Acceptance and Action Questionnaire – Stigma (AAQ-S)

Abstract

The Acceptance and Action Questionnaire – Stigma (AAQ-S) is a 21-item self-report psychometric instrument developed to evaluate psychological flexibility and psychological inflexibility specifically with respect to stigmatizing, prejudicial, and evaluative thoughts toward others. Grounded in the theoretical architecture of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT), the AAQ-S moves beyond traditional measures of prejudice that quantify the endorsement or suppression of biased contents. Instead, the instrument operationalizes how individuals relate functionally to their automatic stereotypes, prejudices, and judgmental evaluations. The measure assesses two distinct yet correlated dimensions: Psychological Inflexibility (11 items), capturing cognitive fusion with prejudicial thoughts, experiential avoidance, and behavioral behavioral disruption or withdrawal; and Psychological Flexibility (10 reverse-scored items), capturing mindful awareness, defusion, cognitive acceptance of automatic evaluations, and values-congruent interpersonal behavior. Items are rated on a 7-point Likert scale ranging from 1 (“never true”) to 7 (“always true”). Initial and subsequent psychometric validation studies demonstrate strong internal consistency (Cronbach’s alpha typically ranging from .80 to .88 across subscales), robust construct and convergent validity with generalized psychological flexibility (AAQ-II), generalized prejudice, modern racism, social dominance orientation, and empathy, as well as predictive validity for discriminatory behavioral patterns, social distance, and intervention responsiveness. This article provides an exhaustive psychometric exposition of the AAQ-S, including its theoretical framework, structural dimensions, exploratory and confirmatory factor analyses, scoring protocols, and research and clinical applications.

Keywords

Acceptance and Action Questionnaire – Stigma, AAQ-S, psychological flexibility, psychological inflexibility, cognitive fusion, experiential avoidance, stigma, prejudice, Acceptance and Commitment Therapy, Relational Frame Theory, psychometrics, factor analysis.

Authors

The Acceptance and Action Questionnaire – Stigma (AAQ-S) was developed by a team of clinical psychologists and contextual behavioral scientists:

• Michael E. Levin, Ph.D. — Professor of Psychology, Utah State University, Logan, UT, USA. Specializes in Acceptance and Commitment Therapy, digital mental health interventions, and the contextual behavioral mechanisms of stigma and prejudice.
• Jason B. Luoma, Ph.D. — Chief Executive Officer at Portland Psychotherapy Clinic, Research, & Training Center, Portland, OR, USA. Leading researcher in the mechanisms of shame, self-stigma, and interpersonal behavior within contextual behavioral science.
• Jason Lillis, Ph.D. — Assistant Professor (Research) at the Warren Alpert Medical School of Brown University and The Miriam Hospital, Providence, RI, USA. Expert in health-related stigma, behavioral weight management, and ACT-based interventions.
• Steven C. Hayes, Ph.D. — Nevada Foundation Professor Emeritus of Psychology at the University of Nevada, Reno, NV, USA. Originator of Acceptance and Commitment Therapy and co-developer of Relational Frame Theory.
• Roger Vilardaga, Ph.D. — Associate Professor in the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA. Researcher specializing in digital interventions, mobile health psychometrics, and empathy within contextual science.

Purpose

The primary purpose of the Acceptance and Action Questionnaire – Stigma (AAQ-S) is to provide an empirically validated, functionally oriented measure that captures how individuals relate to their own stigmatizing and prejudicial thoughts, rather than merely documenting the presence, intensity, or explicit endorsement of those thoughts. For decades, social psychology and clinical assessment predominantly relied upon self-report instruments measuring explicit prejudice (e.g., modern racism scales, symbolic prejudice inventories) or computer-administered reaction-time tasks evaluating implicit bias (such as the Implicit Association Test). While these instruments have yielded valuable insights into cognitive associations and explicit social attitudes, they present substantial theoretical and practical limitations when designing interventions aimed at behavioral change.

Traditional bias reduction models often operated under the premise that in order to eliminate discriminatory behavior, one must first suppress, dispute, or eliminate automatic negative evaluations. However, cognitive psychology and contextual behavioral science have repeatedly shown that thought suppression frequently produces paradoxical rebound effects, where suppressed stereotypical thoughts become hyper-accessible in memory and increase the likelihood of behavioral avoidance or biased decision-making. In contrast, the ACT model posits that implicit prejudices, stereotypic associations, and negative evaluations are natural evolutionary products of human language and relational conditioning. Given that human beings inevitably absorb cultural stereotypes from their sociopolitical environments, completely preventing the emergence of negative judgments is often an unrealistic goal. The critical determinant of discriminatory action is not the occurrence of the biased cognitive event itself, but rather the individual’s level of psychological flexibility with respect to that thought.

