Acceptance and Action Questionnaire (AAQ-II)

1. Abstract

The Acceptance and Action Questionnaire-II (AAQ-II) is an extensively utilized psychometric instrument developed to evaluate experiential avoidance and psychological inflexibility, core transdiagnostic constructs embedded within Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT). Originating as a psychometrically refined revision of the original Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004), the AAQ-II was developed by Bond et al. (2011) to address the unstable factor structures, modest internal consistency, and complex cross-loadings observed in its predecessor. The canonical AAQ-II comprises 7 items scored on a 7-point Likert scale ranging from 1 (never true) to 7 (always true), yielding a single unifactorial composite score ranging from 7 to 49, where higher scores reflect greater levels of psychological inflexibility and experiential avoidance.

Psychometric evaluations across diverse non-clinical, clinical, student, and multinational work samples demonstrate robust internal consistency, with Cronbach’s alpha typically ranging between .84 and .90, alongside satisfactory test-retest reliability across 3-month and 12-month intervals (r = .81 and .79, respectively). Exploratory and confirmatory factor analyses robustly support a unidimensional latent structure across clinical and community populations. Concurrently, a salient contemporary psychometric debate centers on its discriminant validity; empirical investigations (e.g., Wolgast, 2014; Tyndall et al., 2019) suggest substantial conceptual and statistical overlap with neuroticism, general psychological distress, and negative affectivity. Despite these critical debates, the AAQ-II remains a benchmark outcome measure, mediator, and assessment tool across clinical trials, occupational health assessments, and experimental psychopathology research worldwide.

2. Keywords

Acceptance and Action Questionnaire, AAQ-II, psychological inflexibility, experiential avoidance, Acceptance and Commitment Therapy, psychometrics, Relational Frame Theory, emotional distress, construct validity, psychological flexibility

3. Authors

The Acceptance and Action Questionnaire-II was developed by an international consortium of prominent clinical psychologists and behavioral scientists, led by:

• Frank W. Bond, Ph.D. — Professor of Psychology, Department of Psychology, Goldsmiths, University of London, United Kingdom.
• Steven C. Hayes, Ph.D. — Foundation Professor Emeritus, Department of Psychology, University of Nevada, Reno, United States; originator of Acceptance and Commitment Therapy and Relational Frame Theory.
• Ruth Baer, Ph.D. — Professor Emeritus of Psychology, Department of Psychology, University of Kentucky, United States.
• Kelly G. Wilson, Ph.D. — Professor of Psychology, Department of Psychology, University of Mississippi, United States.
• Richard E. Drake, Ph.D. — Research Psychologist, Department of Psychology, Goldsmiths, University of London, United Kingdom.
• David Bunce, Ph.D. — Professor of Cognitive Neuroscience, School of Healthcare, University of Leeds, United Kingdom.
• Lillian Zettle, Ph.D., and Mikael Strosahl, Ph.D. — Central contributors to contextual behavioral science and ACT instrument validation.

4. Purpose

The primary purpose of the Acceptance and Action Questionnaire-II is to quantify the degree to which an individual exhibits experiential avoidance and psychological inflexibility. Within contextual behavioral science, experiential avoidance is defined as an individual’s unwillingness to remain in contact with particular private experiences (such as bodily sensations, emotions, cognitions, memories, and behavioral predispositions) accompanied by concerted efforts to alter the form, frequency, or situational sensitivity of these events, even when doing so leads to significant behavioral disruption or prevents valued living.

Psychological inflexibility represents the overarching transdiagnostic phenotype characterized by rigid psychological dominance of private experiences over personally chosen values and committed actions. Rather than tracking the presence or absence of specific clinical symptoms—such as the frequency of panic sensations, vegetative depressive symptoms, or obsessive intrusions—the AAQ-II was purpose-built to capture an individual’s functional relationship to their internal experiences. By assessing whether difficult internal experiences prevent engagement with meaningful, life-enhancing activities, the scale operates as a transdiagnostic measurement tool across diverse behavioral and psychiatric spectra.

In clinical contexts, the AAQ-II serves multiple functions: as a diagnostic screening mechanism for psychological rigidity, as a baseline index of transdiagnostic vulnerability, and as a repeated-measures tracking device across the course of psychotherapy. Because contextual therapies posit that psychological inflexibility mediates symptom reduction and functional recovery, clinicians employ the instrument to determine whether therapeutic interventions successfully decouple private distress from behavioral inaction. In research applications, the instrument is widely deployed in randomized controlled trials (RCTs) investigating the efficacy of mindfulness-based and acceptance-based protocols, in organizational occupational health studies examining employee absenteeism and burnout, and in health psychology paradigms tracking how patients adjust to chronic somatic conditions, including chronic pain, oncological diagnoses, and cardiovascular illnesses.

