Acceptance and Commitment Questionnaire in the COVID-19 Pandemic (AAQ-COVID)

1. Abstract

The Acceptance and Commitment Questionnaire in the COVID-19 Pandemic (AAQ-COVID) is a specialized psychometric assessment instrument developed by Carmen Antonia Buenfil Heredia, Sally Vanega Romero, and Carlos David Carrillo Trujillo (2024) at the Autonomous University of Yucatan (Universidad Autónoma de Yucatán). Designed within the paradigm of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT), the AAQ-COVID operationalizes event-specific psychological inflexibility and experiential avoidance provoked by the global health crisis, lockdowns, infection threats, and associated social disruptions. Adapted from the Spanish adaptation by Mellín and Padrós (2021) of the Acceptance and Action Questionnaire–Trauma Specific (AAQ-TS; Pinto-Gouveia et al., 2015), the scale comprises 10 self-report items evaluated on a 5-point Likert-type response scale ranging from “It doesn’t look anything like my experience” (1) to “It seems almost completely like my experience” (5).

The scale was developed and evaluated in Mexico among non-clinical adult populations (aged 42 to 76 years), specifically examining educational personnel, administrative workers, and support staff navigating prolonged occupational and ambient health stressors. Psychometric evaluation focused on expert panel content validity, assessing item clarity, conceptual representativeness, and clinical relevance. Higher total scores denote elevated psychological inflexibility, characterizing maladaptive experiential avoidance, fusion with catastrophic thoughts concerning viral contagion, and behavioral paralysis preventing committed engagement in valued life domains. The AAQ-COVID provides clinicians, occupational health practitioners, and behavioral researchers with an empirically grounded, context-sensitive index of contextual coping during epidemiological crises.

2. Keywords

AAQ-COVID, Acceptance and Commitment Therapy, Psychological Inflexibility, Experiential Avoidance, COVID-19 Pandemic, Psychological Flexibility, Trauma-Specific Measurement, Contextual Behavioral Science, Adult Mental Health, Scale Validation

3. Authors

The Acceptance and Commitment Questionnaire in the COVID-19 Pandemic was developed by faculty and clinical researchers affiliated with the Autonomous University of Yucatan (Mérida, Yucatán, Mexico):

• Carmen Antonia Buenfil Heredia, PhD / M.Sc. – Autonomous University of Yucatan; Clinical Psychotherapy and Behavioral Medicine. Email: [email protected]
• Sally Vanega Romero, PhD – Faculty of Psychology, Autonomous University of Yucatan. Email: [email protected]
• Carlos David Carrillo Trujillo, PhD – Faculty of Psychology, Autonomous University of Yucatan. Email: [email protected]

4. Purpose

The primary purpose of the AAQ-COVID is to capture individual differences in psychological flexibility versus psychological inflexibility specifically contextualized to the chronic stress, health anxieties, restrictive measures, and life disruptions engendered by the COVID-19 pandemic. While general measures such as the Acceptance and Action Questionnaire–II (AAQ-II; Bond et al., 2011) assess broad experiential avoidance and psychological distress, psychometric literature increasingly underscores that context-specific and trauma-specific adaptations demonstrate superior predictive utility, clinical sensitivity, and ecological validity when evaluating populations exposed to acute or prolonged collective crises.

The scale serves multiple complementary clinical and scientific objectives:

• Identification of High-Risk Inflexibility: Screen individuals who respond to contagion fears and quarantine mandates through behavioral shutdown, functional interference, cognitive entanglement, and attempts to suppress distressing emotional states.
• Process-Based Clinical Assessment: Facilitate functional analyses in cognitive-behavioral and acceptance-based clinical interventions by targeting experiential avoidance mechanisms that hinder value-congruent living during widespread health emergencies.
• Evaluation of Public Health and Workplace Well-Being: Permit occupational psychologists and educational institutions to determine how teachers, staff, and frontline personnel manage health-related dread, informing the design of targeted psychoeducational workshops and resilience interventions.
• Longitudinal Research on Health Disasters: Provide an empirically robust, domain-targeted instrument for tracing psychological trajectories across waves of epidemics, post-pandemic readjustment phases, and future public health crises.

5. Psychological Construct

The psychological construct evaluated by the AAQ-COVID is COVID-Specific Psychological Inflexibility, conceptualized as an overarching transdiagnostic vulnerability characterized by an individual’s inability to remain in contact with present-moment experiences when confronted with distressing pandemic-related thoughts, physical sensations, and emotions, resulting in rigid actions that undermine personally valued goals.

