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Investigating the role of psychological inflexibility, mindfulness, and self-compassion in PTSD

Authors:
  • VA Portland Health Care System

Abstract and Figures

Psychological inflexibility has been linked to a variety of mental health disorders, including posttraumatic stress disorder (PTSD). The purpose of this cross-sectional self-report study was to examine how psychological inflexibility, along with closely related concepts such as mindfulness and self-compassion, are associated with PTSD among a clinical sample using PTSD DSM-5 criteria. A sample of 200 veterans (mean age = 54.6; 71.0% male, 25.5% female) were recruited from mental health clinics within a Veteran Affairs Medical Center. Controlling for mindfulness and self-compassion, veterans with PTSD had significantly higher levels of psychological inflexibility compared to those without PTSD. In addition, psychological inflexibility was associated with overall PTSD severity, even after controlling for mindfulness, self-compassion, depression, alcohol and substance use, and demographic variables. The observing facet of mindfulness was significantly associated with higher levels of PTSD, while the describing facet was related to lower overall PTSD symptoms. Self-compassion was no longer associated with PTSD symptoms when controlling for other variables. These findings support the relationship between psychological inflexibility and DSM-5 PTSD. Targeting psychological inflexibility may be a key focal point in improving PTSD-related treatment outcomes.
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Journal of Contextual Behavioral Science 22 (2021) 102–107
Available online 28 October 2021
2212-1447/© 2021 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Investigating the role of psychological inexibility, mindfulness, and
self-compassion in PTSD
Zhen Hadassah Cheng
a
,
b
,
*
, Crystal C. Lozier
a
, Meaghan M. Lewis
a
, Maya E. ONeil
a
,
b
,
Jason B. Luoma
b
,
c
, Benjamin J. Morasco
a
,
b
a
Veteran Affairs Portland Healthcare System, Portland, OR, USA
b
Oregon Health & Science University, Portland, OR, USA
c
Portland Psychotherapy Clinic, Research, and Training Center, Portland, OR, USA
ARTICLE INFO
Keywords:
Psychological inexibility
Mindfulness
Self-compassion
PTSD
ABSTRACT
Psychological inexibility has been linked to a variety of mental health disorders, including posttraumatic stress
disorder (PTSD). The purpose of this cross-sectional self-report study was to examine how psychological
inexibility, along with closely related concepts such as mindfulness and self-compassion, are associated with
PTSD among a clinical sample using PTSD DSM-5 criteria. A sample of 200 veterans (mean age =54.6; 71.0%
male, 25.5% female) were recruited from mental health clinics within a Veteran Affairs Medical Center. Con-
trolling for mindfulness and self-compassion, veterans with PTSD had signicantly higher levels of psychological
inexibility compared to those without PTSD. In addition, psychological inexibility was associated with overall
PTSD severity, even after controlling for mindfulness, self-compassion, depression, alcohol and substance use,
and demographic variables. The observing facet of mindfulness was signicantly associated with higher levels of
PTSD, while the describing facet was related to lower overall PTSD symptoms. Self-compassion was no longer
associated with PTSD symptoms when controlling for other variables. These ndings support the relationship
between psychological inexibility and DSM-5 PTSD. Targeting psychological inexibility may be a key focal
point in improving PTSD-related treatment outcomes.
Each year, over 500,000 veterans receive care related to post-
traumatic stress disorder (PTSD) through the Veterans Affairs (VA)
Healthcare System (US Department of VA, 2016). Mindfulness-based
interventions such as Acceptance and Commitment Therapy (ACT)
and mindfulness-based stress reduction (MBSR; see Lang, 2017 for re-
view) are a type of treatment available to trauma survivors within the
VA. Given that many of the mindfulness-based interventions share
similar intervention mechanisms (Keng et al., 2012), clinicians may face
difculties deciding which factors are most important to target when
treating PTSD.
Three overlapping mechanisms in mindfulness-based interventions
include psychological inexibility, mindfulness, and self-compassion.
Psychological inexibility, which ACT seeks to reduce, involves at-
tempts to avoid experiencing unwanted internal events, such as
distressing thoughts, emotions, and other private experiences (Hayes
et al., 1999). Various studies have linked psychological inexibility with
PTSD symptom severity (e.g., Kashdan et al., 2009; Orcutt et al., 2005).
