Experiential Avoidance and Psychological
Acceptance Processes in the Psychological Recovery
from Enduring Mental IllnessVinicius R. Siqueira & Lindsay G. OadesSchool of PsychologyIllawarra Institute for Mental Health
University of Wollongong,
Wollongong Australia & Anhanguera, Cascavel, Brazil.
R. Siqueira has a Master of Science by Research in Psychology by the
University of Wollongong and is a Professor at Anhanguera, Cascavel,
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.
Vinicius R. Siqueira
Rua Belem, n. 5430.
Zip Code: 87502-120.
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
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
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
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.
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.
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),
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, &
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
The features of experiential avoidance and psychological acceptance are discussed in the following section.
Experiential Avoidance and Psychological Acceptance of Cognitive Content
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:
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).
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
While ACT has become popular within psychotherapy, the
concept of psychological recovery has been generating great interest in
mental health circles.
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).
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.,
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
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).
1 Similarities between components of psychological recovery in mental
health and psychological acceptance/experiential avoidance process from
Acceptance and Commitment Therapy
of psychological recovery (Andresen et al., 2003)
in ACT (Hayes et al., 1999)
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.
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.
meaning in life is integral to recovery; however, the source of that meaning
can vary greatly between individuals, and possibly over time.
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.
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.
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.
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
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.
Published Narratives of Recovery from Mental Illness
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
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
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).
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.
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
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.
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.
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
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.
Frequency of occurrence of psychological acceptance
and experiential avoidance in published recovery narratives
with experiential avoidance and/or psychological acceptance
with only psychological acceptance
with only experiential avoidance
with psychological acceptance & experiential avoidance
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.
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.
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).
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).
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.
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.
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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