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Differential Role of CBT Skills, DBT Skills and Psychological Flexibility in Predicting Depressive Versus Anxiety Symptom Improvement

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CBT Skills, DBT Skills
  Differential role of CBT skills, DBT skills and psychological  󿬂 exibility inpredicting depressive versus anxiety symptom improvement Christian A. Webb  a ,  * , Courtney Beard  b , Sarah J. Kertz  c , Kean J. Hsu  b ,Thr € ostur Bj € orgvinsson  b a Department of Psychiatry, Harvard Medical School and Center for Depression, Anxiety and Stress Research, McLean Hospital b Behavioral Health Partial Program, McLean Hospital, Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA c Department of Psychology, Southern Illinois University, Carbondale, IL, USA a r t i c l e i n f o  Article history: Received 4 November 2015Received in revised form24 March 2016Accepted 27 March 2016Available online 30 March 2016 Keywords: DepressionBehavioral activationCognitive restructuringPsychological  󿬂 exibilityPsychiatric hospital a b s t r a c t Objective:  Studies have reported associations between cognitive behavioral therapy (CBT) skill use andsymptom improvement in depressed outpatient samples. However, little is known regarding the tem-poral relationship between different subsets of therapeutic skills and symptom change among relativelyseverely depressed patients receiving treatment in psychiatric hospital settings. Method:  Adult patients with major depression (N  ¼  173) receiving combined psychotherapeutic andpharmacological treatment at a psychiatric hospital completed repeated assessments of traditional CBTskills, DBT skills and psychological  󿬂 exibility, as well as depressive and anxiety symptoms. Results:  Results indicated that only use of behavioral activation (BA) strategies signi 󿬁 cantly predicteddepressive symptom improvement in this sample; whereas DBT skills and psychological  󿬂 exibilitypredicted anxiety symptom change. In addition, a baseline symptom severity X BA strategies interactionemerged indicating that those patients with higher pretreatment depression severity exhibited thestrongest association between use of BA strategies and depressive symptom improvement. Conclusions:  Findings suggest the importance of emphasizing the acquisition and regular use of BAstrategies with severely depressed patients in short-term psychiatric settings. In contrast, an emphasison the development of DBT skills and the cultivation of psychological  󿬂 exibility may prove bene 󿬁 cial forthe amelioration of anxiety symptoms. ©  2016 Elsevier Ltd. All rights reserved. The ef  󿬁 cacy of cognitive behavioral therapy (CBT) for thetreatment of depression has been evaluated in numerous clinicaltrials (DeRubeis, Webb, Tang,  &  Beck, 2010; Epp  &  Dobson, 2010).Despitethelargebodyofevidencesupportingtheoverallef  󿬁 cacyof CBT in alleviating depressive symptoms (Cuijpers et al., 2013), themechanisms that account for symptom improvement remainpoorly understood. One hypothesis is that the acquisition andregular use of core cognitive and behavioral skills represents acentral mechanism through which patients improve.Several relatively brief patient-report measures of CBT skillshave recently been developed, including the Skills of CognitiveTherapy scale (SoCT; Jarrett, Vittengl, Clark,  &  Thase, 2011), theCognitive Behavioral Therapy Skills Questionnaire (CBTSQ; Jacob,Christopher,  &  Neuhaus, 2011) and the Competencies of CognitiveTherapy Scale (CCTS; Strunk, Hollars, Adler, Goldstein,  &  Braun,2014). Studies using these measures have reported that greaterdepressive symptom improvement is associated with greateracquisition and use of CBT skills, as assessed by the SoCT ( Jarrettet al., 2011; 2013), CBTSQ ( Jacob et al., 2011; Webb, Kertz, Bigda-Peyton,  &  Bj € orgvinsson, 2013) and CCTS (Strunk et al., 2014). However, causal inferences regarding the role of CBT skills incontributing to depressive symptom improvement are limitedgiven that most of the associations