1. The development & initial validation of the cognitive fusion questionnaire or, “How I learned not to be afraid of factor analysis and did what I had to do to be published in Behavior Therapy” Dr. David Gillanders Dr. Helen Bolderston University of Edinburgh Bournemouth University Prof. Frank W. Bond University of London, Goldsmiths The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

2. Cognitive Fusion & Defusion Thoughts themselves are not seen as problematic The function of thoughts to lead to action is problematic Content plus contextual cueing The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

3. Proxy measures Despite the centrality of fusion prior to our measure it was measured using the proxy of ‘believability of thoughts’ This is a narrow definition of what we mean by defusion / fusion So we saw a gap….. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

4. Item development Maria Dempster (2007) Prof Frank Bond (University of London, Goldsmiths) & Helen Bolderston (University of Southampton) Items generated based on knowledge of the literature, clinical experience and personal experience The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

5. Item development Breadth of definition: dominance of cognitive events in a person’s experience, inability to view cognitive events from a different perspective, reacting emotionally to thoughts, behavior being highly regulated by cognitive events, attempts to control thinking, over analysis of situations, evaluating and judging thought content, as well as aspects of literality and believability. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

6. Initial item pool 42 items from Edinburgh and 27 items from Dorset Fusion and defusion wordings Positively and negatively keyed The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

7. Initial item pool The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk I get very focussed on distressing thoughts I feel like my thoughts need to change before I can have a good life I over-analyse situations to the point where it’s unhelpful to me My thoughts cause me distress or emotional pain I get so caught up in my thoughts that I forget what I’m actually doing I get upset with myself for having certain thoughts I tend to get very entangled in my thoughts I need to control the thoughts that come into my head I tell myself that I shouldn’t be thinking the way I’m thinking I make judgements about whether my thoughts are good or bad I find it easy to view my thoughts from a different perspective I can be aware of my thoughts without necessarily reacting to them

8. Expert Panel Review Initial list of items rated by ACT experts Items rated as moderately or highly representative 42 items selected Some wording tweaks The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

9. Instruction set and response scale General rather than specific Chose not to offer a time scale 7 point Likert scale The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

10. Philosophical and conceptual aspects Our background in behaviourism The odd language of psychometrics – “latent variables” “traits” Playing both games or talking two languages? The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

11. Exploratory factor analysis and item reduction using a student sample The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk UoE students & associates of Maria and David n = 592

12. Factor extraction / Item reduction Parallel Analysis (Horn, 1965) – suggested 3 factors Increasingly stringent factor loadings The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

13. Item reduction 2 factors explaining 59.8% of the variance 7 fusion scored items and 3 defusion items The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

14. The interim period: 28 and 13 item versions What the article doesn't’t say…. For several years we collected data with the above versions The 10 item version came through the re analysis of data at the end as we wrote up for publication The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

15. Gathering data on diverse samples Community adult sample including a sample of prison officers (n = 447) Lindsey Campbell (NHS Grampian) Louise Tansey (NHS Lothian / NHS Lanarkshire) Joda Lloyd & Lauraine May (University of London, Goldsmiths) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

16. Gathering data on diverse samples Work site stress management sample (n = 242) Paul Flaxman (City University) Economic and Social Research Council (ESRC grant no: RES-061-0232) Multiple sclerosis sample (n = 133) Clive Ferenbach (NHS Fife) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

17. Gathering data on diverse samples Mixed mental health sample (n = 215) Helen Bolderston (University of Southampton) Penelope Noel (NHS Tayside) Samantha Masely (NHS Grampian) Sian Kerr (NHS Grampian) Dementia caregivers (n = 447) Louise Roach (NHS Lothian) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

18. Investigating the factor structure We spent a lot of time exploring if this really was a 2 factor scale Theoretically these are two sides of the same coin Method Effect or Method Variance (Marsh, 1986) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

19. The back and forth with reviewers… There were 3 ‘revise and resubmit’ decisions before acceptance on the 4 th submission. In the end the reviewers asked us to show that the 3 reversed items actually improved the scale. We did a series of correlational, regression, CFA analyses… We couldn’t provide evidence that the reverse scored items improved the scale The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

20. The final 7 item scale 1.My thoughts cause me distress or emotional pain 2.I get so caught up in my thoughts that I am unable to do the things that I most want to do 3.I over-analyse situations to the point where its unhelpful to me 4.I struggle with my thoughts 5.I get upset with myself for having certain thoughts 6.I tend to get very entangled in my thoughts 7.It’s such a struggle to let go of upsetting thoughts even when I know that letting go would be helpful The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

