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Aging & Mental Health

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Development and validation of the Experiential

Avoidance in Caregiving Questionnaire (EACQ)
a

Andrs Losada , Mara Mrquez-Gonzlez , Rosa Romero-Moreno & Javier Lpez

a

Department of Psychology, Universidad Rey Juan Carlos, Madrid, Spain

Department of Biological and Health Psychology, Universidad Autnoma de Madrid,

Madrid, Spain
c

Department of Psychology, Universidad CEU San Pablo, Madrid, Spain

Published online: 31 Mar 2014.

To cite this article: Andrs Losada, Mara Mrquez-Gonzlez, Rosa Romero-Moreno & Javier Lpez (2014) Development
and validation of the Experiential Avoidance in Caregiving Questionnaire (EACQ), Aging & Mental Health, 18:7, 897-904,
DOI: 10.1080/13607863.2014.896868
To link to this article: http://dx.doi.org/10.1080/13607863.2014.896868

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Aging & Mental Health, 2014

Vol. 18, No. 7, 897904, http://dx.doi.org/10.1080/13607863.2014.896868

Development and validation of the Experiential Avoidance in Caregiving Questionnaire (EACQ)

Andr
es Losadaa*, Mar
a M
arquez-Gonz
alezb, Rosa Romero-Morenoa and Javier L
opezc
a

Department of Psychology, Universidad Rey Juan Carlos, Madrid, Spain; bDepartment of Biological and Health Psychology,
Universidad Aut

onoma de Madrid, Madrid, Spain; cDepartment of Psychology, Universidad CEU San Pablo, Madrid, Spain

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(Received 6 November 2013; accepted 16 February 2014)

Objective: Providing care to a relative with dementia is associated with negative health consequences. Experiential
avoidance has been found to be related to caregivers distress. However, no specific measure of experiential avoidance in
the caregiving context is available. The aim of this study is to develop and present the psychometric properties of the
Experiential Avoidance in Caregiving Questionnaire (EACQ).
Method: Face-to-face interviews were conducted with 263 dementia family caregivers (mean age 61.37; SD 14.84;
78.3% female). In addition to the EACQ, the Action and Acceptance Questionnaire (AAQ) was used. Depression, anxiety,
alexithymia, cognitive fusion, dysfunctional thoughts about caregiving, and mean arterial pressure were also measured.
Results: Using principal component analysis, three factors were retained that explained 44.75% of the variance. These
factors were labeled: (1) Active Avoidant Behaviors; (2) Intolerance of Negative Thoughts and Emotions Towards the
Relative; and (3) Apprehension Concerning Negative Internal Experiences Related to Caregiving. Acceptable reliability
indexes (Cronbachs alpha) were found for each factor (.63 for factor 1; .71 for factor 2; and .60 for factor 3) and the total
scale (a .70). Significant positive associations were found between the global scale and anxiety, dysfunctional thoughts,
alexithymia and the AAQ.
Conclusion: The EACQ shows acceptable psychometric properties and may be a useful tool for clinical assessment and
therapeutic work with caregivers.
Keywords: acceptance and commitment therapy; anxiety; blood pressure; dementia care; depression; family caregivers

Introduction
Providing care to a relative with functional or cognitive
needs is associated with negative mental and physical
consequences, especially if the care-recipient has dementia (Cuijpers, 2005; Pinquart & Sorensen, 2003). The
stress and coping model developed by Lazarus and Folkman (1984) has received strong empirical support in terms
of its utility for analyzing caregiver health (e.g., Haley,
Levine, Brown, & Bartolucci, 1987; Knight & Sayegh,
2010; Montoro-Rodriguez & Gallagher-Thompson,
2009). According to this model, difficult situations faced
by caregivers over long periods influence their own mental health (e.g., depression or anxiety) and physical health
(e.g., blood pressure). Their health will vary depending on
their personal resources (risk factors and buffering variables) and sociocultural factors (Losada et al., 2010). These
models highlight the importance of analyzing the influence of personal resources on caregiving distress.
Research has found that caregivers negative emotions
can be reduced through training them in strategies to
reduce behavioral problems associated with dementia
(Logsdon, McCurry, & Teri, 2007) or to change maladaptive thoughts or emotions related to caregiving (Gallagher-Thompson & Coon, 2007; Losada, M
arquezGonz
alez, & Romero-Moreno, 2011).
More recently, from the framework of the Acceptance
and Commitment Therapy approach (ACT), the importance of therapeutically fostering acceptance of thoughts,
images or emotions that are not susceptible to direct
*Corresponding author. Email: andres.losada@urjc.es
2014 Taylor & Francis