reported within these studiesarebasedononeortwoconcurrentassessments(e.g.,onlypre-andpost-treatment) of CBT skills and depressive symptoms. Given thecross-sectional designs used within most studies to date, a signif-icant association between CBT skills and symptom improvementcould be due to skill use causing symptom change or vice-versa (orbe the result of an unmeasured third variable confound).In addition to the above common temporal confounds in theCBT skills literature, the bulk of studies investigating the *  Corresponding author. E-mail address: (C.A. Webb). Contents lists available at ScienceDirect Behaviour Research and Therapy journal homepage: ©  2016 Elsevier Ltd. All rights reserved. Behaviour Research and Therapy 81 (2016) 12 e 20  association between skills and symptom change are conductedwithin the context of outpatient settings or in carefully controlledclinical trials (for an exception, see Jacob et al., 2011). We knowsurprisingly little about the extent to which different subsets of CBT skills predict symptom improvement among more severelydepressed patients receiving treatment in psychiatric hospitalsettings. Data from these treatment contexts are critical toinforming our understanding of the mechanisms that account forsymptom improvement in naturalistic settings and to comple-ment clinical trial data. In terms of clinical implications,  󿬁 ndingsregarding which CBT skills predict symptom improvement mayultimately inform which treatment elements and interventionsare emphasized by CBT therapists in different settings. Null  󿬁 nd-ings may also be theoretically and clinically informative. Namely,if patient acquisition and use of core cognitive or behavioral skillsfails to predict depressive symptom improvement, then it maysuggest that some of these skills are either therapeutically inert,or are moderated by important patient characteristics (e.g., pre-treatment depression severity [Webb et al., 2012], comorbidpersonality disorders [Keefe, Webb,  &  DeRubeis, 2016]) or treat-ment setting (e.g., short-term, intensive inpatient or partial hos-pital treatment vs. longer-term outpatient treatment involvingweekly therapy sessions).The goal of the present study was to expand on prior researchandexaminetheroleofcognitiveandbehavioralskillsinpredictingdepressive symptom improvement within the context of a natu-ralistic psychiatric setting treating severely depressed patients. Asnoted above, previous studies commonly rely on one or two (e.g.,pre- and post-treatment) assessment timepoints to represent thestate of patient CBTskills throughout treatment. To achieve a more 󿬁 ne-grained and statistically powerful test of skill-outcome asso-ciations, we included repeated assessments of CBT skills anddepressive symptoms over the course of treatment. To our knowl-edge, the present study is the 󿬁 rst totest whether patient-reportedCBTskilluse,assessed repeatedlythroughoutthecourseof therapy,predicts  subsequent   depressive symptom improvement. It shouldbe noted that Jarrett et al. (2011; 2013) reported that their SoCTmeasure, assessed at one mid-treatment timepoint, prospectivelypredicted post-treatment depression response (controlling for pre-treatment depression scores). However, the authors did not controlfor (1) concurrentsymptoms (i.e., assessed at the time at which theSoCT was measured) or (2) prior symptom change (i.e., symptomimprovement prior to the SoCT assessment), both of which repre-sent plausible confounds. Indeed, others have noted how measuresof self-reported CBT skills may inadvertently measure and beconfounded with concurrent symptoms (Strunk et al., 2014).Similarly, the abovementioned studies examining the associationbetween self-reported CBT skills and symptom change did notcontrolforpriordepressivesymptomimprovement.Priorsymptomchange may represent a third variable confound in so far as itpredicts  both  subsequent symptom change and CBT skill use. Forexample, a patient in CBT treatment who has experienced signi 󿬁 -cant depressive symptom improvement may be more likely toendorse using cognitive and/or behavioral skills (whether or nottheyinfactacquiredandareusingtheseskills).Thesetwoplausiblesymptom confounds are included as covariates in the analyses re-ported below. 