5. Psychological Construct

The psychological construct assessed by the AAQ-II is fundamentally anchored in the unified transdiagnostic model of psychopathology formulated within Contextual Behavioral Science. Specifically, the instrument quantifies psychological inflexibility along two deeply intertwined and functional dimensions: experiential avoidance and inaction/behavioral immobility.

Experiential Avoidance

Experiential avoidance occurs when an individual evaluates unwanted internal experiences—such as negative affect, distressing memories, or visceral sensations—as inherently dangerous, intolerable, or catastrophic, and subsequently attempts to escape, suppress, or modify them. For instance, item 2 (“I’m afraid of my feelings“) and item 5 (“Emotions cause problems in my life“) illustrate the cognitive appraisal of emotional states as threatening agents requiring defensive posturing. The process does not merely involve normal cognitive or emotional regulation; rather, it reflects a rigid, context-insensitive reliance on suppression and avoidance strategies that paradoxically amplify autonomic arousal and intrusive cognitions over time.

Cognitive Fusion and Dominance of the Conceptualized Past and Future

A central facet contributing to experiential avoidance is cognitive fusion—the tendency for human beings to become entangled with the literal content of their thoughts. Under conditions of high fusion, verbal constructions are responded to as if they were physical realities. Within the AAQ-II, item 4 (“My painful memories prevent me from having a fulfilling life“) and item 3 (“I worry about not being able to control my worries and feelings“) reflect an inability to detach from ruminative verbal rules, allowing historical narratives and prospective catastrophic worries to dictate present-moment functioning.

Inaction, Impoverished Values, and Behavioral Stagnation

The counterpart to avoidance is behavioral stagnation—the failure to execute values-directed actions in the presence of psychological discomfort. Within this construct, psychological inflexibility is manifest when behavioral persistence or switching depends on whether internal discomfort is present. Item 1 (“My painful experiences and memories make it difficult for me to live a life that I would value“) and item 7 (“Worries get in the way of my success“) measure the functional cost of experiential avoidance, capturing the cessation of purposeful, self-congruent living. Instead of pursuing meaningful occupational, interpersonal, or personal trajectories, the individual’s behavioral repertoire becomes constricted around avoiding dysphoria.

6. Theoretical Framework

The AAQ-II is rooted in two intersecting theoretical frameworks: Relational Frame Theory (RFT), a modern post-Skinnerian account of human language and cognition, and the Acceptance and Commitment Therapy (ACT) model of human suffering.

Relational Frame Theory (RFT) Foundations

RFT posits that the core of human language involves arbitrarily applicable relational responding—the capacity to learn that two or more stimuli are related based on arbitrary cues rather than purely physical properties. Through bidirectional derived relational responding and the transformation of stimulus functions, words, thoughts, and memories can evoke the exact same physiological, emotional, and behavioral reactions as the direct physical events they represent. Consequently, a verbal thought such as “I am unlovable” or a memory of a traumatic experience acquires painful psychological properties. Because humans cannot easily eliminate their derived relational networks without profound neurological impairment, efforts to deliberately extinguish, forget, or suppress these verbal networks inevitably backfire, transforming internal life into an inescapable battleground.

The ACT “Hexaflex” Model

ACT conceptualizes psychological health along a dimensional continuum between psychological flexibility and psychological inflexibility, modeled across six interconnected core processes (the Hexaflex):

• Cognitive Fusion vs. Cognitive Defusion: Responding to thoughts as objective truths versus recognizing them as ongoing verbal processes.
• Experiential Avoidance vs. Acceptance: Unwillingness to feel negative private events versus active, non-judgmental openness to experiencing them.
• Dominance of the Conceptualized Past/Future vs. Flexible Contact with the Present Moment: Compulsive rumination or anticipatory dread versus conscious, mindful engagement with the ‘here and now’.
• Attachment to the Conceptualized Self (Self-as-Content) vs. Self-as-Context: Rigidly defining oneself by static self-evaluations versus adopting a stable, observing perspective on internal phenomena.
• Lack of Values Clarity vs. Defined Values: Operating via societal compliance or avoidance of pain versus intentionally delineating chosen directions.
• Inaction, Impulsivity, or Avoidant Persistence vs. Committed Action: Behavioral paralysis or self-defeating habits versus flexible, persistent engagement in value-congruent activities.

