The International Journal of Psychosocial Rehabilitation

Experiential Avoidance and Psychological
 Acceptance Processes in the Psychological Recovery
 from Enduring Mental Illness



Vinicius R. Siqueira & Lindsay G. Oades
School of Psychology
Illawarra Institute for Mental Health
University of Wollongong,
 Wollongong Australia & Anhanguera, Cascavel, Brazil.



Author Note
Vinicius R. Siqueira has a Master of Science by Research in Psychology by the University of Wollongong and is a Professor at Anhanguera, Cascavel, Brazil.
Lindsay G. Oades has a B.A.(Hons) University of Adelaide, PhD (University of Wollongong), MBA with Distinction (University of Wollongong) and is a Senior Lecturer (Clinical Psychology) at the  University of Wollongong.


Correspondence:
Vinicius R. Siqueira
 Rua Belem, n. 5430.
 Umuarama, Parana
Brazil.
 Zip Code: 87502-120.
 Email: vinicius.r.siqueira@aedu.com

Citation:
Siqueira VR & Oades LG (2013)  Experiential Avoidance and Psychological Acceptance Processes in the
Psychological Recovery from Enduring Mental Illness
.  International Journal of Psychosocial Rehabilitation. Vol 18(1)105-114



Abstract
Objective: The concept of recovery has been generating significant interest in mental health contexts, as has the behavioral change approach of acceptance and commitment therapy (ACT) within clinical psychotherapy contexts. This exploratory study sought to examine whether a person in psychological recovery from mental illness would describe the use of psychological acceptance and experiential avoidance, two core concepts of ACT.
Methods: Forty-five published narratives of people in recovery were content analyzed seeking to investigate the role and frequency of experiential avoidance and psychological acceptance given by those narrating their recovery journey.
Results: There was a presence of psychological acceptance in narratives of people self reporting success in their recovery journey suggestive that it will correlate with positive developments in ones journey of recovery. Conversely the role and frequency of experiential avoidance in these narratives may be associated with less progress in psychological recovery from mental illness.
Conclusion: This study showed preliminary data of the presence of experiential avoidance and psychological acceptance in narratives of people with enduring mental illness, indicating that psychological acceptance may play a positive role in the recovery from mental illness.

Key Words: acceptance and commitment theory; psychological recovery; enduring mental illness; qualitative study.



Introduction
The recovery movement is a contemporary approach to understand enduring mental illness (King, Lloyd & Meehan, 2007). This movement challenges the idea that mental illness is a life sentence, suggesting that one should be more optimistic about the future of a person with mental illness (Andresen, Oades & Caputi, 2003; Anthony, 1993). The consumer recovery movement is relatively new in the mental health field, even though strong empirical evidence of positive outcomes has been available for many years (Anthony, 1993). As a result, several psychological therapies have been adapted and developed to assist the objectives set by the recovery movement, such as Cognitive Behavioral Therapy (Durrant, Clarke, Tolland & Wilson, 2007; Kurtz, 1997), among others.

To assist the recovery process, new-generation psychological therapies are constantly being discussed in order to develop more efficient and effective psychosocial treatments. One such therapy which has shown promising initial results in assisting people with psychotic symptoms is the acceptance and commitment therapy or ACT (Bach & Hayes, 2002; Garcia & Perez, 2001). This approach is a multi-factorial and multi-dimensional therapy model that incorporates several components, and may be consistent with the principle of psychological recovery from mental illness – as it will be discussed in more detail later in this article.

Combining the recovery movement with the ACT perspective may prove fruitful. However, recovery and ACT is comprised of too many constructs and variables to be fully covered in this article, therefore the focus of this paper will follow two psychological constructs: Experiential avoidance and psychological acceptance (important ACT constructs) in the psychological process of recovery from mental illness.

Experiential avoidance has pervasive effects in one’s life (Hayes & Wilson, 1994) and is at the core of several significant clinical problems, such as substance abuse and suicide (Baumeister, 1990; Cooper, Frone, Russell & Mudar, 1995). As such, ACT suggests the use of psychological acceptance to deal with the negative effects of avoidance, which has proven successful at improving the quality of life (Hayes, Strosahl, & Wilson, 1999).

