total scale. Omega index was .86, also supporting the adequate factorial reliability of the scale.

Temporal reliability. The results showed a high positive correlation (r = .70, p < .01) between the BEAQ before and after an interval of 4-6 weeks (N = 48). This shows high temporal reliability of the Spanish version of the instrument with a clinical population.

Sources of validity evidence in relation with other variables

The concurrent validity between the BEAQ and the AAQII, analyzed using the Pearson's correlation, was significant with r = .67 (p < .01). To analyze the convergent validity of the BEAQ experiential avoidance scale with other psychopathology measures, both the symptom inventory SCL-90-R (Derogatis, 1977) global severity index, and five of that instrument's subscales (anxiety, depression, phobic anxiety, somatization and obsession-compulsion) were used. The Pearson correlation analyses for the indicators above showed significant correlations for the global BEAQ score in all cases. The results are shown in Table 5

Appendix

Brief Experiential Avoidance Questionnaire

Please indicate the extent to which you agree or disagree with each of the following statements (1= Strongly disagree; 6= Strongly agree)

1. The key to a good life is never feeling any pain [La clave para vivir bien es no sentir nunca ningun dolor]

2. I'm quick to leave any situation that makes me feel uneasy [Rapidamente dejo cualquier situacion que me haga sentir mal]

3. When unpleasant memories come to me, I try to put them out of my mind [Cuando se me vienen a la mente recuerdos desagradables, trato de desecharlos]

4. I feel disconnected from my emotions [Me siento desconectado/a de mis emociones]

5. I won't do something until I absolutely have to [No me pongo a hacer algo hasta que no me veo totalmente obligado/a a hacerlo]

6. Fear or anxiety won't stop me from doing something important [El miedo o la ansiedad no me impediran hacer las cosas importantes]

7. I would give up a lot not to feel bad [Renunciaria a muchas cosas con tal de no sentirme mal]

8. I rarely do something if there is a chance that it will upset me [Dificilmente hago algo si hay alguna posibilidad de que me desagrade]

9. It's hard for me to know what I'm feeling [Es dificil para mi saber lo que estoy sintiendo]

10. I try to put off unpleasant tasks for as long as posible [Trato de retrasar todo lo posible las tareas que son desagradables]

11. I go out of my way to avoid uncomfortable situations [Me esfuerzo en evitar situaciones desagradables]

12. One of my big goals is to be free from painful emotions [Uno de mis mayores objetivos es estar libre de cualquier emocion dolorosa]

13. I work hard to keep out upsetting feelings [Me esfuerzo mucho para evitar las sensaciones desagradables]

14. If I have any doubts about doing something, I just won't do it [Si tengo cualquier duda al hacer una cosa, dejo de hacerla]

15. Pain always leads to suffering [El dolor siempre lleva al sufrimiento]

Discussion

The results of this study show adequate psychometric properties of the Spanish adaptation of the BEAQ in a clinical population and advise its use as a measure of experiential avoidance in this context. Furthermore, in general terms, it could be said that this adaptation achieves psychometric characteristics similar to those reflected by the authors in the original English version of the BEAQ (Gamez et al., 2014).

The mean of the total score in the Spanish sample is 55.60. This is very similar to the two clinical samples analyzed with the original English instrument (M= 56.41 and M= 52.03, respectively). The standard deviation (SD = 13.92) is also similar to the original instrument (SD = 12.64 and SD = 12.23, respectively).

This Spanish adaptation has good internal consistency ([alpha] = .82), which in turn is similar to the [alpha] = .83 found by Gamez et al. (2014) in their clinical population. This result supports the homogeneity of the scale and the contribution of all the items to the measurement of the experiential avoidance construct in the Spanish version analyzed.

However, if the correlation of each item with the total scale is analyzed in detail, lower scores are observed on Items 3 and 6, with correlations of .24 and .21, respectively, when .35 is considered advisable for significant correlation with the total scale (Cohen & Manion, 1989). This suggests lower contribution of the items to the construct to be measured. Item 3 contains the statement "When unpleasant memories come to me, I try to put them out of my mind". Because of this non-significant correlation, the internal consistency of the scale was tested again without Item 3, but the Cronbach's alpha for the scale did not increase, remaining at .82. So the item was kept to maintain the greatest possible similarity with the original scale.