The AAQ-II was designed to serve as an aggregate index reflecting the negative pole of these interrelated processes: an individual stuck in experiential avoidance, fused with catastrophic verbal evaluations, disconnected from core values, and trapped in behavioral stagnation.

7. Validity

The validity of the AAQ-II has been investigated in psychometric studies spanning clinical, occupational, college, and cross-cultural environments. The instrument exhibits complex convergent, concurrent, and predictive validity profiles, accompanied by intense scrutiny regarding its discriminant validity.

Construct and Convergent Validity

In the seminal psychometric validation across multiple samples totaling 2,816 participants, Bond et al. (2011) established that the AAQ-II exhibits substantial convergent correlations with established measures of emotional distress and psychological vulnerability. The AAQ-II correlates strongly and positively with the Beck Depression Inventory-II (BDI-II) (r = .71 to .76), the Beck Anxiety Inventory (BAI) (r = .56 to .58), and the Global Severity Index (GSI) of the Symptom Checklist-90-Revised (SCL-90-R) (r = .63 to .74). Moreover, it demonstrates robust inverse relationships with measures of psychological well-being, including the Satisfaction with Life Scale (SWLS; r = -.50 to -.57) and the mental health summary component of the SF-36 (r = -.61 to -.65).

Predictive and Incremental Validity

Longitudinal studies demonstrate that baseline scores on the AAQ-II predict prospective alterations in depressive symptom severity, occupational absenteeism, and work performance over 3 to 12 months, even after controlling for baseline distress and general cognitive ability. In clinical outcome trials, changes in AAQ-II scores mediate symptomatic recovery across anxiety disorders, major depressive disorder, and chronic pain disability, validating its theoretical role as a functional mechanism of therapeutic change.

The Discriminant Validity Debate: Inflexibility or Neuroticism?

Despite its widespread adoption, the AAQ-II has faced notable psychometric critiques concerning discriminant validity. In a landmark paper, Wolgast (2014) demonstrated that AAQ-II items exhibit substantial conceptual overlap with items measuring general negative affectivity, depression, and neuroticism. Subsequent empirical evaluations (e.g., Rochefort et al., 2018; Tyndall et al., 2019) revealed that the latent construct measured by the AAQ-II correlates exceptionally highly with neuroticism as assessed by the NEO Personality Inventory (r = .70 to .85). In confirmatory factor analyses, models modeling AAQ-II items and neuroticism/distress items under a single general distress factor frequently demonstrate acceptable fit, leading several psychometricians to argue that the AAQ-II acts more as an index of subjective distress and negative affect than as a pure measure of the distinct behavioral process of experiential avoidance. These observations led to the development of alternative measures, such as the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT) and the Multidimensional Psychological Flexibility Inventory (MPFI).

8. Reliability

The reliability of the AAQ-II has been thoroughly established through classical test theory metrics, item response theory calibrations, and longitudinal test-retest analyses across multiple international cohorts.

Internal Consistency

In the original series of validation studies conducted across six distinct samples by Bond et al. (2011), the mean Cronbach’s alpha across samples was .84 (range = .78 to .88). Subsequent large-scale international validations have reaffirmed these findings: Spanish translations have yielded alpha coefficients between .87 and .91; German cohorts have demonstrated alphas between .84 and .89; Italian, Dutch, and Portuguese versions report alphas consistently exceeding .85; and clinical psychiatric inpatient cohorts regularly produce internal consistency estimates between .88 and .92. McDonald’s omega hierarchical ($\omega_h$) and categorical omega ($\omega_c$) estimates typically mirror these figures ($\omega > .86$), confirming high internal scale homogeneity.

Test-Retest Reliability

Longitudinal stability indices demonstrate that the AAQ-II captures a relatively stable dispositional style in the absence of targeted therapeutic intervention, while remaining sensitive to clinical change following treatment. Bond et al. (2011) reported a 3-month test-retest correlation coefficient of $r = .81$ ($p < .001$) and a 12-month test-retest coefficient of$r = .79$ ($p < .001$). In non-clinical collegiate control groups across 2- to 8-week intervals, intraclass correlation coefficients (ICCs) regularly range between .78 and .85, indicating solid temporal stability.

9. Factor Analysis

The factorial structure of the AAQ-II represents a major evolutionary advance over the original AAQ-16 and AAQ-9 instruments, which were frequently plagued by unstable multidimensionality, divergent factor loadings across populations, and poor item stability.