1. Assessing both traditional and  “ newer generation ” cognitive behavioral skills Recent developments in transdiagnostic treatment have sup-ported the integration of newer generation cognitive behavioralstrategies for managing common depressive and anxiety symp-toms. For example, there is evidence that acceptance andcommitment therapy (ACT) is ef  󿬁 cacious for both depressive andanxiety symptoms (Ost, 2014; Swain, Hancock, Hainsworth,  & Bowman, 2013). Further, there is growing evidence of the thera-peutic bene 󿬁 t of dialectical behavior therapy (DBT) skills in alle-viating depression and anxiety in mixed samples of depressed andanxious adults (Neacsiu, Eberle, Kramer, Wiesmann,  &  Linehan,2014; Ritschel, Cheavens,  &  Nelson, 2012). As such, moderncognitive behavioral treatment packages for affective disordershave moved to incorporate both traditional CBT interventions (i.e.,cognitive restructuring [CR] and behavioral activation [BA] tech-niques) as well as those from ACT and DBT that emphasize mind-fulness- and acceptance-based strategies and decreasingexperiential avoidance (e.g., Uni 󿬁 ed Protocol for Emotional Disor-ders; Barlow et al., 2010). The expansion of traditional CBT pro-tocols and increased utilization of a variety of interventions in thetreatmentofdepressioninreal-worldpsychiatricsettingsraisesthequestion:  What elements of treatment are most effective for different subsets of symptoms most commonly experienced by depressed pa-tients  ( in particular  ,  depressive versus anxiety symptoms )? Suchknowledge may ultimately help inform treatment planning andassist providers in selecting the most effective and ef  󿬁 cient in-terventions for different symptom domains.The current study examined associations between differentsubsets of cognitive behavioral skills (both traditional and newergeneration) emphasized within the context of a multi-facetedintervention package, and depression and anxiety outcomes. Spe-ci 󿬁 cally, in addition to assessments of CBT (BA and CR) skills, thestudy included repeated assessments of DBT skills and ACT-basedpsychological  󿬂 exibility in order to investigate differential associ-ations with symptom change in a sample of depressed patientsreceiving treatment in a naturalistic psychiatric setting incorpo-rating CBT-, DBT- and ACT-based group and individual therapy (see Participants and Treatment Setting   below). 2. Assessing both depressive and anxiety symptomimprovement as outcomes Given the exceptionally high rates of co-occurrence betweendepression and anxiety (Kessler et al., 2003), we were interested inexamining the speci 󿬁 city of CBTskills, DBTskills, and psychological 󿬂 exibility in predicting depressive versus anxiety symptomimprovement. Of particular interest is the relative contributions of CBTskills compared tothe developmentofpsychological 󿬂 exibility,given growing evidence to support the role of experiential avoid-ance in anxiety and anxiety disorders. For example, a recent meta-analysis across 63 studies found a signi 󿬁 cant association betweenexperiential avoidance and anxiety (Bluett, Homan, Morrison,Levin,  &  Twohig, 2014). Several reviews and meta-analyses haveconcluded that ACT has comparable outcomes to CBT for anxiety(A-Tjak et al., 2015; Ruiz, 2012; Swain et al., 2013). Further, there isevidence that ACT is associated with greater decreases in experi-ential avoidance relative to cognitive therapy (Lappalainen et al.,2007) and such decreases mediate anxiety and depression out-comes (Forman, Herbert, Moitra, Yeomans,  &  Geller, 2007). Re-searchers have speculated that the development of greaterpsychological 󿬂 exibility mayaccount for the therapeutic bene 󿬁 ts of ACT on anxiety symptoms (For a review, see Bluett et al., 2014;Forman et al., 2007). As previously noted, there is also emergingevidence that DBT skills training is effective