There is also evidence that psychological inexibility is associated with
greater PTSD symptom severity in a variety of populations including
veterans (e.g., Brockman et al., 2016; Meyer et al., 2013; Meyer et al.,
2019), military personnel (Bryan et al., 2015), war survivors (Kashdan
et al., 2009), sexual assault survivors (Gold & Marx, 2007), college
students (Miron et al., 2015; Orcutt et al., 2005; Thompson & Waltz,
2010), community members (Bardeen & Fergus, 2016), and adolescents
(Shenk et al., 2012). Psychological inexibility can interfere with
trauma recovery as it may prevent the emotional processing and new
learning opportunities that are critical in the decrease of PTSD symp-
toms (Meyer et al., 2019). Mindfulness is dened as focused,
The writing of this manuscript was supported in part by the Ofce of Academic Afliations, Advanced Fellowship Program in Mental Illness Research and
Treatment, Department of Veterans Affairs United States. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States
Government. Correspondence concerning this article should be addressed to Zhen H. Cheng. Oregon Health & Science University, Portland, OR 97239. E-mail:
zcheng@uoregon.edu.
* Corresponding author. Veteran Affairs Portland Healthcare System, Portland, OR, USA.
E-mail address: zcheng@uoregon.edu (Z.H. Cheng).
Contents lists available at ScienceDirect
Journal of Contextual Behavioral Science
journal homepage: www.elsevier.com/locate/jcbs
https://doi.org/10.1016/j.jcbs.2021.10.004
Received 5 June 2020; Received in revised form 28 September 2021; Accepted 21 October 2021
Journal of Contextual Behavioral Science 22 (2021) 102–107
103
nonjudgmental attention to the present moment (Germer et al., 2013).
Mindfulness, in general, is associated with lower PTSD symptom
severity, although the specic facets of mindfulness that are negatively
related to PTSD symptoms vary across studies (see Boughner et al.,
2016; Hanley et al., 2017; Kalill et al., 2014; Martin et al., 2018).
Mindfulness may be linked with lower PTSD symptoms because prac-
ticing mindfulness can improve attention, which could help manage
PTSD intrusive experiences, reduce arousal, and foster emotion regula-
tion (King et al., 2016). Overall, MBSR interventions have been found to
reduce PTSD symptoms (Polusny et al., 2015), improve quality of life
(Kearney et al., 2012), and reduce avoidance (Banks et al., 2015).
Self-compassion incorporates kindness and acceptance directed to-
ward the self and internal experiences (Dahm et al., 2015; Neff, 2016).
In a recent systematic review, an inverse relationship between higher
self-compassion and PTSD was consistently found (Winders et al., 2020),
indicating lower self-compassion plays a role in PTSD maintenance.
McLean et al. (2008) identied a signicant relationship between
self-compassion, psychological inexibility, and PTSD among women
seeking treatment for interpersonal violence. Conceptually,
self-compassion may mitigate harmful consequences from trauma
exposure (Kaurin et al., 2018; Tarber et al., 2016) by decreasing
avoidance (Dahm et al., 2015; Forkus et al., 2019; Hiraoka et al., 2015).
Although these three intervention mechanisms have all individually
been linked to PTSD, more studies are needed to examine how they
relate to PTSD when assessed together. Prior research has found that,
after controlling for psychological inexibility, self-compassion is no
longer related to PTSD symptoms (Seligowski et al., 2015) and only
some components of mindfulness predict PTSD avoidance symptoms
when psychological inexibility is controlled (Thompson & Waltz,
2010). Few studies have examined psychological inexibility as a pre-
dictor of PTSD after controlling for other variables. The available
research suggests psychological inexibility predicts PTSD symptom
severity after controlling for PTSD risk factors (e.g., perceived threat)
and personality traits (e.g., neuroticism; Meyer et al., 2013; Meyer et al.,
2019). However, these studies have not examined how mindfulness or
self-compassion may be associated with psychological inexibility and
PTSD.
Prior studies examining the relationship among psychological
inexibility, mindfulness, self-compassion, and PTSD have primarily
studied college populations (e.g., Miron et al., 2015; Seligowski et al.,
2015; Thompson & Waltz, 2010; Tull & Roemer, 2003). Additionally,
prior work used DSM-IV criteria for PTSD. Given emerging research on
PTSD, the DSM-5 criteria for PTSD now include three additional symp-
toms, a new symptom cluster (i.e., negative alterations in cognitions and
mood), and updated scale measurements (Bovin et al., 2016; Hoge et al.,
2014). Service members and veterans may be particularly affected by
the DSM PTSD criteria changes as a substantial portion of service
members (i.e., 30%) no longer meet PTSD criteria under the new DSM-5
criteria (Hoge et al., 2014). Thus, new research with veterans should
include the most current DSM-5 PTSD criteria to better understand
treatment implications.