The Cronbach's alpha for the scale was also analyzed without Item 6, "Fear or anxiety won't stop me from doing something important". However, as it only increased slightly from .82 to .83, it was decided to keep Item 6 for its content representation, as did the authors of the BEAQ.

The temporal reliability of the BEAQ, after 4 to 6 weeks was high (r = .70, p < . 01), showing that its measure of the experiential avoidance construct is stable over time. This contribution of temporal reliability is of special interest because there is no information on it in the original English version.

Concurrent validity of the BEAQ is shown by its significant correlation with another avoidance measure, the AAQII (r = .67, p < .01). In the original English version, they found a significant correlation between these two scales in their sample of students (r = .61, p < .01), and a non significant correlation in the two samples of patients (r = .62 and r = .63, respectively). However, despite the fact that the correlation is not significant in any of these two samples, the authors of the original version concluded that the BEAQ's correlation with other avoidance measures was stronger than its correlation with other measures of negative emotionality. It should be recalled that this was one of their main objectives, specifically, that the instrument should be a reliable and valid measure of experiential avoidance differentiated from other associated constructs, such as neuroticism. Thus, it may be concluded that in this study, the data also support the validity of the BEAQ as a measure of experiential avoidance by confirming its correlation with another measure of experiential avoidance, the AAQII.

In relation to the convergent validity of the BEAQ with the measures of psychopathology measured by the SCL-90-R, it is noteworthy that all were significant at p <. 01. This is also consistent with the result for the original scale. In their study, Gamez et al. (2014) pointed out robust relationships between the BEAQ and various scales of psychopathology, among which are measures of depression, situational phobia and obsession-compulsion.

Based on these results, it may be observed, as in the original instrument, that the BEAQ showed moderate correlations with indicators of negative emotionality (mean r = .39), but stronger correlation with a measure of experiential avoidance (r = .67). Thus, the Spanish adaptation also achieves the objective of the authors of the original instrument of measuring experiential avoidance as discriminated from negative emotionality. These results therefore support the validity of the BEAQ as a measure of the experiential avoidance construct.

The results of factor analysis were similar to those for the English version. Using principal compoment analysis and forcing one factor like the original scale, 30.12% of the variance was explained. This percentage is very similar to the one presented by Gamez et al. (2014), who reported 28.98% as the variance explained by the factor. The first five eigenvalues in the Spanish sample were 4.52, 1.57, 1.11, 1.08 and .94, respectively.

Similar to this study, in a first sample of patients who were administered the English version, Item 6 had the lowest factor loading, which was -.33. The rest of the factor loadings were .38 to .63. It might be thought that because Item 6 was included to cover specific content in the MEAQ questionnaire, despite having an initial factor loading of less than .40, this means that in our sample the same trend is maintained, and that therefore, the loading on the factor is lower. On the other hand, Item 3, "When unpleasant memories come to me, I try to put them out of my mind ", also had a lower factor loading (.33) than the rest of the 13 items with significant loadings. This coincides with the findings by Gamez et al. (2014), who also found this item to have one of the lowest factor loadings. But in this case, it was significant. In view of the results above, we can affirm that the scale fits to the one-factor solution, similar to the one proposed by the authors of the original version.

Regarding limitations, it should be noted that the data was collected exclusively through self-reported measures, so they are vulnerable to possible biases associated with the use of a single method (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). Thus, it would be important to validate the BEAQ data with those found by other methods, such as professional evaluation of the patient concerning the experiential avoidance construct. Another limitation was the non-randomized sample. Therefore, the sample could not be representative of the Spanish population with clinical disorders. Moreover, the diagnosis is not based on a structured interview, but on the clinical judgement of a clinical psychologist or psychiatrist after a clinical interview based on the ICD-10 diagnostic criteria. Besides, the study does not use an infrequency response scale to identify dishonest or non-compliant participants.

Future research should confirm the factor structure with confirmatory factor analysis in a larger sample. In addition, the psychometric characteristics of the present scale should be studied in a Spanish clinical population with other psychopathological disorders, as well as in the general population.

In view of the results of this study, we can conclude by highlighting the adequate psychometric characteristics of this Spanish adaptation of the BEAQ. These good results support the use of the BEAQ as an instrument for measuring experiential avoidance in a Spanish clinical population, and is therefore a relevant contribution providing a short form (approximately 3 minutes) of the instrument considered the most appropriate at present for measuring experiential avoidance (Wolgast, 2014) in various clinical contexts. This enables its administration in care contexts where time management and limited resources prioritize instruments that take a short time for their application.

