Development of the Valuing Questionnaire

1. Development of the Valuing Questionnaire Dr Matthew Davies & Dr Matthew Smout School of Psychology University of Adelaide

2. ACT’s emphasis on values “…creative hopelessness, defusion, connecting with self, acceptance, contact with the present moment, and valuing must lead to actual concrete differences in the client’s behaviour that service those valued ends” (Strosahl et al., 2004) “While ACT allows for symptom alleviation, it is not a main target or the therapeutic goal. Rather the focus is on what we call broadband outcomes. Such outcomes are about helping the client move in life directions that they truly care about” (Eifert & Forsyth, 2005) “All ACT techniques are eventually subordinated to helping the client live in accord with his or her chosen values.” (Hayes et al.,1999, p.205)

3. Values assessment in ACT research to date • Values measures not used as primary outcome measures in most ACT studies • Not all studies include values measures • Those that do usually operationalise as quality of life/satisfaction with life: state not behaviour

4. Existing values measures • Outside ACT • Rokeach Values Questionnaire • Schwartz Values Survey • Values In Action (VIA) • Inside ACT • VLQ • Bull’s Eye • Chronic Pain Values Inventory (CPVI) • Survey of Life Principles • Personal Values Questionnaire (PVQ)

5. Difficulties with individual domains methods • Having domains considered individually do not represent how values work – i.e., out of context of choice, promote intellectualised / idealised choosing; ranking would be more realistic but creates psychometric limitations • Therefore, empirically all domains get high importance ratings: little differentiation (McCracken & Yang, 2006) • Also high social desirability • Difficult to weight/combine across domains meaningfully. • Time is limited; valuing as a verbal-linguistic activity is relatively unlimited. e.g.,Low consistency in one domain due to high consistency in another domain may still reflect living relatively ideal valued living • One behaviour may serve more than one value; one valued domain may be served by many behaviours • Assessing by domain increases number of items; makes it difficult to capture other ACT-specific qualities of values in a brief measure

6. Methodology: Item generation • Searched key ACT texts for “value” references to comprehensively cover the concept from an ACT perspective • Hayes et al (1999) Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford • Hayes & Strosahl (2004). A practical guide to acceptance and commitment therapy. New York: Springer. • Wilson & Dufrene (2009). Mindfulness for two: An acceptance and commitment therapy approach to mindfulness in psychotherapy. Oakland: New Harbinger. • Dahl et (2009) The Art and Science of Valuing in Psychotherapy: Helping Clients Discover, Explore, and Commit to Valued Action Using Acceptance and Commitment Therapy. Oakland: New Harbinger. • Eifert & Forsyth (2005). Acceptance and commitment therapy of anxiety disorders. A Practitioner's Treatment Guide to Using Mindfulness, Acceptance, and Value-Guide Behavior Change Strategies. Oakland CA: New Harbinger. • Luoma et al (2007). Learning Act: An Acceptance & Commitment Therapy Skills-Training Manual for Therapists (Context / Nhp Context / Nhp). • Ciarrochi & Bailey (2008). A CBT-Practitioner's Guide to ACT: How to Bridge the Gap Between Cognitive Behavioral Therapy and Acceptance and Commitment Therapy. Oakland: New Harbinger. • Zettle (2007). Act for Depression: A Clinician's Guide to Using Acceptance and Commitment Therapy in Treating Depression. Oakland CA: New Harbinger. • Plus self help books by Hayes & Smith (2005), Forsyth & Eifert (2008), Strosahl & Robinson (2008)