The AAQ-S was formulated to address this clinical and empirical imperative across diverse domains:

• Intervention Research: Serving as a primary process and mediator measure in randomized controlled trials (RCTs) investigating the efficacy of contextual behavioral interventions (e.g., ACT-based anti-stigma workshops, cultural competence training, and empathy-enhancement protocols) aimed at reducing bias toward racial minorities, individuals with mental health disorders, substance use disorders, weight-related stigma, and sexual orientation minorities.
• Clinical and Educational Assessment: Assessing healthcare providers, psychotherapists, counselors, and educators to determine how their implicit reactions, professional evaluations, or stereotypic judgments influence clinical decision-making, empathetic attunement, therapeutic alliance, and cultural responsiveness.
• Experimental Psychopathology: Disentangling the mechanistic pathways connecting cognitive fusion, behavioral avoidance, social distancing, and interpersonal withdrawal in laboratory-based social interaction paradigms.

Psychological Construct

The AAQ-S operationalizes the contextual behavioral construct of psychological flexibility applied specifically to the domain of stigmatizing evaluations, stereotypes, and prejudiced cognitions. In the Hexaflex model of Acceptance and Commitment Therapy, psychological flexibility is defined as the capacity to contact the present moment fully as a conscious human being, and based on what the situation affords, to change or persist in behavior in the service of chosen values. Its counterpart, psychological inflexibility, represents the dominance of cognitive fusion, experiential avoidance, attentional rigidity, attachment to a conceptualized self, and behavioral inaction or impulsivity.

The AAQ-S evaluates these dynamics across two primary operational subscales:

1. Psychological Inflexibility Subscale (11 items)

This subscale measures the tendency to become entangled with, dominated by, or functionally reactive to automatic negative evaluations and prejudices toward others. It reflects high levels of:

• Cognitive Fusion with Judgments: Treating evaluations and prejudicial thoughts as literal, objective truths about the person being evaluated (e.g., Item 21: “The bad things I think about others must be true”; Item 16: “When talking with someone I believe I should act according to how I feel about him/her, even if its negative”). Under high cognitive fusion, the subjective thought “this person is untrustworthy” functions as an immediate reality, directly prompting exclusionary action.
• Experiential Avoidance and Behavioral Disruption: Unwillingness to experience uncomfortable thoughts, judgments, or biases, leading to interpersonal withdrawal or the abandonment of valued activities (e.g., Item 6: “I stop doing things that are important to me when it involves someone I don’t like”; Item 13: “When I am having negative thoughts about others, I withdraw from people”).
• Perceived Cognitive Barrier to Values: The belief that biased thoughts must be eradicated before one can engage in ethical, culturally competent, or respectful interactions (e.g., Item 4: “I need to reduce my negative thoughts about others in order to have good social interactions”; Item 8: “I feel that my prejudicial thoughts are a significant barrier to me being culturally sensitive”).
• Impulsive Behavioral Reactivity: Inability to inhibit behavioral impulses driven by negative internal evaluations (e.g., Item 9: “I have trouble not acting on my negative thoughts about others”).

2. Psychological Flexibility Subscale (10 items)

This subscale captures mindful, values-oriented, and defused responding toward one’s own evaluative and stigmatizing cognitions. All items on this dimension are reverse-scored when calculating an overall inflexibility index, or analyzed independently as an indicator of adaptive psychological responding. Key components include:

• Mindful Awareness of Judgments: The metacognitive ability to notice automatic stereotypes and evaluations as ongoing mental events without being swept away by them (e.g., Item 10: “I am aware when judgments about others are passing through my mind”; Item 17: “I’m good at noticing when I have a judgment of another person”).
• Cognitive Defusion: Recognizing that evaluations are subjective reactions shaped by learning history rather than literal reflections of external reality (e.g., Item 5: “When I evaluate someone negatively, I am able to recognize that this is just a reaction, not an objective fact”).
• Acceptance and Non-Struggle: Allowing evaluative cognitions to arise without engaging in unproductive internal control struggles, thought suppression, or distress (e.g., Item 12: “I don’t struggle with controlling my evaluations about others”; Item 18: “I rarely worry about getting my evaluations towards others under control”; Item 19: “I accept that I will sometimes have unpleasant thoughts about other people”).
• Interpersonal Value Persistence: Maintaining meaningful relationships and ethical engagements despite the presence of transient negative thoughts (e.g., Item 11: “It’s OK to have friends that I have negative thoughts about from time to time”).