Drawing from the standard ACT Hexaflex model, the AAQ-COVID captures several interdependent functional dimensions manifested in pandemic-related contexts:

• Experiential Avoidance: Unwillingness to remain in contact with aversive internal experiences (such as fear of infection, grief, loneliness, or existential dread) and active efforts to suppress, push away, or distract oneself from these affective states (exemplified by Item 2: “I try to push away the emotions that the pandemic produces in me”).
• Cognitive Fusion: Entanglement with catastrophic verbal thoughts concerning illness, death, vulnerability, and contagion, treating negative predictive cognitions as absolute facts that dictate immediate behavior (captured in Item 1: “Thinking about the possibility of myself or my loved ones getting sick with COVID prevents me from living my life as I would like” and Item 4: “I am distressed by thinking about the dangers of COVID and the confinement in which I am”).
• Loss of Flexible Attentional Contact with the Present Moment: Preoccupation with uncontrollable future perils and retrospective regret concerning lost opportunities, which narrows behavioral responsiveness (reflected in Item 3: “I worry about not being able to control my fears and concerns regarding the pandemic”).
• Valued Inaction and Behavioral Obstruction: Abandonment of committed, meaningful life directions (e.g., career milestones, relational nurturing, creative pursuits) due to emotional suffering and protective hypervigilance (exemplified in Item 9: “The pain and distress that the pandemic produces in me interfere with achieving my goals” and Item 10: “I do not do things that are important to me because of the fear that the pandemic has produced in me”).
• Social Comparison and Self-as-Content: Rigid self-evaluative conceptualizations regarding one’s personal ability to cope relative to peers (captured in Item 7: “I think that I am not coping with the pandemic as well as other people”).

6. Theoretical Framework

The conceptual foundation of the AAQ-COVID is rooted in Contextual Behavioral Science (CBS), specifically articulated through Relational Frame Theory and Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999; Hayes et al., 2006). Relational Frame Theory posits that human language and symbolic cognition derive from the learned capacity to derive relations among arbitrary stimuli. In the context of a lethal pandemic, verbal conditioning rapidly transforms neutral environmental cues (e.g., entering a supermarket, hearing a cough, viewing news reports, being quarantined at home) into conditioned signals of imminent mortality and danger through derived relational responding.

When individuals lack psychological flexibility, they attempt to exert deliberate verbal control over unbidden physiological sensations (e.g., somatic anxiety, dyspnea fears) and thoughts of contagion. This paradoxically amplifies the intensity and frequency of distressing internal stimuli via ironic rebound processes. In the ACT model, psychological suffering is not treated primarily as an excess of negative symptoms, but as a byproduct of experiential avoidance—the ongoing struggle to eliminate or modify private experiences even when doing so incurs substantial functional costs.

The AAQ-COVID specifically builds upon the lineage of the Acceptance and Action Questionnaire–Trauma Specific (AAQ-TS) (Pinto-Gouveia et al., 2015) and its subsequent Spanish adaptation by Mellín and Padrós (2021). The AAQ-TS was engineered to overcome the limitation of generic instruments by framing items around traumatic, life-threatening events. Buenfil Heredia and colleagues recognized that the COVID-19 pandemic represented a collective, enduring traumatic stressor characterized by ongoing physical vulnerability, unpredictability, structural confinement, and pervasive health bereavement. Adapting trauma-specific experiential avoidance metrics to pandemic dynamics allows researchers to assess whether individuals are maintaining flexible, value-based actions despite pandemic-related distress or succumbing to avoidant paralysis.

7. Validity

The validation process for the AAQ-COVID concentrated on rigorous content validity and contextual adaptation within a non-clinical Latin American population. The scale development protocol comprised multiple sequential stages:

• Item Translation and Contextual Adaptation: The original trauma-specific items from Pinto-Gouveia et al. (2015) and Mellín and Padrós (2021) were systematically adapted to reflect pandemic-specific stressors, including quarantine confinement, infection risks for oneself and family members, and the widespread disruption of daily occupational and personal routines.
• Expert Panel Content Validity: A panel of expert psychometricians and clinical psychologists evaluated the candidate item pool. The judges conducted independent evaluations based on three principal psychometric criteria:
  1. Conceptual Validity: Whether each statement precisely mapped onto the theoretical hexaflex dimensions of psychological inflexibility and experiential avoidance.
  2. Linguistic Clarity: Syntactic simplicity, readability, and freedom from cultural or socio-educational ambiguity for adult respondents.
  3. Clinical Relevance: The degree to which each item tapped into authentic functional impairments observed during epidemiological lockdowns.
• Decision Criteria: The development methodology established a retention benchmark requiring at least 50% inter-judge consensus on a given criterion for item preservation or iterative refinement, ensuring that items capturing critical clinical manifestations were preserved even under conservative consensus thresholds.
• Construct and Ecological Relevance: The retained 10 items explicitly capture the real-world friction between internal distress (fear of disease, helplessness) and overt behavior (impairment of daily functioning, abandonment of valued goals, interpersonal distress).