for decreasing anxietyin adults with affective disorders (Neacsiu et al., 2014; Ritschelet al., 2012). Thus, an additional exploratory aim of the study is toexamine differential effects of CBT (BA and CR) skills, DBTskills andincreased psychological  󿬂 exibility on anxiety symptom improve-ment in our depressed sample. C.A. Webb et al. / Behaviour Research and Therapy 81 (2016) 12 e  20  13  3. Hypotheses The theoretical literature on CBT (Beck, Rush, Shaw,  &  Emery,1979; Coffman, Martell, Dimidjian, Gallop,  &  Hollon, 2007) andempirical  󿬁 ndings (Dimidjian et al., 2006) highlight the bene 󿬁 t of BA strategies for more severely depressed patients. Moreover, BAmay be particularly bene 󿬁 cial in briefer treatment contexts, incomparison to relatively more complex CR skills, which mayrequiremoretimetoacquireandlearntocompetentlyutilize.Thus,given the depression severity of the present hospitalized sample(see  Participants and Treatment Setting   below), coupled with theshort-term nature of the treatment setting (average length of treatment  ¼  11.7 days), we hypothesized that only BA strategieswould predict subsequent depressive symptom improvement( Hypothesis 1 ). We further hypothesized that a pretreatmentdepression severity by BA - but not CR   e  strategies interactionwould emerge, such that those patients with higher intakedepression severity would exhibit the strongest associations be-tween use of BA strategies and subsequent depressive symptomimprovement ( Hypothesis 2 ).  3.1. Exploratory hypothesis Finally, given the high comorbidity between depression andanxiety and to test the speci 󿬁 city of our  󿬁 ndings to depression, wealso examined whether BA, CR, DBT skills, or the development of psychological  󿬂 exibility predicted subsequent anxiety symptomchange. Given that depression was the primary treatment target,analyses regarding anxiety symptoms were exploratory. In light of growing data on the ef  󿬁 cacy of ACT for anxiety symptoms ( € Ost,2014; Swain et al., 2013), in particular the therapeutic bene 󿬁 ts of the development of psychological  󿬂 exibility for anxiety (Bluettet al., 2014), we expected that increased psychological  󿬂 exibilitymay be associated with improvement in anxiety symptoms. 4. Method 4.1. Participants and treatment setting  Participants were patients receiving treatment within theBehavioral Health Partial Hospital Program (BHP) at McLean Hos-pital(Belmont,MA),a HarvardMedicalSchoolteachinghospital.Tobe included in the present study, patients had tobe admitted totheBHP, complete the assessment battery described below, and meetcriteriaforacurrentdiagnosisofMajorDepressiveDisorder(MDD).Patients with Bipolar Disorder (i.e., current or past Manic/Hypo-manic episode), or a current or past Psychotic Disorder wereexcluded. A total of 173 patients (ages 18 e 72 years,  M   ¼  35.47, SD ¼ 13.61;56% females)metthesecriteriaduringthestudyperiod(July,2013toJuly,2014)andprovided writteninformedconsentfortheir clinical data to be used for research studies. Participantsclassi 󿬁 ed themselves as 88% White, 5% African-American, 5% Asian,3% Latino, 3% Other (total percentage exceeds 100% as some par-ticipants identi 󿬁 ed with multiple racial/ethnic categories). Withregards to current marital status, 30% were married, 57% werenever married,11% were separated or divorced, and 2% were livingwith a partner. With regards to employment, 29% of the samplereported being currently unemployed (not due to being a currentstudent).Previous episodes of depression were very common in oursample, with a mean of 5.90 ( SD  ¼  8.52) reported previous epi-sodes.Meanageof  󿬁 rstmajordepressiveepisodewas18.1yearsold(median  ¼  16 years; range 5 e 50 years). The pretreatment meanCES-D-10 depression score for the sample (M ¼ 20.30) was doublethe suggested clinical cutoff of 10 (Andresen, Malmgren, Carter,  & Patrick, 1994). Moreover, diagnostic comorbidity was also com-mon, in particular for anxiety disorders (61.3% of the sample metcriteria for a current anxiety disorder). Current diagnoses at thetime of