7. Methodology: Item generation • Apparent key features of values from ACT standpoint: • Clarity • Priority • Chosen; Pliance not main source of control “Justification of actions involves fitting them into existing culturally supported verbal networks…in many ways this is the exact opposite of valuing” (Hayes et al., 1999, p.208) • Enactment “To some degree, we engage in an act of valuing each time we do something that is purposive or instrumental” (Luoma et al., 2007, p.131) • Persistence “If the client bases living entirely on the absence of emotional or cognitive obstacles, then valued directions cannot be pursued in a committed fashion (Hayes et al, 1999, p.210). • Engagement/vitality “living in accord with one’s values lends an inherent sense of purpose and vitality that makes confronting monsters a legitimate and honourable undertaking” (Hayes et al., 1999, p.209) • Consistency/stability “Values are more abstract and global than concrete verbal goals and thus provide a kind of verbal glue that makes sets of verbal goals more coherent” (Hayes et al, 1999, p. 207); “Basic values seldom change” (Hayes et al., 1999, p.259)

8. Methodology: Item generation • Brainstormed a list of items to tap each facet. • Initially gave list of 64 items to friends/family to rate readability (clear, not sure, unclear) & provide comments • A list of the 64 items then given to one group (n=4) of ACT experts to rate how well each item represents valuing on a scale of 0 to 4. • Items deleted/amended on feedback, new items generated, 79-item list provided to 3 other experts to rate for representativeness (Thanks to Patty Bach, Rob Zettle, Robyn Walser, Russ Harris, Joe Ciarrochi, Kirk Strosahl, Jennifer Plumb) • Final list of 70 items. • Questionnaire starts with the statement: • “1. Please read each statement carefully and then select the number which best describes how much the statement was true for you DURING THE PAST WEEK, INCLUDING TODAY. • Likert Scale from 0 (Not At All) to 6 (Completely)

9. Methodology: validation • Administered to n=658 university students: ~50% random split for exploratory/confirmatory • Validation measures • Depression Anxiety Stress Scales (DASS) (symptom measure) • Satisfaction With Life Scales (SWLS) • Valued Living Questionnaire (VLQ) • Positive and Negative Affect Scales (PANAS) • Mindfulness Attention Awareness Scale (MASS) • Acceptance and Action Questionnaire II (AAQ II) • Ryff’s (1989) Wellbeing Scales • Autonomy • Environmental Mastery • Personal Growth • Positive relations with others • Purpose In Life • Self-acceptance

10. Demographics

11. How should a valuing questionnaire be validated? Self-report measures Strongest positive associations • other values measures: VLQ • satisfaction with life • well-being • ?quality of life Moderate positive associations • Measures of mindfulness • Measures of psychological flexibility Low correlations • Affect states • Psychological and physical symptoms

12. Exploratory Factor Analysis • Deleted Multivariate outliers (n=59) • Principal Axis Factoring • 11 Eigenvalues > 1 • 2 factors accounted for 51% variance • Promax (oblique) rotation

13. Factor 1 – “Successful valued living” • Rotation Sums of Squares Loading = 25.6% variance • 40/70 variables loaded > .32 on this factor • 10 variables loaded .8 -.85; Cronbach α = .95 • I continued to get better at being the kind of person I want to be • I did things that brought me closer to what really matters to me in my life • I made progress in the areas of my life I care most about • Most of the things I did were very important to me • I was proud about how I lived my life • I lived my life in a manner I would be happy to be remembered for • I’ve been able to stay focused on the things that are most important to me in life • I was active and focused on the goals I set for myself • I was in touch with what was important to me • My behaviour was a good example of what I stand for in life

14. Factor 2 – Disrupted valued living • Rotation Sums of Squares Loading = 19.4% variance • 30/70 variables loaded > .32 on this factor • 10 variables loaded .7 -.81, Cronbach α = .93 • I tried to work towards important goals, but something always got in the way • I had unpleasant thoughts and emotions that stopped me from achieving my goals • Difficult thoughts, feelings or memories got in the way of what I really wanted to do • It seemed like I was just ‘going through the motions’, rather than focusing on what was important to me • I spent a lot of time trying to please other people • I found it hard to follow through on important activities because of unpleasant thoughts and feelings • Most of what I did was to please other people, rather than doing what’s important to me • I was basically on “auto-pilot” most of the time • When things didn’t go according to plan, I gave up easily • I found it hard to stay focused and engaged with what I was doing