8. Reliability

In the foundational scale development study conducted by Buenfil Heredia, Vanega Romero, and Carrillo Trujillo (2024), the investigative scope focused primarily on content-oriented instrument construction and structural adaptation within educational and administrative community cohorts in Yucatán, Mexico. Consequently, formal classical test theory (CTT) reliability estimates (such as internal consistency via Cronbach’s alpha or McDonald’s omega) and longitudinal indices (such as test-retest intraclass correlation coefficients) were not published in the initial release report.

However, drawing from the parent instruments upon which the AAQ-COVID is architecturally grounded—namely the Acceptance and Action Questionnaire–Trauma Specific (Pinto-Gouveia et al., 2015) and its validated Spanish adaptation (Mellín & Padrós, 2021)—comparable contextual flexibility measures consistently demonstrate robust internal consistency, with alpha coefficients typically exceeding α = .88 to .92. Researchers employing the AAQ-COVID are encouraged to calculate and report internal consistency metrics (α and ω) across distinct clinical and demographic cohorts to build out its empirical reliability database.

9. Factor Analysis

In the published 2024 development study by Buenfil Heredia et al., empirical factor analysis—including exploratory factor analysis (EFA) and confirmatory factor analysis (CFA)—was not conducted as the study concentrated on linguistic and content validity across adult personnel from educational centers. Consequently, empirical factor loadings, scree plot eigenvalues, and structural equation modeling fit indices (e.g., CFI, TLI, RMSEA, SRMR) remain to be established in broader follow-up investigations.

Theoretically, the AAQ-COVID was engineered as a unidimensional construct, consistent with the standard structural architecture of the Acceptance and Action Questionnaire family (AAQ, AAQ-II, AAQ-TS). In generic and trauma-specific AAQ variants, a single higher-order latent factor representing Psychological Inflexibility typically accounts for the majority of common item variance. Methodological frameworks for upcoming validation studies recommend testing both a unidimensional model and bifactor structures separating general inflexibility from specific experiential avoidance versus cognitive fusion components.

10. Instrument / Measurement Tool

• Tool Name: Acceptance and Commitment Questionnaire in the COVID-19 Pandemic (AAQ-COVID)
• Alternative Title: Cuestionario de Aceptación y Compromiso en la Pandemia de COVID-19
• Construct Measured: COVID-Specific Psychological Inflexibility / Experiential Avoidance
• Theoretical Framework: Acceptance and Commitment Therapy (ACT) / Contextual Behavioral Science (CBS)
• Instrument Type: Self-report rating scale
• Administration Format: Electronic questionnaire (online survey platforms) or paper-and-pencil
• Target Population: Adults aged 18 years and older; validated initially in working and community adults aged 42 to 76 years
• Administration Time: Approximately 3 to 5 minutes
• Number of Items: 10 items
• Response Scale: 5-point Likert-type scale with the following anchors:
  • 1 = It doesn’t look anything like my experience
  • 2 = It looks a little like my experience
  • 3 = It moderately looks like my experience
  • 4 = It looks a lot like my experience
  • 5 = It seems almost completely like my experience
• Scoring Procedure: Items are summed to produce a continuous global score ranging from 10 to 50. All items are positively keyed toward psychological inflexibility (no reverse-scored items). Higher overall scores indicate greater psychological inflexibility, severe experiential avoidance, and elevated behavioral interference driven by pandemic-related distress.

11. Permissions & Fee and Test Year

• Test Year: 2024
• Copyright & Licensing: The AAQ-COVID was developed at the Autonomous University of Yucatan and made accessible under a Creative Commons Attribution 4.0 International License (CC BY 4.0).
• Usage Fee: Free of charge. Open-access instrument for academic, non-commercial research, clinical practice, and public health evaluation.
• Permission Requirements: Formal permission is not required provided appropriate academic attribution and citation are accorded to the original authors (Buenfil Heredia, Vanega Romero, & Carrillo Trujillo, 2024).

12. References

• 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
• Buenfil Heredia, C. A., Vanega Romero, S., & Carrillo Trujillo, C. D. (2024). Acceptance and Commitment Questionnaire in the COVID-19 Pandemic (AAQ-COVID). Autonomous University of Yucatan. Creative Commons License CC BY 4.0. https://creativecommons.org/licenses/by/4.0/deed.en
• 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. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. Guilford Press.
• Mellín, M. C., & Padrós, F. (2021). Adaptación y propiedades psicométricas del Cuestionario de Aceptación y Acción–Específico para Trauma (AAQ-TS) en población hispanohablante. Revista Iberoamericana de Psicología, 14(2), 45–56.
• Pinto-Gouveia, J., Gregório, S., Dinis, A., & Xavier, A. (2015). Experiential avoidance in trauma: Psychometric properties of the Portuguese version of the Acceptance and Action Questionnaire–Trauma Specific (AAQ-TS). Journal of Clinical Psychology, 71(12), 1184–1196. https://doi.org/10.1002/jclp.22213

13. Items of the Scale (Questionnaire)