modification has been highlighted (Hayes, Stroahl, &

Wilson, 2012). Specifically, ACT considers as a central
dimension of many forms of psychopathology peoples
tendency to be unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions,
thoughts, memories, behavioral predispositions) and take
steps to alter the form or frequency of these events and
the contexts that occasion them (Hayes, Wilson, Gifford,
Follette, & Strosahl, 1996, p. 1154). This tendency has
been called experiential avoidance (EA) and, when inflexibly applied to unavoidable or hard-to-change internal
experiences (emotions and thoughts), it may lead to a paradoxical increase in those aversive experiences and, eventually, to exacerbated levels of anxiety or depression. EA
has been considered as a component of a broader construct, called psychological flexibility, which consists in
the ability to fully contact the present moment and the
thoughts and feelings it contains without needless defense,
and, depending upon what the situation affords, persisting
in or changing behavior in the pursuit of goals and values
(Bond et al., 2011, p. 678). EA broadly subsumes behaviors or strategies such as thought and emotional suppression, alexithymia, and avoidant coping styles (e.g.,
distracting oneself or refusing to think about the situation)
(e.g., Fledderus, Bohlmeijer, & Pieterse, 2010; Thompson
& Waltz, 2010). When avoidant behaviors are pervasive
or ineffective, the result may be a clinical disorder or the
exacerbation of an existing disorder (Forsyth, Eifert, &
Barrios, 2006; Kashdan, Barrios, Forsyth, & Steger,

Downloaded by [Ondokuz Mayis Universitesine] at 00:37 11 November 2014

898

A. Losada et al.

2006). EA has been found to be associated not only with

depression and anxiety, but also with poorer physical
health and health-related quality of life, among other outcomes (Hayes, Luoma, Bond, Masuda, & Lillis, 2006;
Lillis, Levin, & Hayes, 2011), as well as with other maladaptive coping strategies (Chawla & Ostafin, 2007), such
as dysfunctional cognitions (Cristea, Montgomery,
Szamoskozi, & David, 2013) or cognitive fusion or the
extent to which we are psychologically tangled up with
and dominated by the form or content of our thoughts
(Gillanders et al., 2014). EA has also been linked to emotional suppression (Kashdan et al., 2006), a variable found
to be associated with increased blood pressure (Butler,
Lee, & Gross, 2009). However, to our knowledge, no
study has analyzed the relationship between EA and blood
pressure in caregivers.
In the context of caregiving, caregivers frequently
have to cope with unchangeable losses (e.g., behavioral
problems such as emotional change in the care-recipient,
memory problems, diagnosis of the disease) and the associated private experiences or events (e.g., painful
thoughts, memories, feelings) that are unavoidable or very
difficult to change. While EA can be beneficial in the
immediate term by decreasing distress, it ultimately
becomes maladaptive, producing a paradoxical effect of
increasing distress and interfering with the persons ability
to live a life consistent with his/her values (Hayes et al.,
2012).
In this research area, the beneficial effects of acceptance strategies versus control/change strategies in the
dementia caregiving situation, as well as the negative consequences of trying to suppress or control private experiences, have recently been highlighted (M
arquezGonz
alez, Romero-Moreno, & Losada, 2010; Whitebird
et al., 2013). However, as far as the authors know, there is
only one published study with the aim of analyzing EA in
the context of dementia caregiving. Spira et al. (2007)
analyzed the relationship between EA and depressive
symptomatology in 28 female dementia family caregivers.
Using the Acceptance and Action Questionnaire (AAQ;
Hayes et al., 2004), they found significant and positive
correlations between EA and depressive symptomatology
and negative affect.
To date, the AAQ has been the most widely used measured of EA in adulthood. It assesses negative evaluations
of feelings, avoidance of thoughts and feelings, difficulties
to distinguish a thought from its referent, and behavioral
maladjustment in the presence of difficult thoughts and
feelings (Hayes et al., 2004). There is substantial evidence
that the AAQ accurately measures this construct and also
demonstrates fair to good levels of reliability (Hayes
et al., 2004). In order to optimize the internal consistency
of the AAQ, Bond et al. (2011) recently developed a second version of this instrument: the AAQ-II.
Assuming that both the AAQ and the AAQ-II are general measures of EA, the importance of developing specific measures of EA for particular clinical domains or
populations, with items specific to them, has been suggested (Hayes et al., 2004). In addition, Hayes et al.
(2004) suggested that researchers needing process