intake were as follows: 27.2% ( n  ¼  47) of our sample metcriteriaforconcurrentGeneralizedAnxietyDisorder,28.3%( n ¼ 49)for Social Anxiety Disorder,12.1% ( n ¼ 21) for Post-Traumatic StressDisorder, 22.5% ( n  ¼  39) for Panic Disorder, and 11.6% ( n  ¼  20) forObsessive Compulsive Disorder. In addition, 13.3% ( n  ¼  23) of thesamplemetcriteriafor AlcoholAbuseor Dependence.Twenty-ninepercent ( n  ¼  51) of the sample scored above the cut-off (totalscore    7) suggesting a BPD diagnosis on the McLean ScreeningInstrument for Borderline Personality Disorder (MSI-BPD; Zanariniet al. 2003). Nearly half (47%) of the sample had previously beenhospitalized (inpatient) at least once for their psychiatric problems(30% received inpatient psychiatric treatment in the week prior toadmissiontotheBHP).Twenty-ninepercent(51/173)receivedpriorpsychiatric treatment within either a partial hospital program orintensive outpatient program. With regards to data on pharmaco-logical treatment, we began tracking medications prescribed topatients after data collection for the current study began. However,wereport descriptive information fromour medication database toprovide some detail about the typical pharmacological treatmentreceived in the BHP. Upon admission, all MDD patients were pre-scribed at least one antidepressant (77% SSRI, 4% Tricyclic, 4% Tet-racyclic, 15% other). MDD patients were also prescribed thefollowing types of medications upon admission: 17% benzodiaze-pine, 3% non-benzo anti-anxiety medication, 8% atypical antipsy-chotic, 7% anti-epileptic mood stabilizer, 1% other mood stabilizer,6% stimulant/ADHD medication.TheBHPdeliversCBTandrelatedbehavioralapproaches(bothingroup and individual formats) and pharmacological treatment topatients suffering from a wide range of psychiatric disorders(principally mood and anxiety disorders). Individual treatmentplans were constructed for each patient by clinical team managerswho conducted intake assessments, developed an initial concep-tualization, and oversaw all aspects of treatment. Treatment con-sisted primarily of CBT-based groups provided by psychologists,social workers, occupational therapists, postdoctoral and graduatelevel psychology trainees, and mental health counselors. Patientsattended up to  󿬁 ve 50-min groups each day,  󿬁 ve days per week(Monday-Friday). Of these, one group per day focused on behav-ioral activation (BA) strategies, based on a protocol adapted fromMartell, Dimidjian, and Herman-Dunn (2010). A second groupfocused on identifying and challenging negative automaticthoughts related to depression and was guided by a protocoladaptedfromBecketal.(1979).Althoughdepressionistheprimarytreatment target, given the elevated prevalence of co-occurringanxiety patients also attended a number of CBT anxiety-relatedgroups. Speci 󿬁 cally, treatment included groups focused on worryand stress management (Craske  &  Barlow, 2006). Patients alsoattended a number of groups focused on cultivating core DBTskills(i.e., distress tolerance, emotion regulation, and interpersonaleffectiveness; Linehan,1993). Finally, patients also attended groupsfocused on an ACT approach to emotional problems (Hayes  & Smith, 2005). The ACT-based groups focused on the ineffective-ness of emotional avoidance and on cultivating psychological 󿬂 exibility, or the ability to accept distressing internal experiencesand act in accordance with one's values. Of note, mindfulnessgroups were relevant to both DBT and ACT approaches. Theremaining group content included psychoeducation, self-monitoring, and wellness. We began collecting data on groupattendance after data collection for the current study began. Wereport descriptive information from this database to provide moredetail about the typical treatment received at this partial hospital.For these descriptive data, and similar to the pharmacological C.A. Webb et al. / Behaviour Research and Therapy 81 (2016) 12 e  20 14  treatment data reported above, we applied the same inclusioncriteria as the current study (current MDD, consented to