The primary aim of the present research was to examine how psy-
chological inexibility, mindfulness, and self-compassion are associated
with PTSD. As basic demographic characteristics (Kessler, 2003; Sue &
Chu, 2003) contribute to differences in mental health outcomes and
depression, and alcohol and substance use have a high rate of comor-
bidity with PTSD (Galatzer-Levy et al., 2013), these potential con-
founding variables were controlled for in our models. We also sought to
model these associations using a clinical population and with current
DSM-5 criteria for PTSD. This study included the following hypotheses:
1) participants who meet criteria for PTSD will have higher levels of
psychological inexibility and lower levels of mindfulness and
self-compassion than those who do not meet criteria for PTSD; 2) higher
levels of psychological inexibility and lower levels of mindfulness and
self-compassion will be signicantly correlated with greater PTSD
symptoms, and 3) psychological inexibility will be associated with
PTSD symptoms even after controlling for demographic and other
mental health outcomes.
1. Method
1.1. Participants and procedures
Two hundred veterans were recruited from mental health clinics in a
large VA Medical Center in the Pacic Northwest region of the US.
Veterans were recruited from the clinics waiting rooms and mental
health groups. They completed a variety of pencil-and-paper question-
naires and were compensated with a $10 gift card for their participation.
The samples average age was 54.6 (SD =13.3). Participants were
predominantly male (71.0% male, 25.5% female) and White (78.5%
White, 10.0% mixed/other, 3.5% Latino, 3% African American, 1.5%
Native American, 0.5% Asian American and Pacic Islander). The IRB at
the VA facility reviewed and approved this study.
1.2. Measures
The Acceptance and Action Questionnaire (AAQ-II; Bond et al.,
2011) was used to measure psychological inexibility. Items are
responded to on a Likert-type scale (1 =never true; 7 =always true) with
higher scores indicating greater levels of psychological inexibility. The
Five-Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) was
used to assess the ve factors of mindfulness (i.e., observing, describing,
acting with awareness, non-judging of inner experiences, and
non-reactivity to inner experience). The Likert scale ranges from 1 (never
or very rarely true) to 5 (very often or always true) with higher scores
indicating greater levels of mindfulness. The Self-Compassion Scale
Short Form (SCS-SF; Raes et al., 2011) was used to measure
self-compassion. The Likert-scale (1 =almost never; 5 =almost always) is
scored with higher scores indicating greater levels of self-compassion.
The Patient Health Questionnaire (PHQ-8; Kroenke et al., 2009) was
used to measure depression. The Likert-scale (0 =not at all; 3 =nearly
every day) is scored with a higher number indicating greater severity of
depressive symptoms. The Alcohol Use Disorders Identication Test-C
(AUDIT-C; Bush et al., 1998) was used to identify hazardous drinking
behavior. Scores of three or higher in women and four or higher for men
are indicative of hazardous alcohol use. The Drug Abuse Screening Test
(DAST-10; Skinner, 1982) was used to assess substance use. Scores of
two or higher on the DAST-10 indicates possible substance use disorder.
The Posttraumatic Stress Disorders Checklist for DSM-5 (PCL-5;
Weathers et al., 2013) was used to assess PTSD symptoms. The
Likert-scale (0 =not at all; 4 =extremely) is scored with a higher number
indicating greater symptom severity. This study included an additional
question asking whether participants experienced a traumatic event to
assess criterion A of PTSD. Prior research suggests a total PCL-5 score of
3133 had the best prediction of PTSD diagnosis when compared with
the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Bovin et al.,
2016). We used a conservative PCL-5 cut-off score of 33 or higher and an
endorsement of a criterion A event to identify participants with PTSD.
All measures used in this study were self-report.
2. Results
The majority of participants reported experiencing or witnessing a
traumatic event (n =167; 84%) and met current DSM-5 criteria for PTSD
(n =119; 60%). Chi-square and independent samples t-tests showed
there were no differences in demographic characteristics based on
whether participants met criteria for PTSD (Table 1). Veterans who met
criteria for PTSD had signicantly higher depressive symptoms
compared to those who did not meet criteria for PTSD. No differences in
hazardous alcohol use and probable substance use disorder based on
PTSD status were found. Compared to those who did not meet criteria
for PTSD, veterans who met criteria for PTSD had signicantly higher
Z.H. Cheng et al.