Exploratory Factor Analysis (EFA)

During the developmental phase of the AAQ-II, Bond et al. (2011) iteratively refined a candidate pool of items derived from clinical and theoretical frameworks. Principal axis factoring with oblique rotations (Promax, Oblimin) conducted on large community and undergraduate cohorts indicated that a single dominant factor explained the vast majority of the common item variance (often exceeding 50% of the total variance). The scree test, alongside parallel analysis, conclusively pointed toward a unifactorial solution. All 7 final items demonstrated substantial primary factor loadings ranging from .58 to .87, without significant cross-loadings.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analyses conducted across clinical and non-clinical cohorts consistently affirm the adequacy of the unidimensional measurement model. Standard goodness-of-fit indices routinely meet or exceed conventional psychometric benchmarks:

• Comparative Fit Index (CFI): Routinely observed between .96 and .99.
• Tucker-Lewis Index (TLI): Typically spans between .95 and .98.
• Root Mean Square Error of Approximation (RMSEA): Generally ranges from .045 to .075 (90% confidence interval spanning < .08).
• Standardized Root Mean Square Residual (SRMR): Frequently documented below .040.

Multigroup confirmatory factor analytic studies (MGCFA) have further confirmed full metric and scalar measurement invariance across genders, age demographics, and clinical versus non-clinical sample partitions, ensuring that observed differences in composite scores reflect genuine variations in the underlying construct rather than differential item functioning.

10. Instrument / Measurement Tool

The technical characteristics of the Acceptance and Action Questionnaire-II measurement tool are summarized below:

• Test Type: Self-report psychological assessment / psychometric rating scale.
• Format: Paper-and-pencil or computer-administered interactive digital questionnaire.
• Primary Item Count: 7 items (in the canonical AAQ-II version). Note: The historical and research development lineage includes the original AAQ (9-item and 16-item variants) as well as the experimental 10-item and 22-item developmental item pools.
• Response Scale: 7-point Likert rating scale structured as follows:
  • 1 = Never true
  • 2 = Very seldom true
  • 3 = Seldom true
  • 4 = Sometimes true
  • 5 = Frequently true
  • 6 = Almost always true
  • 7 = Always true
• Scoring Rules:
  • On the standardized 7-item AAQ-II, all items are keyed in the direction of psychological inflexibility and experiential avoidance.
  • There are no reverse-scored items on the canonical 7-item AAQ-II (unlike the historical AAQ-1, which utilized multiple reverse-coded items).
  • Total scores are computed by summing the ratings across all 7 items, yielding an absolute total score range of 7 to 49.
  • Higher total scores indicate greater levels of experiential avoidance, cognitive fusion, and psychological inflexibility.
  • Scores of 24 to 28 or above are frequently cited in clinical literature as indicative of clinically meaningful psychological inflexibility, signifying elevated risk for clinical depression or anxiety disorders.

11. Permissions & Fee and Test Year

The standard 7-item Acceptance and Action Questionnaire-II was formally validated and published in 2011 by Frank W. Bond and colleagues in the journal Behavior Therapy (following preliminary working model development by Hayes et al. in 2004). In accordance with the principles of Contextual Behavioral Science and the ethos of the Association for Contextual Behavioral Science (ACBS), the instrument is situated in the public domain for academic, clinical, educational, and research uses. No licensing fees or commercial royalties are required to administer the instrument. Researchers and licensed clinicians are granted permission to reproduce, translate, and utilize the AAQ-II provided appropriate formal scientific citation is accorded to the original authors (Bond et al., 2011; Hayes et al., 2004).

12. References

• Bond, F. W., & Bunce, D. (2003). The role of acceptance and job control in mental health, job satisfaction, and work performance. Journal of Applied Psychology, 88(6), 1057–1067. https://doi.org/10.1037/0021-9010.88.6.1057
• Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. https://doi.org/10.1016/j.beth.2011.03.007
• Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006
• Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M. A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., Forsyth, J. P., Karekla, M., & McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54(4), 553–578. https://doi.org/10.1007/BF03395493
• Rochefort, C., Baldwin, A. S., & Chmielewski, M. (2018). Experiential avoidance: An examination of the construct validity of the AAQ-II and MEAQ. Behavior Therapy, 49(3), 435–449. https://doi.org/10.1016/j.beth.2017.08.008
• Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Dawson, D. L. (2019). The Acceptance and Action Questionnaire-II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity. Journal of Contextual Behavioral Science, 12, 278–284. https://doi.org/10.1016/j.jcbs.2018.09.005
• Wolgast, M. (2014). What does the Acceptance and Action Questionnaire (AAQ-II) really measure? Behavior Therapy, 45(6), 831–839. https://doi.org/10.1016/j.beth.2014.07.002

13. Items of the Scale