Theoretical Framework

The AAQ-S is rooted in Relational Frame Theory (RFT), a comprehensive contextual behavioral account of human language and cognition, and its direct clinical application, Acceptance and Commitment Therapy (ACT). According to RFT, human cognition is characterized by the capacity to relate stimuli arbitrarily, regardless of their formal physical properties. Once relational networks are established, stimulus functions (e.g., fear, aversion, disgust, superiority) transfer and transform across derived relations.

In the context of social categorization and stigma:

1. Arbitrary Categorization and Derived Relational Responding: Language allows humans to group individuals into categorical classes based on arbitrary cultural markers (such as skin tone, ethnicity, psychiatric diagnosis, sexual orientation, or physical disability). Through social conditioning, cultural stories, and media representation, negative evaluative frames (e.g., “dangerous,” “lazy,” “immoral,” “incompetent”) are relationally coordinated with these categories. Because relational responding is generative, individuals can derive prejudice toward a novel person belonging to a category without having had any direct experiential contact with that individual.
2. Transformation of Stimulus Functions: Once a social group is linked relationally with a negative attribute, meeting a member of that group automatically elicits the aversive stimulus functions associated with that attribute. The person is no longer perceived merely as an individual; their physical presence evokes conditioned affective distress, wariness, or discomfort.
3. Cognitive Fusion and Literality: When individuals are cognitively fused with language, they treat relational evaluations (“This person is dangerous”) as literal descriptions of the world rather than conditioned ongoing verbal behavior. This fusion compels avoidant or discriminatory actions designed to protect oneself from the derived threat.
4. Experiential Avoidance of Biased Cognitions: In modern egalitarian societies, having prejudicial thoughts frequently generates internal shame, moral distress, or self-condemnation. Individuals often respond with experiential avoidance—attempting to suppress, deny, or control their biased thoughts. However, RFT and experimental cognitive science demonstrate that suppression strengthens the relational networks sustaining the thought, making it more salient and triggering paradoxical behavioural withdrawal from the stigmatized group to avoid experiencing the internal distress altogether.

The theoretical framework of the AAQ-S posits that psychological health and social justice do not require an impossible eradication of all culturally conditioned cognitive associations. Instead, through the cultivating of defusion (looking at thoughts rather than from thoughts) and acceptance (willingness to experience unpleasant mental evaluations), individuals can unhook their values-based behaviors from automatic internal reactions, fostering compassionate, equitable, and culturally responsive interpersonal engagements.

Validity

Empirical validation of the AAQ-S across multiple psychometric investigations provides robust evidence for construct, convergent, discriminant, and predictive validity.

Construct and Structural Validity

During the scale development study conducted by Levin, Luoma, Lillis, Hayes, and Vilardaga (2014), exploratory and confirmatory factor analyses verified that the AAQ-S is best conceptualized as having a two-factor structure (Psychological Inflexibility and Psychological Flexibility) that is distinct from generalized measures of experiential avoidance. Construct validity was corroborated by showing that the two subscales account for unique variance in prejudice-related behaviors above and beyond generalized psychological inflexibility measures such as the AAQ-II.

Convergent Validity

Convergent validity has been established through statistically significant correlations with established constructs in social and personality psychology:

• Generalized Psychological Inflexibility: The Inflexibility subscale demonstrates moderate-to-strong positive correlations with the Acceptance and Action Questionnaire – II (AAQ-II) (r values typically ranging from .42 to .56, p < .001), indicating that while it shares core variance with generalized experiential avoidance, it measures a distinct, domain-specific functional process.
• Prejudice and Social Distance: Inflexibility scores correlate positively with explicit measures of prejudice, including the Modern Racism Scale, symbolic racism, and social distance inventories (r = .30 to .48, p < .01). Individuals high in inflexibility report greater discomfort and higher desire to maintain interpersonal distance from stigmatized group members.
• Social Dominance and Authoritarianism: The AAQ-S Inflexibility subscale exhibits moderate positive associations with the Social Dominance Orientation (SDO) scale and the Right-Wing Authoritarianism (RWA) scale (r = .25 to .39).
• Empathy and Perspective Taking: The Psychological Flexibility subscale shows robust positive correlations with the Perspective Taking and Empathic Concern subscales of the Interpersonal Reactivity Index (IRI) (r = .34 to .45, p < .001), demonstrating that individuals capable of defusing from their evaluations exhibit enhanced empathetic attunement.

Discriminant Validity

Discriminant validity is supported by modest or non-significant correlations with unrelated constructs, such as social desirability response bias (e.g., Marlowe-Crowne Social Desirability Scale, r = -.08 to .12, non-significant). This confirms that self-reported psychological flexibility with stigmatizing thoughts is not merely an artifact of impression management or egalitarian self-presentation. Furthermore, the AAQ-S retains significant predictive utility even when controlling for general neuroticism and negative affectivity.