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Raquel Vazquez-Morejon (1), Jose Maria Leon Rubio (1), Agustin Martin Rodriguez (1), and Antonio J. Vazquez Morejon (2)

(1) Universidad de Sevilla and (2) Hospital Universitario Virgen del Rocio

Received: March 2, 2019 (*) Accepted: May 17, 2019

Corresponding author: Raquel Vazquez-Morejon

Departamento de Psicologia Social Universidad de Sevilla 41018 Sevilla (Spain)

e-mail: vazquezraquel@us.es

doi: 10.7334/psicothema2019.60
Table 1 Sociodemographic information (N = 332)

Variables                                           N    %

Marital Status
Single                                              109   32.8
Married/domestic partner                            147   44.3
Separated/Divorced                                   45   13.6
Widowed                                               6    1.8
Unknown                                              25    7.5
Total                                               332  100
Educative level
Primary school                                       37   11.1
Secondary School                                     44   13.3
Secondary school certificate/Professional training   92   27.7
University                                          126   38
Unknown                                              33    9.9
Total                                               332  100
Employment
Working                                             169   50.9
Unemployed                                           67   20.3
Pensioned                                            20    6
Retired                                               6    1.8
Student                                              27    8.1
Homemaker                                            20    6
Other                                                23    6.9
Total                                               332  100
Primary Diagnostics
Depression                                           41   12.3
Anxiety                                             117   35.3
Adjustment Disorder                                 125   37.7
Eating Disorder                                      30    9
Personality Disorder                                 19    5.7
Total                                               332  100

Table 2 Saturation for the items on the BEAQ after principal component
analysis for a one-factor solution (N = 332)

Item No  Factorial loadings

 1       .55
 2       .56
 3       .33
 4       .43
 5       .55
 6       .26
 7       .57
 8       .61
 9       .44
10       .68
11       .61
12       .71
13       .57
14       .63
15       .56

Table 3 Descriptive statistics (N = 332)

Item No BEAQ  Mean   SD     Skewness  Kurtosis

 1             3.24   1.84   0.10     -1.48
 2             3.55   1.70  -0.08     -1.30
 3             4.00   1.64  -0.36     -1.09
 4             2.78   1.75   0.47     -1.24
 5             3.64   1.85  -0.12     -1.46
 6             3.45   1.85   0.05     -1.47
 7             4.12   1.74  -0.54     -1.07
 8             3.32   1.70   0.11     -1.31
 9             3.43   1.84   0.01     -1.45
10             4.09   1.74  -0.50     -1.10
11             4.46   1.56  -0.82     -0.44
12             4.03   1.71  -0.45     -1.10
13             4.14   1.53  -0.49     -0.82
14             3.17   1.67   0.28     -1.16
15             4.17   1.81  -0.50     -1.21
Total         55.60  13.92  -0.24     -0.27

Table 4 Internal consistency, item-total statistics (N= 332)

                     Scale
Item No  Scale mean  variance    Corrected    Cronbach's
BEAQ     if item is  if item is  total-item   alpha if item
         deleted     eliminated  correlation  is eliminated

 1       52.36       168.91      .45          .81
 2       52.05       170.17      .46          .81
 3       51.60       180.22      .24          .82
 4       52.82       173.54      .37          .82
 5       51.96       167.94      .47          .81
 6       52.15       179.64      .21          .83
 7       51.48       169.55      .47          .81
 8       52.28       168.84      .50          .81
 9       52.17       172.99      .36          .82
10       51.51       164.95      .58          .80
11       51.14       171.08      .50          .81
12       51.57       164.22      .61          .80
13       51.46       173.40      .45          .81
14       52.43       167.94      .53          .81
15       51.42       168.77      .46          .81

Table 5 Convergent validity. Pearson correlations between BEAQ and
SCL-90-R global severity index and subscales

SCL-90-R               N    BEAQ

Anxiety                112  .34 (**)
Depression             110  .46 (**)
Phobic anxiety         110  .35 (**)
Somatization           109  .27 (**)
Obsesive-Compulsive    109  .43 (**)
Global Severity Index   96  .48 (**)

(**) p<.01
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Author:Vazquez-Morejon, Raquel; Rubio, Jose Maria Leon; Rodriguez, Agustin Martin; Morejon, Antonio J. Vazq
Publication:Psicothema
Date:Jul 1, 2019
Words:5158
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