measures of EA in actual clinical trials should not assume

that the AAQ will be sensitive to their interventions, as
more targeted measures in specific areas are needed. Following this recommendation, some measures based on the
AAQ but adapted for its application to specific populations have also been developed. This is the case of the
Chronic Pain Acceptance Questionnaire (CPAQ;
McCracken, 1998), which measures recognition that pain
may not change, ability to refrain from fruitless efforts to
avoid or control pain, and engaging in valued life activities despite the presence of pain. Other examples of EA
specific measures are the Acceptance and Action Diabetes
Questionnaire (AADQ; Gregg, Callaghan, Hayes, &
Glenn-Lawson, 2007), which assesses acceptance of diabetes-related thoughts and feelings and ability to engage
in valued actions while having these experiences; the
Avoidance and Fusion Questionnaire for Youth (AFQ-Y;
Greco, Lambert, & Baer, 2008), a measure of EA in children and adolescents; and the Parental Acceptance and
Action Questionnaire (PAAQ), an instrument designed to
assess EA specifically in the context of parenting (Cheron,
Ehrenreich, & Pincus, 2009).
To our knowledge, there are no assessment instruments that specifically address EA in the dementia caregiver population. Considering that (1) significant levels of
emotional distress have been found in dementia family
caregivers (Pinquart & Sorensen, 2003) and (2) EA seems
to play a relevant role in the explanation of this distress
(Spira et al., 2007), the main objective of the present study
was the development and validation of an instrument that
specifically assesses EA in the particular context of
dementia caregiving.

Methods
Participants and procedure
Participants in the study were 263 family caregivers
(78.3% female) looking after their relatives in community
settings, with a mean age of 61.37 years old (SD
14.84). Most of the caregivers were sons or daughters of
the care-recipient (49.5%) or spouses (41.8%), and had
been caring for a mean number of years of 3.8 years
(SD 3.05), devoting 14.04 hours per day to caregiving
duties (SD 8.28). Care-recipients mean age was
79.52 years old (SD 8.84), and most of them (60.2%)
had a medical diagnosis of Alzheimer (39.8% had other
types of dementia). All of them were recruited through
social and health care centers in Madrid (Spain) or
through advertisements in the media. In order to participate in the study, caregivers were required to be at least
18 years old, to identify themselves as the main source of
help for their relative, and to report that more than 1 hour
of their day was devoted to caregiving duties and that they
had been providing care for more than three consecutive
months, so that the caregiving role was established. Caregivers gave their informed consent to participate in the
study, which was approved by the Spanish Ministry of
Science and Innovation and the Ethics Committee at the
Universidad Rey Juan Carlos (Madrid).

Aging & Mental Health

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Measures
Care-recipients Functional Status. Patients functional
status was measured using the Barthel Index (Mahoney &
Barthel, 1965). Caregivers are requested to report on a 10item scale the level of independence for Activities of
Daily Living (ADL) of their care-recipient (e.g., To what
extent is your relative able to feed her/himself?). Total
score ranges from 0 to 100. Higher scores are indicative
of higher level of independence in the patient. The internal consistency (Cronbachs alpha) for this scale in this
study is .92.
Depressive symptomatology. The Center for Epidemiological Studies-Depression Scale (CES-D; Radloff,
1977) was used. It consists of 20 items assessing depressive symptoms that caregivers might have felt over the
last week (e.g., I felt sad). Scores range from 0 (rarely
or none of the time) to 3 (most or all of the time). The
internal consistency (Cronbachs alpha) for this scale in
the present study is .88.
Anxiety. Anxiety symptomatology was measured via
the Tension-Anxiety subscale from the Profile of Mood
States (POMS; McNair, Lorr, & Droppleman, 1971), a 9item scale (e.g., tense) with Likert-type answers ranging
from 0 (not at all) to 4 (extremely). Internal consistency
for the scale in this study was .85 (Cronbachs alpha).
Mean arterial pressure (MAP). Three blood pressure
measurements were carried out at different points during
the interview. The blood pressure readings were obtained
using a noninvasive monitor (OMRON M7) validated
according to the British Hypertension Society Protocol
(Coleman, Steel, Freeman, de Greeff, & Shennan, 2008),
following the recommendations for its measurement
(OBrien et al., 2003). MAP was calculated using the formula provided by Mausbach et al. (2007).
Cognitive fusion. Cognitive fusion was measured by
means of the Spanish version (Romero-Moreno,
M
arquez-Gonz
alez, Losada, Gillanders, & Fern
andezFern
andez, in press) of the Cognitive Fusion Questionnaire (CFQ; Gillanders et al., 2014). It is a seven-item
scale (e.g., I tend to get very entangled in my thoughts)
with response scores ranging from 1 (never true) to 7
(always true). The internal consistency (Cronbachs
alpha) of the original scale ranged from .88 to .90, while
the Cronbachs alpha of this scale in the present study is
.87.
Dysfunctional thoughts about caregiving. The dysfunctional thoughts about caregiving questionnaire
(DTCQ; Losada, Montorio, Izal, & M
arquez-Gonz
alez,
2006) was used. It is a 16-item scale that measures barriers or obstacles to an adaptive coping style with regard
to caregiving (e.g., It is selfish for a caregiver to dedicate
time to himself/herself when a relative is frail/sick and
needs care). Responses are coded on a Likert scale that
ranges from 0 (totally disagree) to 4 (totally agree). The
internal consistency (Cronbachs alpha) for this scale in
the present study was .89.
Alexithymia. This variable was assessed with the factor difficulty identifying and describing feelings of the
Toronto Alexithymia Scale (TAS-20; M
uller, B
uhner, &