Journal of Contextual Behavioral Science 22 (2021) 102–107
104
psychological inexibility scores and lower self-compassion scores
(Table 1). Veterans who met criteria for PTSD scored lower on all facets
of mindfulness except for the observing aspect of mindfulness.
Controlling for facets of mindfulness and self-compassion, analysis of
covariance (ANCOVA) revealed there was a signicant main effect of
PTSD criteria for psychological inexibility, F (1,182) =64.49, p <
0.001,
ηρ
2
=0.26. Veterans who met criteria for PTSD had signicantly
higher levels of psychological inexibility than those who did not.
Controlling for psychological inexibility and self-compassion, veterans
who met PTSD criteria had signicantly lower scores on the describing
aspect of mindfulness than those who did not meet criteria for PTSD, F
(1,186) =5.00, p =0.026,
ηρ
2
=0.03. No signicant differences were
detected for other facets of mindfulness. Similarly, there was no signif-
icant main effect of PTSD criteria for self-compassion, while controlling
for psychological inexibility and facets of mindfulness, F (1,182) =
0.03, p =0.854,
ηρ
2
<0.001.
Among veterans who reported experiencing a traumatic event (n =
167), zero-order correlations showed that greater psychological inex-
ibility and lower levels of self-compassion were all related to higher
PTSD and depressive symptoms (Table 2). Lower scores on mindfulness
were signicantly related to higher levels of PTSD and depression,
except for the observing aspect of mindfulness.
To further examine the relationship between each of the psycho-
logical variables with PTSD symptoms, nested ordinary least squares
(OLS) linear regression was used to examine how psychological inex-
ibility, the ve factors of mindfulness, and self-compassion were asso-
ciated with PTSD. In regression analyses controlling for demographic
characteristics, depression severity, alcohol and substance use, and
intervention factors, higher levels of psychological inexibility were
signicantly related to greater overall PTSD symptom severity. The
observing aspect of mindfulness was signicantly associated with higher
levels of PTSD while the describing aspect of mindfulness was related to
lower overall PTSD symptom severity (Table 3). Self-compassion was
unrelated to PTSD symptoms when all other variables were controlled.
3. Discussion
The primary objective of this study was to examine the relationship
between psychological inexibility, mindfulness, and self-compassion
with PTSD using updated DSM-5 criteria in a clinical population.
Consistent with hypothesis 1, those who met criteria for PTSD had
signicantly higher levels of psychological inexibility and lower levels
of self-compassion than those who did not meet criteria for PTSD. Those
who met criteria for PTSD also had lower levels of mindfulness, except
for the observing facet of mindfulness. However, when intervention
factors were controlled, individuals who met criteria for PTSD were
found to only have signicantly higher levels of psychological
Table 1
Demographics, mental health outcomes, and intervention factors based on PTSD
status.
Did not meet
PTSD criteria
Met PTSD
criteria
p-
value
Effect
size
Demographics
Age 58.0 (14.1) 52.6 (12.3) 0.008 0.40
Gender 0.858 0.01
Female 37.3% (19) 62.7% (32)
Male 38.7% (53) 61.3% (84)
Ethnicity 0.226 0.09
White 40.5% (62) 59.5% (91)
Ethnic minorities 29.7% (11) 70.3% (26)
Mental Health Outcomes
Depression (PHQ-8) 15.6 (5.2) 23.5 (4.7) <.001 1.61
Hazardous alcohol use
(AUDIT-C)
22.2% (16) 27.1% (32) 0.451 0.06
Probable substance use
disorder (DAST-10)
27.4% (20) 24.6% (29) 0.664 0.03
Intervention Factors
Psychological Inexibility
(AAQ-II)
19.5 (8.9) 35.2 (8.7) <.001 1.79
Mindfulness (FFMQ)
observe
26.0 (5.6) 26.0 (6.2) 0.986 0.00
Mindfulness describe 27.4 (6.1) 22.2 (6.8) <.001 0.79
Mindfulness act 27.4 (6.7) 22.7 (5.8) <.001 0.76
Mindfulness nonjudge 27.0 (6.9) 22.1 (6.8) <.001 0.72
Mindfulness nonreact 19.5 (5.3) 17.3 (5.1) <.01 0.42
Self-compassion (SCS-SF) 37.1 (9.6) 29.0 (7.6) <.001 0.97
Note. PHQ-8 =The Patient Health Questionnaire-8 (
α
=0.88 in this sample);
AUDIT-C =The Alcohol Use Disorders Identication Test-C (
α
=0.84 in this
sample); DAST-10 =The Drug Abuse Screening Test (
α
=0.84 in this sample);
AAQ-II =The Acceptance and Action Questionnaire-II (
α
=0.94); FFMQ =The
Five-Facet Mindfulness Questionnaire (
α
=0.90 in this sample); SCS-SF =The
Self-Compassion Scale Short Form (
α
=0.85 in this sample). Numbers repre-
sent % (n) for categorical variables and M (SD) for linear variables. Effect sizes
were Cohens D for continuous variables and Phi Coefcient for categorical
variables.