Predictive and Incremental Validity

In behavioral laboratory tasks and prospective intervention studies, the AAQ-S has demonstrated notable predictive validity:

• Predicting direct behavioral avoidance: In experimental settings where participants were given choices regarding seating proximity or collaborative partners involving individuals labeled with psychiatric diagnoses or belonging to minority groups, participants with higher AAQ-S Inflexibility scores chose significantly greater physical distance and exhibited fewer interactive verbal behaviors.
• Treatment mediation: In randomized controlled trials evaluating ACT-based stigma reduction workshops, changes in AAQ-S scores significantly mediated post-treatment reductions in stigmatizing attitudes and behavioral follow-through, whereas traditional measures of thought frequency or explicit bias failed to demonstrate mediation effects.

Reliability

The AAQ-S demonstrates high internal consistency and stability across diverse community, undergraduate, and clinical professional samples.

Internal Consistency

Across validation and replication studies:

• Psychological Inflexibility Subscale (11 items): Cronbach’s alpha (α) coefficients consistently range between .83 and .88, indicating excellent internal homogeneity among items assessing cognitive fusion, avoidance, and behavioral interference. McDonald’s omega total (ω) has similarly yielded estimates between .84 and .89.
• Psychological Flexibility Subscale (10 items): Cronbach’s alpha coefficients consistently range between .80 and .85 (ω = .81 to .86), reflecting robust internal consistency among items capturing defusion, non-struggle, and mindful awareness of judgments.
• Full Scale (21 items, with Flexibility reversed): Cronbach’s alpha values typically exceed .85 across general adult samples. However, psychometricians generally recommend evaluating the two subscales independently due to their distinct theoretical and structural profiles.

Test-Retest Reliability

Temporal stability assessments conducted over intervals ranging from two to four weeks have shown strong intraclass correlation coefficients (ICC) and Pearson correlation coefficients:

• Two-week test-retest reliability: r = .81 for Inflexibility and r = .78 for Flexibility.
• Four-week test-retest reliability: r = .76 for Inflexibility and r = .73 for Flexibility in non-intervention control cohorts.

These statistics confirm that the AAQ-S reflects stable individual trait-like behavioral patterns while remaining sufficiently sensitive to detect mechanistic changes following targeted psychological interventions.

Factor Analysis

The structural dimensionality of the AAQ-S was established through rigorous exploratory factor analysis (EFA) and subsequent confirmatory factor analysis (CFA) during initial instrument construction and independent cross-validation studies.

Exploratory Factor Analysis (EFA)

In the initial scale construction phase, an initial pool of candidate items derived by expert contextual behavioral scientists was administered to sample cohorts. Principal axis factoring with oblique rotation (e.g., Promax or Direct Oblimin) was conducted, as the theoretical dimensions of psychological flexibility and inflexibility were anticipated to be interrelated.

Scree plot examination, parallel analysis, and Kaiser’s criterion (eigenvalues > 1.0) unequivocally indicated a two-factor solution:

• Factor 1: Psychological Inflexibility: Accounted for the largest proportion of total variance (~26–30%). Items loaded heavily on themes of behavioral interference (e.g., Item 6, loading = .71), fusion with negative evaluations (e.g., Item 21, loading = .65), and inability to refrain from acting on judgments (e.g., Item 9, loading = .68).
• Factor 2: Psychological Flexibility: Accounted for an additional ~12–16% of total variance. Items loaded distinctly on themes of defusion (e.g., Item 5, loading = .67), awareness of passing evaluations (e.g., Item 10, loading = .72; Item 17, loading = .74), and non-struggle with cognitions (e.g., Item 18, loading = .62).

Cross-loadings between the two factors were consistently low (< .25), affirming clean structural separation between the positively and negatively valenced functional processes.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analyses testing alternative structural models have systematically supported the correlated two-factor model over unidimensional or orthogonal configurations:

• Unidimensional Model (1 Factor): Displayed inadequate goodness-of-fit indices (e.g., Comparative Fit Index [CFI] < .80; Tucker-Lewis Index [TLI] < .78; Root Mean Square Error of Approximation [RMSEA] > .09; Standardized Root Mean Square Residual [SRMR] > .08).
• Correlated Two-Factor Model (Inflexibility & Flexibility): Demonstrated superior and acceptable-to-good fit parameters across independent replication samples:
  • χ²/df ratio: < 2.50
  • CFI: .91 to .94
  • TLI: .90 to .93
  • RMSEA: .048 to .058 (90% CI [.041, .065])
  • SRMR: .051 to .062

The correlation between the two latent factors is typically moderate and negative (r ≈ -.38 to -.52), reinforcing the theoretical premise in contextual behavioral science that flexibility and inflexibility are functionally related yet non-redundant behavioral processes.