899

Ellgring, 2003), which measures difficulty identifying

feelings and distinguishing between feelings and the
bodily sensations of emotional arousal (e.g., I am often
confused about what emotion I am feeling). Answers are
rated on a five-point Likert scale ranging from 1 (strongly
disagree) to 5 (strongly agree). The internal consistency
(Cronbachs alpha) obtained for this scale is .86.
Experiential avoidance. The Spanish version of the
Action and Acceptance Questionnaire (AAQ) was used
(Barraca, 2004). It is a 9-item questionnaire (e.g.,
Anxiety is bad) designed to assess a high need for emotional and cognitive control, avoidance of negative private
events, inability to take needed action in the face of private events, and forms of cognitive entanglement, such as
excessively negative evaluations of private experiences or
negative self-references (Hayes et al., 2004, pp. 556
557). Items are rated on a seven-point Likert scale ranging
from 1 (never true) to 5 (always true). The internal consistency (Cronbachs alpha) obtained in the original study
was .70 (Hayes et al., 2004). Cronbachs alpha obtained
for the AAQ in the present study is .55.

The Experiential Avoidance in Caregiving

Questionnaire
An initial pool of 15 items was developed for measuring
EA in caregivers. Item content was modeled after the
AAQ (Hayes et al., 2004) and drawing on our clinical
observations of diverse manifestations of EA in caregivers
(fear and avoidance of specific negative emotions or
thoughts about the care recipient, reluctance to accept or
reflect upon ones own emotions, etc.). The Experiential
Avoidance in Caregiving Questionnaire (EACQ) was
developed to address the specific manifestations of EA
most prevalent in caregivers. This preliminary scale was
tested in a pilot study carried out with a sample of 44
dementia family caregivers (M
arquez-Gonz
alez et al.,
2010), and some changes to both item content and
response options were considered necessary due to theoretical or practical issues. For example, the seven Likerttype response options (from 1, totally disagree, to 7,
totally agree) of the EACQ described in M
arquezGonz
alez et al. (2010) were changed to five (ranging from
1, not at all, to 5, a lot) in response to comments from the
caregivers regarding the difficulty of selecting one option
or another. The definitive list of 15 items (see the Appendix) making up the EACQ is analyzed in the present
study.

Data analysis
In order to determine the construct validity of the EACQ,
principal components analysis with Oblimin rotation was
used for analyzing the factor structure of the scale. With
the aim of understanding the underlying dimension of each
factor, factor loadings of over .20 were considered, following a criterion used in the development of measures for
assessing experiential avoidance, such as the AAQ (Hayes
et al., 2004) and the CPAQ (Nilges, Koster, & Schmidt,

900

A. Losada et al.

Table 1. Factor loadings, means, standard deviations and range

of the EACQ items.
Item

Factor 1

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12
11
10
7
3
15
5
1
4
2
8
9
6
14
13

.823
.726
.636
.560
.294
.227
.207

Factor 2

Factor 3

.256
.408
.828
.786
.679
.542

.428
.615

.279
.667
.667
.576
.525
.505

Mean

SD

Range

3.26
3.02
3.26
3.29
2.55
2.51
3.61
3.33
3.40
2.74
3.95
2.20
2.83
2.52
2.90

1.50
1.55
1.43
1.50
1.48
1.57
1.60
1.63
1.48
1.47
1.22
1.38
1.48
1.49
1.56

15
15
15
15
15
15
15
15
15
15
15
15
15
15
15

Note. Numbers in bold in each column represent items clustered to the

corresponding factor.