Given the pervasiveness of experiential avoidance and the benefits of psychological acceptance, this study sought to observe whether these two psychological constructs are present in the psychological recovery from mental illness, and examine the part that these two psychological constructs may take in the recovery journey.
The features of experiential avoidance and psychological acceptance are discussed in the following section.

Experiential Avoidance and Psychological Acceptance of Cognitive Content
Avoidance of unpleasant feelings and thoughts is a widely investigated process within cognitive psychology (Clark, Ball & Pape, 1991; Szentagotai, 2006; Wenzlaff, 2002). This is an extension of the idea from the “material” world: If there is something physical interfering in your life, one should try to change it, control it or eliminate it (Wenzlaff & Wegner, 2000). However, attempting to control private experiences under some circumstances can actually cause more harm than good: Attempts at suppressing thoughts and emotions can lead to a later increase of these psychological contents (Wegner, Schneider, Carter, & White, 1987).

Experiential avoidance is defined by Hayes, Wilson, Gifford, Follette & Strosahl (1996) as the:
“phenomenon that occurs when a person is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to alter the form or frequency of these events and the contexts that occasion them” (p. 1154).

Using experiential avoidance as a strategy to deal with unwanted private contents can lead to an inability to take necessary action in the face of such experiences (Hayes, & Strosahl, 2004). ACT focuses on the pervasiveness of experiential avoidance when dealing with cognitive content, seeking to promote greater psychological flexibility to assist one to be in a more direct relation with the environment and not be dominated by verbally mediated process, such as judgments, avoidance and cognitive control (Hayes, et al., 1999).

ACT suggests the use of psychological acceptance to deal with the possible harm of using experiential avoidance following a small but growing body of evidence that has indicated that in certain contexts the lack of psychological acceptance in favor of experiential avoidance may correlate with a number of psychological problems (Barnes-Holmes, Cochrane, Barnes-Holmes, Stewart, & McHugh, 2004).

Acceptance can be defined as: “actively contacting psychological experiences -- directly, fully, and without needless defense -- while behaving effectively” (Hayes, et al., 1996, p. 1163).

Acceptance however should not be regarded as a passive tolerance or a fatalistic resignation, but as the ability to embrace internal experiences (thoughts, emotions, etc.) as they occur (Hayes, et al. 1994; Hayes, et al., 1999). Such a stance brings benefits to the person since he or she can then become more in touch with the “workability” of their behaviors, in other words, he or she can see more clearly what behaviors works better in their pursued of their individual valued goals (Hayes, Follette & Linehan, 2004; Hayes & Strosahl, 2004).

The acceptance of unavoidable private events instead of the use of avoidance has proven to be beneficial in the context of mental illness. Bach and Hayes (2002), found that the use of this technique combined with others provided by ACT, significantly reduced rehospitalization and improved social functioning.
While ACT has become popular within psychotherapy, the concept of psychological recovery has been generating great interest in mental health circles.

Psychological Recovery
Andresen, Oades and Caputi (2003) used the term “psychological recovery” to refer to the formation of a new established sense of self based on hope and personal responsibility, placing no limitations on the consumer’s life – the term “consumer” is inserted to distance the passive term “patient”, designating those who had or are having treatment for mental illness or psychiatric disorder. The term was coined in an attempt do capacitate people with mental health problems in making their own choices regarding his/her treatment, considering that without them, it could not exist mental health providers (Reaume, 2002).

The same researchers mentioned above identified five stages of recovery from mental illness: (1) Moratorium: A time of withdrawal characterized by a profound sense of loss and hopelessness; (2) Awareness: Realization that all is not lost, and that a fulfilling life is possible; (3) Preparation: Taking stock of strengths and weaknesses regarding recovery, and starting to work on developing recovery skills; (4) Rebuilding: Actively working towards a positive identity, setting meaningful goals and taking control of one’s life; and (5) Growth: Living a full and meaningful life, characterized by self-management of the illness, resilience and a positive sense of self (Andresen et al., 2003).
In a later study these authors demonstrated the capacity of these constructs to be measured through the development of the Stages of Recovery Instrument (STORI) and the brief Self-Identified Stage of Recovery (Andresen, Caputi, & Oades, 2006), validating the concept of recovery as described by mental health consumers.