Table 2
Pearson correlations of intervention and mental health factors with PTSD (n =167).
1 2 3 4 5 6 7 8 9 10 11
1. Psychological
Inexibility
1.00 -.08 -.40*** -.48*** -.53*** -.37*** -.69*** .73*** .11 .12 .75***
2. Mindfulness observe 1.00 .37*** .15 -.06 .47*** .21** .04 .04 .04 .02
3. Mindfulness
describe
1.00 .41*** .18* .40*** .35*** -.37*** -.01 -.03 -.43***
4. Mindfulness act 1.00 .51*** .30*** .52*** -.47*** -.10 -.05 -.39***
5. Mindfulness
nonjudge
1.00 .21** .58*** -.47*** -.07 -.05 -.41***
6. Mindfulness
nonreact
1.00 .48*** -.28** -.15 -.08 .30***
7. Self-Compassion .1.00 -.57*** -.10 -.07 -.50***
8. Depression (PHQ-8) 1.00 .09 .09 .72***
9. Alcohol Use (AUDIT-
C)
1.00 .14 .14
10. Substance Use
(DAST-10)
1.00 .12
11. PTSD (PCL-5 total) 1.00
M (SD) 30.64
(11.11)
26.03
(5.87)
24.01
(7.08)
23.95
(6.44)
23.41
(6.94)
18.04
(5.20)
31.32
(8.99)
21.15
(6.02)
1.96
(2.72)
1.23
(2.10)
43.73
(18.81)
Min/Max Range 749 1140 740 740 740 535 854 832 013 010 178
Note. Results of participants who endorsed Criterion A of PTSD. PCL-5 =Posttraumatic Stress Disorders Checklist for DSM-5 (
α
=0.95 in this sample). * at p <0.05, **
at p <0.01; *** at p <0.001; two tailed.
Z.H. Cheng et al.
Journal of Contextual Behavioral Science 22 (2021) 102–107
105
inexibility and lower levels of the describing facet of mindfulness.
There were no differences in self-compassion when psychological
inexibility and mindfulness were controlled. Consistent with hypoth-
esis 2, psychological inexibility was associated with overall PTSD
symptoms after controlling for demographic variables, depression,
alcohol use, substance use, the ve facets of mindfulness, and self-
compassion. Additionally, the observing and describing facets of
mindfulness were signicantly related to overall PTSD symptom severity
after controlling for all other variables.
In zero-order correlations, we found that the observing mindfulness
facet was not associated with PTSD symptoms. However, once inter-
vention factors were controlled for, the observing facet was related to
higher PTSD symptoms. Previous studies with college students have
found the observing facet associated with lower PTSD symptoms
(Hanley et al., 2017; Kalill et al., 2014). However, other studies,
including those that use community samples, have demonstrated posi-
tive associations between the observing facet with worse mental health
outcomes, including PTSD symptoms (Boughner et al., 2016; Cheng
et al., 2017; Stanley et al., 2019). One possibility is that the observing
facet may capture less adaptive aspects of mindfulness, such as an
overfocus on interoceptive experiences, which may potentially exacer-
bate hypervigilance symptoms (Cheng et al., 2017; Stanley et al., 2019).
The describing facet of mindfulness was associated with fewer PTSD
symptoms in both zero-order correlations and the regression models,
suggesting the ability to mindfully put to words ones inner experiences
may be protective in the context of PTSD. This nding aligns with
common treatments for PTSD (e.g., Cognitive Processing Therapy and
Prolonged Exposure) that target talking and writing about ones inner
experiences related to trauma.