2007). Convergent and criterion validity were analyzed

through correlations between the assessed variables. In
order to determine the discriminant validity of the EACQ
factors, a series of hierarchical regression analyses were
carried out. In each of the regressions, one of the EACQ
factors was entered in a first step. In a second step, an
EACQ factor different from that entered in the first step
was entered. A significant incremental change in percentage of explained variance (R2) from Step 1 to Step 2 gives
an estimate of the unique, construct-specific component for
each factor. Reliability of the EACQ was determined
through the internal consistency (Cronbachs alpha) of the
scale and its subscales and through analysis of the interitem correlation for each factor. An inter-item correlation
in the range of 0.20 to 0.40 is considered to represent an
optimal level of homogeneity (Briggs & Cheek, 1986).

Results
Construct validity
Principal components analysis with Oblimin rotation was
used for analyzing the factor structure of the scale. Three

principal components were retained through the Scree test

and Kaiser criterion that explained 44.75% of the variance. Factor loadings are shown in Table 1. A conceptual
analysis of the content of those items with loadings higher
than .20 in more than one factor led to the inclusion of
items 13 and 15 in factors 3 and 1, respectively. Item 13
makes reference to negative consequences of analyzing
negative internal experiences, and item 15 makes reference to actively avoiding talking with others about conflictive situations, with no reference to negative internal
experiences.
A first factor (factor 1) is made up of six items that
measure caregivers behaviors for avoiding negative
thoughts or feelings related to caregiving issues. This first
factor was labeled Active Avoidant Behaviors, with an
eigenvalue of 3.04 accounting for 20.25% of the variance.
The second factor (factor 2), with an eigenvalue of 2.08
accounting for 13.88% of the variance, includes four
items with content related to rigid verbal rules and absolutistic thinking about negative emotions and thoughts with
regard to the care-recipient, and was labeled Intolerance
of Negative Thoughts and Emotions Towards the Relative.
Finally, the third factor (factor 3) is composed of five
items referring to apprehensive, reluctant and fearful attitudes towards negative internal events or self-understanding of ones own private events regarding the relative.
This factor, with an eigenvalue of 1.59 accounting for
10.62% of the variance, was labeled Apprehension Concerning Negative Internal Experiences Related to
Caregiving.

Convergent validity
The correlations between the assessed variables are shown
in Table 2. Significant associations were found between
all the EACQ subscales and the EACQ total score. No significant correlation was found between factor 2 (Intolerance of Negative Thoughts and Emotions Towards the
Relative) and factor 3 (Apprehension Concerning Negative Internal Experiences Related to Caregiving). Significant associations between EA, as measured through the
AAQ, and the EACQ total score and factor 1 (Active

Table 2. Correlations between variables.

Variable
Caregiver age
Time caring (in years)
Daily hours caring
Care-recipient functional status
Depression
Anxiety
Mean arterial pressure (MAP)
Dysfunctional thoughts
Alexithymia
Cognitive fusion (n 170)
Experiential Avoidance (AAQ)
EACQ Factor 1
EACQ Factor 2
EACQ Factor 3


p < .05; p < .01.

EACQ Factor 1 EACQ Factor 2 EACQ Factor 3 EACQ total score

.03
.04
.07
.03
.13
.18
.04
.08
.20
.17
.19

.17
.22

.05
.02
.02
.06
.03
.04
.18
.14
.01
.05
.06

.02

.19
.09
.14
.07
.07
.03
.01
.24
.19
.08
.12

.12
.07
.07
.02
.09
.14
.09
.22
.19
.12
.14
.78
.60
.53

Mean (SD)

Range

61.37 (14.84)
2189
3.8 (3.05)
4240
14.04 (8.28)
124
63.08 (28.87)
0100
22.22 (11.77)
148
17.65 (8.45)
136
95.39 (14.47) 65.56174.33
26.07 (12.92)
064
6.13 (5.86)
026
54.12 (12.19)
2192
33.85 (7.72)
1557
17.89 (5.36)
630
13.08 (4.51)
420
16.84 (3.65)
929

Aging & Mental Health

Avoidant Behaviors) were found. Active Avoidant Behaviors (factor 1) is associated with cognitive fusion. Both
Active Avoidant Behaviors (factor 1) and Apprehension
Concerning Negative Internal Experiences Related to
Caregiving (factor 3) are significantly correlated with
alexithymia.