researchstudy). For MDD patients, the average number of groups attendedover the course of their stay at the BHP was 31 (SD  ¼  10).Approximately 88% of MDD patients attended CBT, DBT, and ACT-based groups. On average, patients attended the following num-ber of groups for the skills examined in the current paper: fourbehavioral activation, three cognitive restructuring, two distresstolerance, one emotion regulation, one interpersonal effectiveness,one mindfulness, and one acceptance and values-oriented.Group leaders were rated for adherence to the group protocolstwice per year by trained research assistants. Inter-rater reliabilityisexcellent(r ¼ 0.99),andgroupleaders,onaverage,addressed83%of protocol components during each group (Garner, Stein, Beard,  & Bjorgvinsson, 2014). It is important to note that given the short-term nature of the BHP unit (i.e., average length of stay  ¼  11.7days in the presentsample), the abovementioned groups are short-term skills-based groups, and do not represent the  “ full-package ” or comprehensive treatment in each of the above psychotherapymodalities (e.g., DBT typically requires both a skills group and DBT-speci 󿬁 c individual therapy). In addition to group therapy andmedication consults with a psychiatrist, all patients also receivedtwo to three weekly individual therapy sessions from graduate-level psychologists to reinforce and tailor the skills and lessonslearned in groups to the patient's unique needs (for additionaldetails on the BHP program, see Beard  &  Bj € orgvinsson, 2013). 4.2. MeasuresMini International Neuropsychiatric Interview  (MINI; Sheehanet al., 1998). The MINI is a structured interview assessing forDSM-IV Axis I symptoms (e.g., mood, anxiety, substance abuse,psychosis). Each MINI diagnostic module consists of a series of screening items followed by questions about speci 󿬁 c symptom-atology. The MINI has strong reliability and validity in relation tothe Structured Clinical Interview for DSM-IV (SCID-IV), with inter-rater reliabilities ranging from kappas of 0.89 e 1.0 (Sheehan et al.,1998). For the partial hospital patients, inter-rater reliability be-tween the MINI and the program psychiatrists is 0.69 for MDD and0.75 for Bipolar Disorder-Depressed (Kertz, Bigda-Peyton, Ros-marin,  &  Bj € orgvinsson, 2012). The MINI was administered bydoctoral practicum students and interns in clinical psychology whoreceivedweeklysupervisionfromapostdoctoralpsychologyfellow.Training included reviewing administration manuals andcompleting mock interviews. All clinicians were required to pass a 󿬁 nal training interview with their supervisor before administeringMINIs for the program. Center for the Epidemiological Studies of Depression - 10  (CES-D-10; Andresen et al., 1994). The CES-D-10 is a widely used, brief patient-report instrument for measuring depressive symptoms.Itemsassessforsymptomsofdepression(e.g., “ I felt depressed ” )andresponse anchors range temporally from 0 ( rarely or none of thetime ) to 3 ( most or all of the time ). The CES-D-10 has been shown tohave high internal consistency in similar psychiatric samples( a  ¼  0.87; Webb et al., 2013) and in the current study ( a  ¼  0.85).Given that patients completed the CES-D-10 daily, we modi 󿬁 ed theinstructions and asked patients to rate the frequency of symptomsover the past 24 h (with the exception of the initial admission,whereweusedtheoriginalCES-D-10temporalanchor,i.e.,overthepast week). We altered the 4-point Likert scale accordingly byremoving the number of days from each anchor. Internal consis-tency for the measure was good ( a ¼ 0.88). The same modi 󿬁 cationto the instructions of a similar scale did not affect its psychometricproperties (Beard  &  Bj € orgvinsson, 2014). Generalized Anxiety Disorder 7  - item Scale  (GAD-7; Spitzer,Kroenke, Williams,  &  L  € owe, 2006). The GAD-7 is a commonlyused, brief self-report questionnaire designed to assess generalizedanxiety symptoms. Respondents rate how often they were both-ered by different symptoms. Upon initial admission, patients wereassessed