Psychological recovery shares some similarities with the ACT approach as it will be explored in the next section.

Psychological Recovery and Acceptance and Commitment Therapy
To further the understanding of individuals with mental illness and possibly develop new ideas and practices, it is informative to compare and contrast the recovery and ACT models. Table 1 illustrates similarities between key processes in psychological recovery as defined by Andresen et al. (2003) and the ACT model as defined by Hayes, Strosahl and Wilson (1999).


Table 1  Similarities between components of psychological recovery in mental health and psychological acceptance/experiential avoidance process from Acceptance and Commitment Therapy

Key processes of psychological recovery (Andresen et al., 2003)

Key processes in ACT (Hayes et al., 1999)

Loss of self-identity is a recurrent theme in mental illness, in which there is a process of redefining one’s identity by seeing the illness as a small part of the whole self.

A new formation of sense of self could be interpreted through the lens of ACT as a way to escape the excessive fusion with the conceptualised self of being a mentally ill person.

Finding meaning in life is integral to recovery; however, the source of that meaning can vary greatly between individuals, and possibly over time.

Finding valued goals, i.e., discovering what is important/meaningful in one’s life, is one of the most important and motivational foci of therapy for ACT.

Taking responsibility for recovery includes self-management of wellness and medication, autonomy in one’s life, accountability for one’s actions, and willingness to take informed risks in order to grow, in other words, making one’s own choices.

ACT states that “pliance”, i.e., blindly following rules by practitioners, family or friends, may not represent the best course of action for some contexts; in the case of recovery the act of choosing by oneself may led to empowerment, self-determination and commitment to recover.


Clarifying some of the contents of Table 1, it is considered that stigmatization it’s still a big problem for people with a mental illness (SANE Australia, 2008). The subtle change from “being” a mentally ill person and “having” a mental illness is significant, since the individual ceases to see himself through a static and detrimental perspective, and starts to deal with his situation, in the moment, in a more conscious way (Hayes, et al., 1999).

The definition of: “Pliance”; mentioned in Table 1 is: The process of following a rule because, in the person’s social history, following rules in itself resulted in reinforcements (Hayes, et al., 1999). Thus, in the case of recovery from mental illness where active new ways of dealing with his environment are necessary, pliance can lead to a passive static existence.

Hope is another key process identified by Andresen et al. (2003) within psychological recovery. ACT, however, is a behaviorally committed base approach that does not necessarily need to instill feelings or cognitive contents so to achieve value goals (Harris, 2008). This apparent difference can nevertheless be resolved by examining the definition of hope according to Andresen et al. (2003). These authors adopt Snyder’s hope theory (Snyder, Michael, & Cheavens, 1999), in which hope is comprised of three distinct elements: A goal; envisaging pathways to the goal; and belief in one’s ability to pursue the goal. It is also described as anticipation of a continued good state, an improved state or a release from perceived entrapment. From this perspective, ACT is also a therapy with a philosophical foundation of instilling hope as a catalyst for a person’s work (Hayes, et al., 1999).

This brief comparison between ACT and recovery revealed some parallels and possible points of conjunction that could prove beneficial to those on their journey of recovery, and at the same time expand the use of ACT as a treatment model to deal with mental illness. However, it must be stressed that further in-depth practical work should be pursued to better observe the detailed relation between these two movements. It must be also noted that there are several other movements in psychology that have been used with the recovery movement and have proven to be effective, such as cognitive-behavioural psychology (Durrant, Clarke, Tolland & Wilson, 2007; Kurtz, 1997) and positive psychology (Resnick & Rosenheck, 2006), among others.

Next it will be cover how the two psychological constructs: Experiential avoidance and psychological acceptance was observed and analyzed in published narratives of recovery from mental illness.

Method
Published Narratives of Recovery from Mental Illness
A convenience sample of forty-five published personal accounts were selected from Medline, PsycInfo and Cinahl databases, along with supplement material at-hand and relevant works cited within the literature collected. The criteria for selecting these sources were that they should be a consumer account of recovery, or a paper based on consumer accounts.