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Criterion and discriminant validity

As shown in Table 2, significant associations were found
between Active Avoidant Behaviors (factor 1) and depression and anxiety. Caregivers with higher scores in this factor report higher levels of depression and anxiety.
Intolerance of Negative Thoughts and Emotions Towards
the Relative (factor 2) is significantly associated with
MAP and dysfunctional thoughts: higher scores in this
factor are associated with higher scores in MAP and dysfunctional thoughts. Positive associations with dysfunctional thoughts were also found for factor 3
(Apprehension Concerning Negative Internal Experiences
Related to Caregiving). This factor and the EACQ total
score are positively associated with daily number of hours
caring. Higher scores in the EACQ total score are associated with higher scores in anxiety and dysfunctional
thoughts. No significant association was found between
care-recipients functional status and the EACQ total
score or the subscale scores. Regarding discriminant
validity (Table 3), a significant incremental change in percentage of explained variance of the EACQ total score
was found for each of the EACQ factors from Step 1 to
Step 2, showing an estimate of the unique, construct-specific component for each factor.

Reliability
The internal consistency for the global scale, measured
through Cronbachs alpha, is .70. An inspection of the
changes in alpha if items are removed showed that the
alpha obtained cannot be increased. The Cronbachs
alphas obtained were as follows: .63 for factor 1 (Active
Avoidant Behaviors); .71 for factor 2 (Intolerance of Negative Thoughts and Emotions Towards the Relative); and
.60 for factor 3 (Apprehension Concerning Negative Internal Experiences Related to Caregiving). The mean interitem correlation obtained for factor 1 was .22. For factor 2
it was .37 and for factor 3 it was .23.

901

Discussion
The objective of this study was to present the psychometric properties of a new measure that has been developed
for measuring EA in caregivers. The results support a
three-dimensional structure of the scale. Specifically, the
factors were labeled Active Avoidant Behaviors, Intolerance of Negative Thoughts and Emotions Towards the
Relative, and Apprehension Concerning Negative Internal
Experiences Related to Caregiving. The results suggest
that a significant proportion of variance of EA in caregiving was explained by these three factors. In addition, the
factor loadings of the 15 items making up the EACQ are
in a similar range to those obtained for the AAQ (Hayes
et al., 2004). The EACQ has acceptable psychometric
properties. Even though the reliability indexes for two of
the three factors making up the EACQ may be considered
only marginally acceptable, as found for other scales measuring EA (e.g., the CPAQ developed by McCracken,
Vowles, & Eccleston, 2004), the global internal consistency is acceptable and similar to that reported for the
AAQ (Hayes et al., 2004). In addition, the mean interitem correlations obtained for the EACQ factors are in the
range considered to represent an optimal level of homogeneity (Briggs & Cheek, 1986). A very low Cronbachs
alpha was obtained for the AAQ. In the development of
the AAQ-II, Bond et al. (2011) state that the internal
consistency of the AAQ [. . .] has often been a problem
(p. 677), and have been found to be lower than .70 in community samples and less educated populations. We agree
with Bond et al. (2011) that the low alpha problem
appears to result, at least in part, from unnecessary item
complexity and the subtlety of the concepts addressed
(p. 678), an issue that may also be influencing the results
obtained with the EACQ.
The validity indexes suggest that the EACQ is associated with other scales or constructs (e.g., the AAQ, anxiety, depression or alexithymia) in the expected directions,
and the three EACQ factors demonstrated discriminant
validity. Especially interesting is the significant association found between MAP and Intolerance of Negative
Thoughts and Emotions Towards the Relative (factor 2).
The items composing this factor are related to rigid and
absolutistic rules about the experience of negative emotions, which may well be associated with a tendency to
suppress these types of emotions, and emotional suppression has been linked to increased blood pressure (Butler

Table 3. Between factors discriminant validity.

Step
1
2a
2b

F1
F1
F2
F1
F3

Beta

DR2

.78
.70
.49
.70
.38

20.21
27.58
19.17
21.96
12.01

.61
.23
.14

F2
F2
F1
F2
F3

Beta

DR2

.61
.49
.70
.62
.55

12.275
19.171
27.58
17.11
15.15

.37
.47
.30

F3
F3
F1
F3
F2

Beta

DR2

.53
.38
.70
.55
.62

10.18
12.01
21.96
15.15
17.11

.28
.47
.38

Note: Two hierarchical regressions have been done per each of the EACQ factors. The first step is the same for the two regressions, and amakes reference
to the second step of the first hierarchical analysis (e.g., discriminant validity between factors 1 and 2) and bmakes reference to the second step of the
second hierarchical analysis (e.g., discriminant validity between factors 1 and 3); F1 EACQ Factor 1; F2 EACQ Factor 2; F3 EACQ Factor 3;
DR2: Increase in the percentage of explained variance;  p < .01.

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902

A. Losada et al.

et al., 2009). With regard to Apprehension Concerning

Negative Internal Experiences Related to Caregiving, its
positive association with daily hours caring may be
reflecting the fact that the demands and emotional strains
related to dementia caregiving increase caregivers emotional vulnerability (Gilliam & Steffen, 2006).
The different patterns of correlations for each factor
suggest that EA in caregiving is a multidimensional construct: not all factors of the EACQ correlate with each
other, and nor do they correlate with the same measures.
Results suggesting the multidimensionality of EA have
also been found in previous studies aimed at developing
an EA scale for specific domains (e.g., McCracken et al.,
2004). The complexity and multidimensionality of EA
have been suggested previously by G
amez, Chmielewski,
Kotov, Ruggero, and Watson (2011), who found a fivefactor structure for their Multidimensional Experiential
Avoidance Questionnaire (MEAQ). It is interesting to
note the similarities in content between EACQ factor 1
and MEAQ factors 1 (behavioral avoidance) and 4 (distraction and suppression), and between EACQ factors 2
and 3 and MEAQ factor 2 (distress aversion). At the same
time, it should be acknowledged that the absence of significant associations between EACQ factors 2 and 3 and
emotional outcomes and the AAQ may be indicating that
the EACQ covers psychological dimensions which are not
themselves EA, but rather other markers of psychological
rigidity.
One of the implications of these results is that EA
in dementia caregiving, as measured by the scale developed here, may be made up of different components,
likely regulated by different psychological dimensions.
On one hand, we can distinguish a central dimension of
active avoidance (factor 1), mainly involving specific
cognitive and behavioral avoidant procedures and strategies, which may represent the procedural dimension of
EA, comprising the avoidant responses or routines
which are eventually associated with negative emotional
consequences. On the other hand, Intolerance of Negative Thoughts and Emotions Towards the Relative (factor 2) and Apprehension Concerning Negative Internal
Experiences Related to Caregiving (factor 3) are mainly
composed of items referring to thoughts and evaluations
regarding ones own thoughts and emotions, and thus
may be addressing more explicit and declarative cognition, more likely to be regulated by controlled
processes.
Taken together, the results of this study appear to support the view that EA may be a mechanism through which
caregiving stress results in negative mental and physical
health outcomes for caregivers. These results are consistent with those of Spira et al. (2007), which showed a link
between EA and depressive symptomatology. Focusing
on the EACQ, this instrument may prove to be a useful
clinical tool for the identification of both general EA and
the subtle and varied forms of avoidance which can be frequently observed in distressed dementia caregivers, and
which may explain the maintenance or exacerbation of
their high levels of anxiety or depression. Thus, the information provided by caregivers responses to EACQ items

may significantly help clinicians to tailor interventions

more accurately to each caregivers specific profile and
particular needs.
Some limitations of the study should be acknowledged. Although the EACQ items do not make explicit
mention of issues related to caregiving in the specific
context of dementia, the sample employed (dementia
caregivers) limits the generalization of the obtained
results to caregivers of people presenting other illnesses.
Future studies should analyze the usefulness of EACQ in
samples including caregivers for a wider range of
conditions.
Even though EACQ was found to be associated with
the AAQ, the correlation is low, and, as discussed above,
this association involves only one of the EACQ factors. It
would be interesting for future studies to analyze the
EACQs concurrent validity using the AAQ-II or other
measures developed for measuring EA. Likewise, the correlations found between the EACQ and other variables,
although in the expected direction, are also low. These
findings, together with the above-mentioned differential
associations between the EACQ factors and emotional
distress and EA as measured by the AAQ, and the comparatively low Cronbachs alphas for the Active Avoidant
Behaviors and the Apprehension Concerning Negative
Internal Experiences Related to Caregiving factors may
result in part from the complexity of the construct of EA,
deriving from its underlying contextual theory (Bond
et al., 2011). Considering the low cut-off factor loadings
interpreted in this study, and the fact that some items
loaded in more than one factor, future studies are needed
to confirm the factor structure reported here, and to continue exploring both the psychometric properties of the
EACQ and its clinical utility. More generally, there is a
need to continue exploring the specific mechanisms and
processes involved in EA, in order to clarify the nature
and dimensions of this complex construct (G
amez et al.,
2011).
In spite of the mentioned limitations, we believe that
the EACQ shows acceptable psychometric properties, and
may be a useful tool for clinical assessment and therapeutic work with caregivers who present difficulties for
acknowledging and accepting negative thoughts, feelings
or emotions, or show different manifestations of EA that
may severely interfere with their important task, and contribute to maintaining or increasing their levels of emotional distress.
Acknowledgements
We thank all the caregivers for their participation in the study
and also the following organizations and institutions for collaborating with us in the project: Fundaci