Interestingly, while self-compassion was associated with lower PTSD
in zero-order correlations, it was no longer correlated with PTSD once
other intervention factors were added to regression models. Our nding
that psychological inexibility had a stronger association with PTSD
than self-compassion contrasts with some research (Braehler & Neff,
2020; Seligowski et al., 2015), suggesting the need for further research.
This aligns with a recent meta-analysis showing that there are few
studies examining trauma, self-compassion, and psychological inexi-
bility simultaneously (Winders et al., 2020). In addition, fear of
self-compassion has been shown to be unrelated to PTSD symptoms
when psychological inexibility and mindfulness are controlled for
(Boykin et al., 2018) or when individuals are low on psychological
inexibility (Miron et al., 2015). Together, these results suggest that
further research is needed to understand the relationships between PTSD
and psychological inexibility, self-compassion, and related variables
such as fear of self-compassion.
4. Limitations, implications, and future directions
This study has several limitations. It was conducted with veterans
recruited from outpatient mental health clinics and included a high
proportion of respondents who identied as male and White. Recruiting
a more diverse clinical sample is important for future research. Although
this study updated the current literature by using DSM-5 criteria for
PTSD, it was based on self-report. Using a gold-standard diagnostic
interview such as the CAPS-5 to assess PTSD should be considered for
future studies to differentially diagnose PTSD. In addition, while the
study controlled for important related variables to examine the variance
of psychological inexibility in PTSD, other variables such as emotion
dysregulation may be involved that were not captured.
Psychological inexibility shared 48% of its variance with self-
compassion and had signicant overlapping variance with mindfulness
facets. Since self-compassion, mindfulness, and psychological inexi-
bility have considerable conceptual overlap, we are unsure exactly what
psychological inexibility consists of once these other variables are
controlled for. However, psychological inexibility added additional
variance to the prediction of PTSD above and beyond self-compassion
and facets of mindfulness. The association between psychological
inexibility and PTSD was conserved across both zero-order correlations
and regression analyses suggesting it is a more robust predictor of PTSD
than any of these other variables. These results suggest that there may be
something additional that psychological inexibility contributes to, and
future studies can explore what this may be.
One alternate possibility is that these results may reect psycho-
metric problems with the AAQ-II, which previously had discriminant
validity issues from constructs such as neuroticism and negative affect/
emotionality (Rochefort et al., 2018; Tyndall et al., 2019; Wolgast,
2014). Our inclusion of depression in regression models mitigates this
concern somewhat. However, future studies should include other mea-
sures that have smaller associations with negative affect or those that
focus on specic aspects of psychological inexibility, such as the Brief
Experiential Avoidance Questionnaire (G´
amez et al., 2014) or the
Table 3
Nested OLS linear regression results for PTSD symptoms (n =167).
PTSD Symptoms (total) B β R2 R2 change F change
Step 1. .03 .03 1.48
Age -.22 -.16
Gender 2.17 .05
Ethnicity 1.88 .04
Step 2. .58 .55 63.66***
Age -.11 -.08
Gender 2.54 .06
Ethnicity -.24 -.005
Depression 2.31 .74***
Alcohol Use .35 .05
Substance Use .33 .04
Step 3. .64 .06 4.10**
Age -.06 -.04
Gender 3.17 .08
Ethnicity 1.00 .02
Depression 1.94 .62***
Alcohol Use .34 .05
Substance Use .17 .02
Mindfulness observe .62 .19**
Mindfulness describe -.51 -.19**
Mindfulness act .16 .05
Mindfulness nonjudge -.13 -.05
Mindfulness nonreact -.57 -.16*
Self-Compassion -.09 -.05
Step 4. .71 .07 32.69***
Age -.09 -.06
Gender 4.37 .10*
Ethnicity .94 .02
Depression 1.33 .42***
Alcohol Use .35 .05
Substance Use -.10 -.01
Mindfulness observe .56 .17**
Mindfulness describe -.41 -.16**
Mindfulness act .16 .06
Mindfulness nonjudge .02 .01
Mindfulness nonreact -.40 -.11
Self-Compassion .24 .11
Psychological Inexibility .79 .47***
Note. Results of participants who endorsed Criterion A of PTSD. Regression re-
sults are presented with standardized and unstandardized beta weights for PTSD
outcomes. Asterisks indicate signicance levels (* at p <0.05, ** at p <0.01, ***
at p <0.001). In Step 1, age, gender (1 =male, 2 =female), ethnicity (1 =
White, 2 =ethnic minority) were entered. In Step 2, depression, alcohol use, and
substance use were included in addition to demographic variables. In Step 3,
facets of mindfulness and self-compassion were entered while controlling for
depression, alcohol use, substance use, and demographic variables. In Step 4,
psychological inexibility was entered while controlling for facets of mindful-
ness, self-compassion, depression, alcohol use, substance use, and demographic
variables. A sensitivity analysis with all three intervention factors entered into
the same step (i.e., Step 3) was conducted. Given that the results were identical,
we report the results with psychological inexibility completely partialed out in
Step 4.