Procedures
A content analysis method was developed, identifying textual examples of the two psychological constructs: Experiential avoidance and psychological acceptance in these narratives. Categories that represented instances of psychological acceptance and experiential avoidance were defined as follows.
Psychological acceptance was defined as wholly direct way to contact psychological experiences without the need to defend oneself from such experiences, while still trying to behave effectively in the world (Hayes, et al., 1996). Experiential avoidance was defined as a phenomenon that come to pass when a person is unwilling to stay in contact with certain private experiences, such as bodily sensations, emotions, thoughts, memories, behavioral predispositions, among others, thus seeking to alter the form or frequency of these experiences and the contexts in which they occur (Hayes, et al., 1996).

The content analysis involved quantifying the presence of the two chosen constructs by selecting terms that are both explicitly as well as implicitly implicated with the idea of either construct.

All the words and phrases identified in the published narratives that could represent a presence of psychological acceptance or experiential avoidance were analyzed within the context in which they appeared. The approval or rejection of such possible textual examples were based upon the theoretical definition of the constructs.

Thus in the sentence “I tried to drown those concerns with loud music” it can be seen how somebody could pursue ways in which they tried to alter the form or frequency of undesirable private contents.  In the sentence “I wouldn’t battle against myself anymore” although appearing to be related to experiential avoidance because of the word “battle”, the negatives “wouldn’t” and “anymore” change the meaning of the phrase to acceptance.

In the sentence “I embrace those feelings that upset me” the word “embrace” signals psychological acceptance. In the sentence “struggling with thoughts that are not welcome” also seemed to resemblance psychological acceptance because deals with unwanted psychological contents. However when compared with the theoretical definition of such a construct it can be observed that it does not represent psychological acceptance.

The researcher identified the number of times that textual examples of experiential avoidance and psychological acceptance were present in the published narratives. This rating was based upon the protocol of the content analysis described above. The number of appearances of experiential avoidance and psychological acceptance within each story was then counted. The researcher added the number of appearances identified as experiential avoidance or psychological acceptance in all narratives. It was assumed that the frequency of its appearance within the stories could represent its relevance to the success or otherwise of the recovery process as described by each individual. 
Following the initial analysis of the data, a peer agreement approach was used to validate the methodology. Ten of the narratives that presented experiential avoidance and/or psychological acceptance were randomly selected to represent all the narratives. They were then analyzed by a peer following the same methodology described.

The peer, who had completed four years in psychology, had no specific training or familiarity with acceptance-based treatment approaches, having been chosen to counterbalance a possible bias by the initial rater, who has significant knowledge of ACT. The peer rater had an introductory level understanding of psychological acceptance and experiential avoidance, gained from the material presented in this manuscript. The peer was blind to the initial ratings, so to not influence their results.
Of the overall 63 textual examples of the two constructs in the sample, there was disagreement regarding only two instances. One of these related to psychological acceptance and the other to experiential avoidance. This represents a 97% rater agreement of the methodology, providing preliminary evidence of its utility as a method to identify textual examples of experiential avoidance and psychological acceptance in published narratives of recovery from mental illness.

Considerations regarding the method. It must be noted that qualitative research does not see “role” as the term is used in quantitative research, that is, findings that may be generalized to all people in similar situations. The focus in qualitative research is whether it is possible to identify patterns and themes that develop the idea, in this case, to improve the understanding of patterns common in the lived experience of recovery, such as the use (or not) of psychological acceptance and experiential avoidance in published first person accounts of recovery from psychiatric disability. The chosen strategy was content analysis, since through this method it is possible to quantify the use of common themes and patterns and therefore extrapolate the possible function of the two psychological constructs in the recovery process (Mack, 2005).

Results and Discussion
In the 28 stories in which examples of psychological acceptance or experiential avoidance were observed, the total number of instances of psychological acceptance was 92, and of experiential avoidance 25, yielding a total of 117 textual indications of these psychological constructs, as set out in Table 2.