Instrument / Measurement Tool

• Full Instrument Name: Acceptance and Action Questionnaire – Stigma
• Acronym: AAQ-S
• Construct Assessed: Psychological flexibility and psychological inflexibility with stigmatizing and prejudicial thoughts
• Theoretical Basis: Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT)
• Administration Format: Self-report questionnaire; available in paper-and-pencil or secure computer-based/online survey formats
• Target Population: Adults (aged 18 and older); adaptable for university students, healthcare professionals, community samples, and clinical trainees
• Completion Time: Approximately 4 to 7 minutes
• Item Count: 21 items
• Response Scale: 7-point Likert-type scale:
  • 1 = never true
  • 2 = very seldom true
  • 3 = seldom true
  • 4 = sometimes true
  • 5 = frequently true
  • 6 = almost always true
  • 7 = always true
• Subscale Breakdown:
  • Psychological Inflexibility Subscale: 11 items (Items 1, 4, 6, 7, 8, 9, 13, 15, 16, 20, 21). Scored directly (1 = 1 to 7 = 7). Higher scores indicate higher cognitive fusion, experiential avoidance, and behavioral disruption related to prejudicial thoughts.
  • Psychological Flexibility Subscale: 10 items (Items 2, 3, 5, 10, 11, 12, 14, 17, 18, 19). All items are marked with an asterisk (*) denoting reverse scoring when computing an overall inflexibility index (1 = 7, 2 = 6, 3 = 5, 4 = 4, 5 = 3, 6 = 2, 7 = 1), or scored directly when maintaining Flexibility as an independent subscale.
• Scoring Options:
  • Two-Subscale Approach (Recommended): Compute separate subscale sums or item means for Inflexibility (sum: 11 to 77) and Flexibility (sum: 10 to 70). Item mean scores retain the interpretable 1–7 response metric.
  • Total Inflexibility Score: Reverse-score the 10 Flexibility items and sum all 21 items (range: 21 to 147). Higher total scores represent greater overall psychological inflexibility with respect to stigmatizing evaluations.

Permissions & Fee and Test Year

• Publication Year: 2014
• Copyright & Ownership: Copyright © 2014 by the authors (Michael E. Levin, Jason B. Luoma, Jason Lillis, Steven C. Hayes, Roger Vilardaga) and the Association for Contextual Behavioral Science (ACBS) / Elsevier Inc.
• Licensing and Accessibility: The AAQ-S is an open-access psychometric instrument made freely available for non-commercial academic research, empirical study, and clinical evaluation. Researchers and practitioners do not need to pay a licensing fee or seek formal written permission to utilize the instrument in non-commercial contexts.
• Commercial Use: Any commercial deployment, inclusion in proprietary software platforms, or monetization requires formal written permission from the copyright holders.
• Repository & Documentation: The scale, scoring protocols, and psychometric documentation are hosted via the Utah State University Contextual Behavioral Science repository and the Association for Contextual Behavioral Science official repository: https://contextualscience.org.

References

• Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006
• Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
• Levin, M. E., Luoma, J. B., Lillis, J., Hayes, S. C., & Vilardaga, R. (2014). The Acceptance and Action Questionnaire – Stigma (AAQ-S): Developing a measure of psychological flexibility with stigmatizing thoughts. Journal of Contextual Behavioral Science, 3(1), 21–26. https://doi.org/10.1016/j.jcbs.2013.11.003
• Lillis, J., & Hayes, S. C. (2007). Applying acceptance, commitment, and relational frame theory to transfer of prejudice. Behavior Modification, 31(4), 389–403. https://doi.org/10.1177/0145445506298413
• Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., Bunting, K., & Rye, A. K. (2008). Reducing self-stigma in substance abuse through Acceptance and Commitment Therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory, 16(2), 149–165. https://doi.org/10.1080/16066350701850295
• Masuda, A., Hayes, S. C., Fletcher, L. B., Seignourel, P. J., Bunting, K., Herbst, S. A., Twohig, M. P., & Lillis, J. (2007). The impact of Acceptance and Commitment Training and multicultural training on ethnic prejudice: A laboratory test. Behaviour Research and Therapy, 45(11), 2804–2814. https://doi.org/10.1016/j.brat.2007.07.017

13. Items of the Scale (Questionnaire)