Z.H. Cheng et al.
Journal of Contextual Behavioral Science 22 (2021) 102–107
106
Valuing Questionnaire (Smout et al., 2014).
Compared to mindfulness and self-compassion, higher levels of
psychological inexibility were consistently associated with PTSD
severity among veteran participants who reported experiencing a trau-
matic event. These results are congruent with prior research high-
lighting the role that psychological inexibility plays in the
development and maintenance of PTSD (Meyer et al., 2013, 2019). The
present ndings indicate psychological inexibility may play an
important role in trauma recovery and should be further investigated in
PTSD treatment research. Avoiding difcult internal events may pro-
duce a short-term alleviation of trauma-related symptoms, but long term
it may increase and maintain PTSD symptoms over time (Kelly et al.,
2019; Palm & Follette, 2011). Thus, psychological inexibility may limit
emotional processing and new learning opportunities that could pro-
mote natural recovery from PTSD. Since this study was cross-sectional,
longitudinal research is needed to conrm the temporal and causal
order of these associations. Future research should further investigate
explicit mechanisms of change and how interventions designed to
decrease psychological inexibility may improve PTSD recovery.
Declarations of competing interest
None.
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Z.H. Cheng et al.
... Research shows psychological inflexibility is associated with PTSD symptom severity (e.g., Meyer et al., 2019;Schramm et al., 2020). The positive association between psychological inflexibility and the severity of PTSD symptoms spans across contexts and populations including military veterans (e.g., Cheng et al., 2021;Kachadourian et al., 2021;Meyer et al., 2019), patients and caregivers (e.g., Janssen et al., 2022;Lappalainen et al., 2021), and refugees (e.g., Gray et al., 2021). Psychological inflexibility and PTSD symptoms have also shown a strong relationship during the COVID-19 pandemic (e.g., Hernández-López et al., 2021;Pakenham et al., 2020;Smith et al., 2020). ...
... F. Hayes, 2018), which tests for the mediation and moderation effects simultaneously. Basic demographic characteristics, including age, gender (sex), type of settlement, and education, are determinants of differences in mental health outcomes (Cheng et al., 2021;Galatzer-Levy et al., 2013) and also determinants of COVID-19-related behaviors such as uptake of COVID vaccines (Shiloh et al., 2022). Therefore, we controlled for the effects of these variables in our regression models because they are potential confounding factors. ...
... Conceptual model depicting the hypothesized direct, indirect, and conditional effects of psychological inflexibility on adherence to COVID-19 preventive measures psychological inflexibility was positively associated with PTSD symptom severity. High levels of inflexibility are likely to amplify manifestations of PTSD symptoms, which is consistent with previous research findings (e.g., Cheng et al., 2021;Meyer et al., 2019;Schramm et al., 2020). Refugees who have already been exposed to traumatic events are more likely to experience heightened PTSD symptoms severity when further faced with stressful situations. ...
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Refugees are vulnerable to developing mental health problems. The unprecedented appearance and rapid spread of COVID-19 exacerbated this vulnerability, especially in low-income countries where refugees survive on humanitarian aid and live in congested settlements. These appalling living conditions are a stressor, making adherence to COVID-19 control measures impractical and an additional psychological strain for refugees. The present study examined how psychological inflexibility is associated with adherence to COVID-19 control measures. A sample of 352 refugees from Kampala City and Bidibidi settlements were recruited. Refugees with high levels of psychological inflexibility reported higher PTSD symptom severity and low adherence to COVID-19 control measures. Moreover, PTSD severity mediated the association between psychological inflexibility and adherence, while avoidance coping moderated both direct and indirect effects. Interventions for reducing psychological inflexibility and avoidance coping may be essential in boosting adherence to measures relevant to the current and future status of the pandemic, along with other crises that refugees face.