Table 2
Frequency of occurrence of psychological acceptance and experiential avoidance in published recovery narratives
 
 
Total Narratives
 
45
 
100%
 
Narratives with experiential avoidance and/or psychological acceptance
 
 
28
 
 
62%
 
Narratives with only psychological acceptance
 
10
 
22%
 
Narratives with only experiential avoidance
 
2
 
4%
 
Narratives with psychological acceptance & experiential avoidance
 
 
16
 
 
36%
 
These numbers are relatively low in light of the length of these narratives of an average of 2,000 words. It might be suggested that these psychological constructs do not appear more frequently throughout the short narratives of recovery simply because these processes were not important or significant enough to the participants to be expressed at greater length throughout the narratives. However, it should be taken into account that the focus of the stories was not on displaying these constructs. Therefore their spontaneous appearance in 62% of the stories can possibly point to their relevance in the recovery process.

The narratives were relatively brief, understandably so since they were to be contained in a journal or part of a collection of stories for a book. The brevity of the narratives meant that the authors needed to choose their words carefully in order to produce a text that contained what they considered to be important. Consequently this raises the issue of the importance of the manifestations of psychological acceptance and experiential avoidance in these narratives.

In the majority of cases, experiential avoidance was mentioned in the past tense, referring to bad experiences and mistakes made: “I felt hurt and humiliated and I just wanted it all to go away” (Schmook, 1994, p. 2). Others were related to first steps in recovery or wrong decisions made in approaching their illness: “If I didn’t try, then I wouldn’t have to undergo another failure” (Deegan, 1996, p. 94).

Psychological acceptance was almost always used in the present tense regarding positive attitudes, good results, improvement and later stages of recovery: “I cope by recognizing and confronting my paranoid fears immediately and then moving on with my life, freeing my mind for other things” (Leete, 1989, p. 198).

Whenever indications of psychological acceptance and experiential avoidance appeared they were in the same sentence or in sentences close to each other, usually displaying contrast and/or internal conflict: “Sometimes it’s hard to accept that I generated these seemingly external observations. I avoid the use of ‘voice’ to describe what occurs in my thinking. Instead, I prefer to conceptualize these occurrences by saying it is as if I hear ‘voices’” (Greenblat, 2000, p. 244).

In some cases individuals reported examples of psychological acceptance and experiential avoidance by other people in which psychological acceptance was seemingly related to role models and experiential avoidance to the damaging figures in their lives. Deegan (1988), based on a similar principle, recommends the employment of people with some sort of disability in rehabilitation programs to serve as models, since “It becomes very difficult to continue to convince oneself that there is no hope when one is surrounded by other equally disabled persons who are making strides in their recovery!” (p. 13).

Evidence in published narratives shows that the use of psychological acceptance is more prominent in self-reported cases of successful recovery, possibly indicating that the role of psychological acceptance in recovery is related to positive developments in one’s journey of recovery. Conversely, the presence of experiential avoidance is seemingly associated with negative consequences when dealing with aspects of mental illness, possibly indicating a negative role of experiential avoidance in the recovery process.

It could be expected that experiential avoidance processes might be more prominent in those who are unsuccessful in recovery. The stories of those people are less likely to be published, since published reports are likely to be biased towards success stories. It can be speculated consequently that experiential avoidance might be more prominent in reports of those struggling or in early stages of recovery and is not represented in the published literature of first person accounts of recovery in mental illness. Another issue regarding avoidance is that this psychological construct was difficult to detect in this study, since it is assumed that it depends on a great deal of insight into his or her condition to recognize experiential avoidance in their behavior and thus they may not express this in their stories.

General Conclusion

This preliminary study sought to qualitatively observe the role and frequency of psychological acceptance and experiential avoidance in narrative accounts of recovery. The results cautiously suggest that the high prevalence of psychological acceptance in narratives of recovery of people who self-report success in their recovery journey is consistent with positive developments in recovery. Conversely, experiential avoidance, as seen through its frequency and role in the published narratives, is possibly associated with setbacks and difficulties when dealing with aspects of mental illness.

Though preliminary, this article hopes to instigate more elaborated and related studies on the interaction of ACT and recovery since ACT is a treatment modality that can be comparable with the principles of psychological recovery, thus opening a window for positive dialogue between them. Furthermore, collaborations between models can lead to the development of improved focused therapeutic strategies that can promote psychological recovery in individuals with a mental illness.


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