16. Confirmatory Factor Analysis Fit Indices • CMIN/DF = 1.914 (< 3 OK) • NFI = .945 (.9 - .95 OK, > .95 ideal) • GFI = .912 (should be > .9) • AGFI = .877 (should be > .9) • CFI = .973 (closer to 1 better) • RMSEA = .058 (< .06 good, closer to .05 better) • TLI = .966 (close to 1 better, can exceed 1)

17. Validation with Existing Measures

18. Symptom Measures – DASS-21 & PANAS

19. Well-Being & Life Satisfaction

20. Valued Living Questionnaire

21. Mindfulness & Acceptance

22. Alison Christie – Honours thesis • N = 555 • Age: M = 32.9, sd 14.87 • 69.5% Female • Country: • Australia = 78% • North America = 15.2% • Europe = 4% • Education: • <12 years schooling: 5% • Year 12 = 39% • University = 44% • Other professional = 7% • Income: • < $20,000 = 19% • $20,000-$69,999 = 29% • $70,000-$129,999 = 28% • > $130,000 = 24%

23. Christie cont.. • Tested a 35-item version (2 items dropped – did not load). EFA: 2 factors accounted for 52.2% variance All significant p < .001

24. Christie cont.. • Tested a 35-item version (2 items dropped – did not load). EFA: 2 factors accounted for 52.2% variance All significant p < .001

25. Preliminary sensitivity to change - Dewar N=24 government department workers & friends attending an “ACT for the general public” pilot 5-session program VQ was a 12-item verson (top 3 loading items of an early 4-factor PCA) summed (with reverse coded items reversed)

26. Summary of Valuing Questionnaire Findings • General (rather than domain-specific) values measure • Captures two facets of valuing (r = -.516) • Factors are internally reliable • Items generated in consultation with ACT experts and literature • Convergent Validity demonstrated with established ACT & Non-ACT measures, although is VQ functioning as mood measure in current form or is it that existing ACT Values measures are problematic?

27. How should a valuing questionnaire be validated? Future work • ?Test more “behavioural” item version • Comparing questionnaire responses to other means of capturing valued behaviour (e.g., diaries, EMA) • Correlation between Valuing Questionnaire responses and size of domain-specific values-behaviour correlations • Developing norms for clinical and high-achieving/ “successful” populations • Sensitivity to change: in general; to values-focused interventions AND OF COURSE FINALISING THE STATISTICAL ANALYSES ON THE CURRENT DATA SET

28. Primary outcome measures in ACT studies 17 studies: 8 measure distress/symptoms; 2 measure willingness, 4 measure problem behaviours, 3 objective/indirect measures of problem behaviour. 0 directly measure changes in valued living.

29. Use of values measures in ACT studies since Hayes et al (2006) Bricker et al (2010) telephone-delivered ACT smoking: Intent-to quit & smoking cessation. No values measures Hayes et al (2010) acceptance-based behaviour therapy for GAD: VLQ, “What percentage of the time did you feel you were spending time on the things that are important to you?” (0-100) % time spent in things important: 48.31% → 71.55% over therapy Valued action was not a significant predictor of quality of life after acceptance controlled Hernandez-Lopez et al (2009): ACT v CBT smoking.No values measures Johnson et al (2010): ACT self-help for chronic pain (n=14) Chronic Pain Values Inventory: discrepancy between importance and success across various life domains Both ACT and control group reduced values-discrepancy scores over time, no differences Lillis et al (2009): 1-day mindfulness & acceptance workshop for obesity. Used weight-related quality of life measure (ORWELL). 3-mo FU better QOL for intervention group.