... Psychological flexibility is defined as the ability to flexibly alternate between and manage challenging thoughts, emotions, or mental sets in the service of carrying out valued actions 37 . Given that psychological inflexibility has been implicated as a maintaining factor in multiple mental health disorders including PTSD 38 , it is possible that enhanced flexibility under ayahuasca may accompany therapeutic processes, e.g., cognitive processing of previous trauma and trauma-related beliefs 39 , fear extinction. ...
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The present study examined the safety and efficacy of the ceremonial use of ayahuasca in relation to reports of heightened life event reexperiencing under psychedelics. The study examined (1) the prevalence of specific types of adverse life event reexperiencing, (2) characteristics predictive of reexperiencing, (3) the psychological character of reexperiencing, and (4) the impact of reexperiencing on mental health. Participants were recruited from three ayahuasca healing and spiritual centers in South and Central America (N = 33 military veterans, 306 non-veterans) using self-report data at three timepoints (Pre-retreat, Post-retreat, 3-months post-retreat). Reexperiencing adverse life events under ayahuasca was common, with women showing particularly high probability of reexperiencing sexual assault, veterans reexperiencing combat-related trauma, and individuals with a self-reported lifetime diagnosis of post-traumatic stress disorder exhibiting a substantively higher prevalence of reexperiencing. Reexperiencing was associated with states of cognitive reappraisal, psychological flexibility, and discomfort during ceremonies, and participants who reexperienced adverse life events exhibited greater reductions in trait neuroticism following their ceremonies. Clinical implications of these results for the application of psychedelics to mood and stress disorders are discussed.
... Nonreacting displayed a weak positive correlation with CS in the high CS subsample. This positive association has been documented in clinical samples (e.g., Cheng et al., 2021) and could possibly be explained by nonreacting functioning as a pathway to emotional suppression that exacerbates CS, especially hyperarousal (García-Batista et al., 2021;Iani et al., 2019;Reffi et al., 2019). Additionally, nonreacting was not correlated with CS in the overall sample, and describing was not correlated with CS in the subsample. ...
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Psychological inflexibility and experiential avoidance are key constructs in the Acceptance and Commitment Therapy (ACT) model of behavior change. Wolgast (2014) questioned the construct validity of the Acceptance and Action Questionnaire-II (AAQ-II), the most used self-report instrument to assess the efficacy of ACT interventions. Wolgast suggested that the AAQ-II measured psychological distress rather than psychological inflexibility and experiential avoidance. The current study further examined the construct validity of the AAQ-II by conducting an online cross-sectional survey (n = 524), including separate measures of experiential avoidance and psychological distress. Confirmatory factor analyses indicated that items from the AAQ-II correlated more highly with measures of depression, anxiety, and stress than the Brief Experiential Avoidance Questionnaire (BEAQ). Implications include that, as broad measures of experiential avoidance, the AAQ-II and BEAQ may not measure the same construct. In terms of psychological distress, the BEAQ has greater discriminant validity than the AAQ-II, and perhaps an alternative instrument of psychological inflexibility might be needed to assess core outcomes in ACT intervention research.
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Firefighters are frequently exposed to highly stressful, potentially traumatic events (PTEs). More than 50%, however, show no significant elevation in trauma-related symptomatology (e.g., depression). In the past, self-compassion has been discussed to promote psychological and behavioral flexibility that is vital to a successful adaptation to PTEs. The goal of this study was to understand whether and how self-compassion may alleviate personal suffering in the face of PTEs. We hypothesized that individuals who encounter their profession-related affective experiences with greater self-compassion, show lower levels of depressive symptoms because self-compassion buffers processes that perpetuate negative affectivity in response to PTEs (i.e., self-critical tendencies). Male firefighters (N = 123) completed self-report questionnaires about the severity of current depressive symptoms; prior traumatic, duty-related events; and the self-compassion scale that assesses two distinct factors: self-criticism and self-compassion. A stepwise regression model was employed to examine differential and interactive contributions of self-criticism and self-compassion to symptoms of depression across the cumulative range of exposure to PTEs. Our results indicate that the positive association between self-criticism and depression is buffered by enhanced levels of self-compassion. This moderation, however, only emerged for firefighters with substantial amounts of PTEs experience in the past. The present work provides insight into protective effects of self-compassion in the face of cumulative PTEs. It suggests that, particularly for severely trauma-exposed firefighters, self-compassion may confer resilience, that is, act as a protective factor from the development of depressive symptoms. Findings are discussed in light of counseling implications.
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