21. The final CFA of 7 items The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk CFQ 1 CFQ 2 CFQ 3 CFQ 4 CFQ 5 CFQ 6 CFQ 7 e1e2e3e4e5e6 e7 Fusion Factor regression weights: CFQ11.000 CFQ20.955 CFQ31.224 CFQ41.210 CFQ51.151 CFQ61.203 CFQ71.394

22. The final CFA of 7 items The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk Sample χ2χ2 df Χ 2 ÷ dfCFIIFIRMSEA Community (n=448) 40.857*142.918.986.065 Stress management (n= 242) 44.388*143.171.971.095 Mixed mental health (n = 215) 20.333141.452.991.046 Multiple Sclerosis (n = 133) 25.852141.847.983.101 Dementia Caregivers (n = 219) 45.024*143.216.962.963.101

23. Psychometric Properties F (4,1844) = 96.87, p <.0001 1 month test retest reliability: r =.80, p <.001 (Community sample n = 82) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk Student & Community (n = 1040) Work stress (n = 242) Mental Health (n = 215) Multiple Sclerosis (n = 133) Dementia caregivers (n = 219) Mean (SD) 22.28 a (8.30) 25.84 b (8.52) 34.31 c (8.06) 21.22 a (10.36) 23.48 a (8.24) Cronbach’s α.90.92.88.93.90

24. Convergent validity The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk AAQIISMSFFMQKIMS CFQ.80-.70-.50-.59 n10201674778 Mindfulness and acceptance measures

25. Convergent validity The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk HADSaHADSdBDI-IISCL90-GSI CFQ.69.54.69.62 n277 77 Measures of distress / emotional disturbance

26. Convergent validity The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk Deiner’sWHOQoLJob satisfactionVLQ - success CFQ-.39-.45-.42-.21 n167113144109 Measures of quality of life, living well, satisfaction

27. Incremental validity The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk StepVariable β tpR2R2 R 2 changep 1Helplessness beliefs (ICQ).4265.384<.001.181 <.001 2Helplessness beliefs (ICQ).1302.328.021.655.474<.001 AAQ-II.74913.37<.001 3Helplessness beliefs (ICQ).1162.098.038.670.015.017 AAQ-II.5615.897<.001 CFQ.2292.416.017 Prediction of distress in multiple sclerosis over and above helplessness and psychological flexibility

28. Sensitivity to treatment effects The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk For the whole sample Group by time interaction: F (2,113) = 9.998, p <.001, partial η 2 =.150 (large effect)

29. So what do we have? A brief, psychometrically robust measure that has a theoretically and empirically valid factor structure, across diverse samples, that correlates as it should with other constructs, and has incremental validity in comparison to them, that is stable across time, but sensitive to intervention and that such changes mediate the impact of that intervention. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

30. So what do we have? A useful tool in the hands of clinicians and researchers A good publication in Behavior Therapy The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

31. Reflecting on the process of publication We departed from our initial behavioural stand point The introduction was totally re-written to talk the psychometric language more clearly The scale is very different to how we started Broad to narrow ‘The data is your friend’ The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

32. Translations Currently translated into: Dutch, French, Spanish, German, Portuguese (European and Brazilian), Japanese, Hebrew, Greek, Turkish, Catalan, Polish, Italian, Farsi, Chinese & Korean. The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

33. CFQ News >2400 views on Scopus Cited in 31 papers Ongoing studies in our lab in cancer, fear of recurrence, muscle disease, healthy ageing, self help treatment. Development of a state version by Helen Bolderston The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

34. A scientific development community All of this has been possible through the international ACBS community www.contextualscience.org CFQ The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

35. UoE Graduates: Dr Maria Dempster Dr Lindsey Campbell Dr Sian Kerr Dr Louise Tansey Dr Penelope Noel Dr Clive Ferenbach Dr Samantha Masely Dr Louise Roach Dr Emma Miller Dr Ashleigh Sinclair Dr Louise Keir Current UoE Trainees: Kate Randall Shane Forde Dr Christopher Graham Victoria Thomson External Partners: Dr Helen Bolderston (Bournemouth University) Prof Frank Bond (U. of London, Goldsmiths) Dr Paul Flaxman (City University, London) Dr Joda Lloyd (U. of London, Goldsmiths) Ms Lauraine May (U. of London, Goldsmiths) Prof Susan Clarke (U. of Bournemouth) Prof Bob Remington (U. of Southampton) The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk