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The Acceptance-Based model of mental distress stipulates the activation of a rigid, inflexible response to inner aversive experiences, termed experiential avoidance, to be a key component in maintaining anxiety disorders. The model stems from Hayes‘ model of experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996) and Borkovec‘s Cognitive Avoidance model (Borkovec, 1994; Borkovec et al., 2004). The focus of this model is not on what is wrong with what people think, but on the aversive states that accompany thoughts (Hayes, Strosahl, & Wilson, 1999). Friman and Colleagues (1998) offered an example of this concept and suggested

that when someone has agoraphobia they are not avoiding open spaces as such, but the thoughts, images and body sensations that have become associated with the panic that may be experienced when in that situation (Friman, Hayes, & Wilson, 1998). People avoid the negative experiences that become associated with the fear experience, therefore it is the ‗fear of the fear’ as described in an early paper (Chambless & Gracely, 1989) or a fear of negative affect (Eifert & Forsyth, 2005) that is thought to drive worry and GAD.

With experiential avoidance, a person is unwilling to experience certain private experiences (e.g. body sensations, emotions, thoughts, memories, behavioural predispositions) and finds strategies to either avoid or reduce the frequency of these experiences (Hayes et al., 1996). Increased worry is caused by failed attempts to control or avoid unpleasant experiences through the ineffective strategy of experiential avoidance and as a result, behaviours that the individual engages in are narrowed for fear of engaging with the avoided experiences (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Individuals start to ‗live in their heads’ reducing their flexibility for engaging in unpleasant experiences by engaging in experiential avoidance. Thus, this impacts on the individual‘s quality of life as their long-terms hopes, desires and goals (e.g. values) become less of a priority as feeling good becomes more of a priority and they lose contact with what was previously important in their lives (Hayes et al., 2006).

The Acceptance-Based model has been used to explain the development and maintenance of GAD (Roemer et al., 2005). Roemer et al., 2005, suggest that GAD may be maintained by the individual‘s attempts to avoid internal experiences. Moreover, those individuals develop positive beliefs about the usefulness of experiential avoidance as a coping strategy. Individuals are more likely to worry about less distressing events, serving a function of avoiding experiences that are

more distressing (Roemer et al., 2005). The main focus of this model is the lack of tolerance or non-acceptance of anxiety (Hayes et al., 1996). Although the authors have not developed a diagrammatic version of the model, Behar and colleagues depicted a model in their review (Behar et al., 2009), which has been adapted for this literature review, demonstrated in Figure 3.

Figure 3: An Acceptance-Based Model of GAD (Roemer et al., 2005) depicted by Behar et al (2009).

2.3.5.1 Empirical Support for the Acceptance-Based Model

Although in its infancy, recent studies have tested the central construct of experiential avoidance, as it has been considered a risk factor in the development of mental distress. Specifically, it has been found to mediate the effects of passive coping on both increased anxiety and depression, but more generally demonstrating a reduction in emotional and psychological well-being (Fledderus, Bohimeijer, &

Perceived External Threat Internal experiences Problematic Relationship with Internal Experiences Experiential Avoidance Behavioural Restriction R ed uce d shor t- ter m di st ress In cr ea sed di st ress Increased di st ress

This text box is where the unabridged thesis included the following third

party copyrighted material:

Roemer, L., Salters, K., Raffa, S., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research, 29(1), 71-88.

Diagram is from:

Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011- 1023.

Pieterse, 2010). Experiential avoidance is thought to be a common experience in those experiencing mental distress, but some report it is not specific to GAD (Buhr & Dugas, 2012). In support of this idea, Hayes and colleagues report experiential avoidance to be a general psychological vulnerability, a common construct underlying many disorders (Hayes et al., 1996).

However, several studies indicate experiential avoidance is involved in the development and maintenance of GAD. First, a direct relationship in the role of experiential avoidance and a fear of emotions has been observed in worry in a non- clinical sample and GAD severity in a clinical sample, suggesting those with high levels of worry and those with GAD share a common experience of experiential avoidance. Although the authors also suggested experiential avoidance may not be unique to GAD and may be present in other anxiety disorders (Roemer et al., 2005).

Also in support of an Acceptance-Based model of GAD, Lee et al (2010) used a clinical sample to explore the role of experiential avoidance and IU, compared to a control group. Findings suggest that those with GAD report significantly higher levels of experiential avoidance and distress about their emotions. Experiential avoidance was found to share a unique variance in IU, thus suggesting, situations that elicit uncertainty may lead to individuals avoiding internal experiences, which leads to increased experiential avoidance. This study provides additional support for the role of fear of emotions, specifically experiential avoidance in understanding worry and GAD in a clinical sample (Lee, Orsillo, Roemer, & Allen, 2010). In addition, individuals experiencing GAD have been found to live a life with significantly less valued actions and an overall diminished quality of life, which is thought to be the result of experiential avoidance from individuals seeking to avoid their internal experiences (Michelson, Lee, Orsillo, & Roemer, 2011).

As this model is still in its developmental phase, most of the research has been focused on this construct being a general vulnerability for psychopathology and not specific to GAD. There are methodological limitations of the current studies; small clinical samples, cross-sectional designs (Roemer et al., 2005) and heterogeneous clinical samples (Lee et al., 2010). In addition, there has also been no longitudinal research looking at causality, therefore further studies with more rigorous methodology are required to understand the role of experiential avoidance in the development and maintenance of worry and GAD.