regarding the past two weeks, with responses anchorsranging from 0 ( not at all ) to 3 ( nearly every day ). During all otherassessments, patients were assessed regarding the past 24 h, withresponse anchors modi 󿬁 ed to range from 0 ( not at all ) to 3 ( nearlyall the time ). Scores can range from 0 to 21, with higher scoresindicating greater anxiety severity. The GAD-7 has shown goodreliability and validity (Kroenke, Spitzer, Williams, Monahan,  & L  € owe, 2007) and as measure of general anxiety in our partial hos-pital population, including the 24-h version (Beard  & Bj € orgvinsson,2014). The internal consistency for the GAD-7 in our sample wasgood ( a ¼ 0.84). Cognitive Behavior Therapy Skills Questionnaire  (CBTSQ-16; Jacobet al., 2011). The CBTSQ is a 16-item measure designed to assesscognitive behavioral skills. The measure is divided into two sub-scales assessing cognitive restructuring skills (CR;  “ Catch myself when I jump to conclusions ” ) and behavioral activation strategies(BA;  “ Socialize even though I don't feel like it  ” ). Itemsare rated on a 1( I don't do this ) to 5 ( I always do this ) Likert-type scale. Participantswere asked how much they actually used said skills/strategies inthe past month at admission and wereasked about howmuch theyactually used them  in the past 24 h  at all other assessments. TheCBTSQ-16 was validated among patients within the BHP anddemonstrated high internal consistency ( a  ¼  0.84 for cognitiverestructuring,  a  ¼  0.80 for behavioral activation; see Jacob et al.,2011). In our sample, the internal consistency of the overall mea-sure was good ( a  ¼  0.89), with acceptable to good consistency of the subscales for behavioral activation ( a  ¼  0.76) and cognitiverestructuring ( a ¼ 0.83). Dialectical Behavior Therapy Ways of Coping Checklist   (DBT-WCCL; Neacsiu, Rizvi, Vitaliano, Lynch,  &  Linehan, 2010). The DBTSkills Subscale (DSS) of the DBT-WCCL is a 38-item subscaleassessing frequency of DBT skills use over the past month. Re-sponses are rated on a 4-point Likert-type scale, from 0 (neverused) to 3 (regularly used). Examples of items include:  “ Steppedback and tried to see things as they really are ” ,  “ Talked to someoneabout how I've been feeling ” ,  “ Did something to feel a totallydifferent emotion (like going to a funny movie) ” ,  “ Tried to distractmyself by getting active. ”  For daily assessments and at discharge,thepatients wereasked toconsider skillusageover thepast 24hinthe face of stressors. The measure has demonstrated adequate toexcellent reliability and validity, including the ability to discrimi-nate from treatment conditions providing DBT skills versus thosethat do not (Neacsiu, Rizvi,  &  Linehan, 2010; Neacsiu, Rizvi,Vitaliano, et al., 2010). The DSS has also demonstrated adequatepsychometric properties in a transdiagnostic sample from the BHP(Stein, Hearon, Beard, Hsu,  &  Bj € orgvinsson, 2016). The internalconsistency of this subscale in our sample was excellent ( a ¼ 0.94).  Acceptance and Action Questionnaire d II   (AAQ-II; Bond et al.,2011). The AAQ-II is a 7-item scale designed to assess psychologi-cal  󿬂 exibility/in 󿬂 exibility. Individuals rate how true a list of state-ments are for them (e.g.,  “  I'm afraid of my feelings ” ) on a scale of 1( never true ) to 7 ( always true ). For daily assessments and atdischarge, patients were asked how true the statements were forthem in the past 24 h. Total scores range from 7 to 49, with higherscores re 󿬂 ecting greater levels of psychological  in 󿬂 exibility. Thereliability and validity of the measure have been found to besatisfactory (Bond et al., 2011). Internal consistency in our samplewas good ( a  ¼  0.84). The AAQ-II is the most commonly usedmeasure to assess the extent to which patients have developedgreaterpsychological 󿬂 exibilityinACT(forreviews,seeBluettetal.,2014; Ciarrochi, Bilich,  &  Godsell, 2010; Hayes, Levin, Plumb- C.A. Webb et al. / Behaviour Research and Therapy 81 (2016) 12 e  20  15
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