30. Use of values measures in ACT studies since Hayes et al (2006) Lungdren et (2008): n=18 RA ACT v yoga for drug-refractory epilepsy. Used SWLS & WHO-QOL (both groups improved equally on these measures) Wicksell et al (2009) ACT v TAU chronic pain whiplash. Improvements in SWLS Dalrymple & Herbert (2007) n=19 uncontrolled ACT social anxiety. Used VLQ (importance-consistency discrepancies) & QOLI, both improved over time. Forman et (2007) 101 Randomly assigned ACT v CBT. Both groups improved on SWLS, QOLI Forman et (2007) acceptance v control-based strategies coping with food cravings. No values measures Gregg et (2007): RCT Education + ACT v Education. No values measures Lappalainen et (2007) CBT and ACT in trainees. No values measures Lungdren et (2008) mediators of ACT on epilepsy in n=28 South Africans. Values attainment and persistence in face of barriers (measured by BullsEye) correlated with seizures, SWLS, WHO-QOL, wellbeing (magnitude .61 - .73) Luoma et (2008) 6-hour group workshop for reducing self-stigma for people in addiction Tx. Used Quality of Life Scale but no values specific measures.

31. Existing values measures Values In Action (VIA) Designed to measures 24 “character strengths” (e.g., creativity, vitality, kindness) Individual rates agreement with statements describing behaviour representative of strength (e.g., “am able to come up with new and different ideas”) A = very much like me – E = very much unlike me High item numbers (e.g., 213-item version used by MacDonald et al, 2008) Trait-like in standard form: encourages personality assessment

32. Existing values measures Valued Living Questionnaire (VLQ) (Wilson et al., 2010) Individual rates each of 10 valued domains 1-10 for Importance and how consistently has lived according to how much they value the domain: Family relations Marriage/couples/intimate relations Parenting Friendships/social Employment Education/training Recreation Spirituality Citizenship/Community Life Physical Well-being

33. Existing values measures Bull’s eye (Lungdren et al, 2005): Individual places x to represent how consistent his/her actions are to his/her valued direction Distance from bull’s eye = discrepancy in valued living Final Bullseye = psychological barriers to valued living. Individual places X representing persistence in pursuing values in face of barriers Test-retest reliability r = .86 Mediation of follow-up changes in seizures, personal wellbeing from ACT for epilepsy (Lungdren et al., 2008)

34. VLQ (Wilson et al., 2010) Validation with n=338 undergraduates and Butcher Treatment Planning Inventory Importance range limited: mean ratings from 7.43 – 9.46 Importance-consistency product normally distributed One factor accounts for 35% variance: item-factor loadings ranged .39 - .65. Internal consistency importance α = =.77 and consistency α =.75 : interpretation needs validation.

35. VLQ (Wilson et al., 2010) Consistency subscale correlation with ‘% time on things that are important to you’ = .4 (Hayes et, 2010) Very low correlation with AAQ r = -.14 Correlation with MCSD r = .25 ?VLQ ‘consistency’ wording confusing when individuals rate domain low importance

36. CPVI McCracken & Yang, 2006: 6 domains (family, intimate relations, friends, work, health, growth & learning) Rate importance 0 (not at all) - 5 (extremely important) Rate success 0(not at all) – 5 (extremely successful) Importance-success discrepancies unrelated to pain intensity α = .82 (success, discrepancy)

37. CPVI CPVI cont.. Discrepancy score is sensitive to change (Johnston et al., 2010) Moderate relations to general health (SF-36) .36-.53 & unique variance after Acceptance & mindfulness in 7/8 SF-36 scales (McCracken & Vellerman, 2010) Prospectively predict pain-related anxiety and impairment (Vowles & McCracken, 2008)

38. CPVI McCracken & Keogh (2009)

39. Survey of Life Principles (see Ciarrochi & Bailey, 2008) 52 items representing 10 universal values cluster of Schwartz Each rated 1-9 for importance, pressure to hold & 1-5 putting into practice & success in implementing. Norms for university students for Importance, Pressure, Success, Activity for each item.

40. Personal Values Questionnaire (PVQ) (Blackledge et al) 9 values domains (full version); 3 value domains (family, couple relationships, friendships) Individual writes down their value statement in each domain and then rates on 1-5 scale: Importance Commitment to living the value Desire to improve progress Success in living the value in last 10 weeks Social pressure to hold value Guilt/shame if value was not important Importance free of social pressure Extent the value makes life meaningful Experience fun and enjoyment when living consistently with value