on Cien, Fundaci

on Mar
a
Wolff, Servicio de Geriatr
a del Hospital Ram

on y Cajal, Centros de d
a Vitalia, Centro de Salud General Ricardos, Centro de


Salud Garc
a Noblejas, Centro de Salud Benita de Avila,
Centro
de Salud Vicente Muzas, Centro Reina Sof
a de Cruz Roja, Unidad de Memoria de Cantoblanco, Servicio de Neurolog
a del
Hospital La Paz, Asociaci

on de Familiares de Alzheimer de
Alcorc

on, Instituto de familia de la Universidad CEU San Pablo,
Centro de Psicolog
a Aplicada de la Universidad Aut

onoma de
Madrid and Servicios Sociales de Getafe.

Aging & Mental Health

Funding
This work was supported by the Spanish Ministry of Science and
Innovation [grant number PSI 2009-081327PSIC]; the Spanish
Ministry of Economy and Competitiveness [grant number
PSI2012-31293].

Downloaded by [Ondokuz Mayis Universitesine] at 00:37 11 November 2014

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Appendix: Experiential Avoidance in Caregiving

Questionnaire (EACQ)
Below you will find a list of statements. Please rate the truth of
each statement as it applies to you using the following scale: 1
not at all, 2 a little, 3 somewhat, 4 often and 5 a lot.
1. One should not have bad thoughts about the person you are
caring for (No se deben tener malos pensamientos hacia la
persona a la que se cuida).
2. I have never felt bad in relation to caring for my relative
(Nunca me he sentido mal con motivo del cuidado de mi
familiar).
3. I avoid thinking that other relatives are behaving selfishly,
and always tend to excuse them by thinking things like
theyre busier, poor guys,. . . they have their own lives. . .
(Evito pensar que otros familiares se portan de forma ego
sta
y tiendo siempre a excusarlos pensando cosas como que
ellos est
an m
as ocupados, pobres, tienen sus vidas. . ..).
4. I cannot bear it when I get angry with my relative (No
soporto enfadarme con mi familiar).
5. One should not feel rejection or other unpleasant emotions
about the person you are caring for (No se debe sentir
rechazo u otras emociones desagradables hacia la persona a
quien se cuida).
6. It is normal for a caregiver to have negative thoughts about the
person they are caring for (Es normal que un cuidador tenga
pensamientos negativos sobre la persona a la que cuida).
7. Every time I start to have bad thoughts about my relative or
my situation as a caregiver, I try to escape from them and
distract myself (Cada vez que vienen pensamientos malos
sobre mi familiar o mi situaci

on como cuidador, intento
escapar de ellos y distraerme).
8. It is normal to feel stress and depression when you are caring
for a dependent relative (Es normal sentir estr
es y depresi

on
cuando se cuida a un familiar dependiente).
9. I am scared by the emotions and thoughts I have about my
relative (Me asustan las emociones y pensamientos que tengo
en relaci

on a mi familiar).
10. When I have negative emotions in relation to the caregiving,
I try to occupy myself with some other activity to make them
go away quickly (Cuando tengo emociones negativas en
relaci

on al cuidado procuro entretenerme con otra actividad
para que se me pase r
apidamente).
11. If a caregiver has negative thoughts toward his/her relative,
the best thing to do is try to ignore them (Si un cuidador tiene
pensamientos negativos hacia su familiar lo mejor es intentar
ignorarlos).
12. I tend to ignore the negative thoughts that come to me
about my relative (Tiendo a no hacer caso a los
pensamientos negativos que me surgen hacia mi familiar).
13. It is harmful for a caregiver to stop and analyze his/her
negative feelings toward his/her ill relative or another
relative (Es perjudicial que un cuidador se pare a analizar los
sentimientos negativos que tiene con respecto a su familiar
enfermo o alg

un otro familiar).
14. Thinking too much about what a caregiver feels and thinks
about his/her caregiving situation is harmful (Reflexionar
sobre lo que un cuidador siente y piensa sobre su situaci

on de
cuidado es da~
nino).
15. In difficult caregiving situations where I need some type of
support, I prefer not to talk about it with other relatives if it
might lead to conflict (En situaciones dif
ciles del cuidado,
en las que necesitar
a alg

un tipo de apoyo, prefiero no
hablarlo con otros familiares si esto puede suponer un
conflicto).