Measuring Progress in ACT: AAQ-II, CFQ & VLQ Explained

Acceptance and Commitment Therapy (ACT) has grown into one of the most robustly researched behavioral therapies of the last three decades, with more than 1,000 randomized controlled trials supporting its use across depression, anxiety, chronic pain, substance use, and psychosis [Association for Contextual Behavioral Science, 2024]. But unlike symptom-focused therapies, ACT does not primarily aim to reduce anxiety, sadness, or intrusive thoughts. Instead, it targets psychological flexibility — the ability to contact the present moment fully and, based on what the situation affords, act in service of chosen values [Hayes et al., 2006]. Choosing the right ACT outcome measures is therefore central to knowing whether therapy is actually working.

This creates a measurement puzzle. If we are not tracking symptom reduction as the primary outcome, how do we know a client is getting better? How do we know our ACT interventions are actually shifting the six core processes — acceptance, defusion, present-moment awareness, self-as-context, values, and committed action?

The answer lies in a small family of validated, process-based questionnaires. Three stand out as the workhorses of ACT research and clinical practice: the Acceptance and Action Questionnaire-II (AAQ-II), the Cognitive Fusion Questionnaire (CFQ), and the Valued Living Questionnaire (VLQ). Used together, they offer a triangulated view of psychological flexibility that no single symptom scale can provide.

This guide unpacks each measure — what it captures, its psychometric strengths and limitations, how to score and interpret it, and how to weave repeated administration into ongoing therapy. Whether you are a clinician new to ACT, a researcher designing an outcome study, or a curious client who wants to understand what your therapist is tracking, this article will help you use these tools with confidence and nuance.

Key Takeaways

• ACT targets psychological flexibility, not symptom reduction — so process-based measures are essential to track true progress.
• The AAQ-II (7 items) captures experiential avoidance; look for a 5–7 point drop as clinically meaningful change.
• The CFQ (7 items) measures cognitive fusion with better discriminant validity than the AAQ-II; a 6–8 point drop signals reliable improvement.
• The VLQ assesses values importance and consistency across 10 life domains, revealing behavioral gains symptom scales miss.
• Administer the full battery at intake, mid-treatment, termination, and 3-month follow-up for a triangulated view of flexibility.
• Discuss scores openly with clients — measurement without conversation adds burden without benefit.

Why ACT Needs Its Own Outcome Measures

ACT requires dedicated outcome measures because it does not treat symptom reduction as the primary mechanism of change. Traditional inventories like the PHQ-9 or GAD-7 miss the behavioral and process-level gains that define ACT progress. Process measures such as the AAQ-II, CFQ, and VLQ make psychological flexibility visible and trackable.

Traditional therapy outcome tracking leans heavily on symptom inventories such as the PHQ-9 for depression or the GAD-7 for anxiety. These are excellent tools — brief, sensitive, and validated across populations [Kroenke et al., 2001]. But they measure what ACT explicitly does not target as the primary mechanism of change: the frequency or intensity of unwanted internal experiences.

An ACT client may still report a PHQ-9 score of 12 after twelve sessions, yet be volunteering weekly at a food bank, reconnecting with an estranged sibling, and no longer avoiding meaningful work because of self-doubt. From an ACT perspective, that client has made profound progress. Symptom scales miss this entirely.

The American Psychological Association's Division 12 lists ACT as an empirically supported treatment for chronic pain and depression, in part because researchers have used process measures like the AAQ-II and CFQ to demonstrate that mediators of change — not just outcomes — track with clinical improvement [APA Division 12, 2023]. In other words, when clients get more flexible, they get better, and process measures are how we see that flexibility shifting.

What are the six core processes measured in ACT?

Before diving into individual measures, it helps to remember what each questionnaire is trying to capture:

• Experiential avoidance (targeted by the AAQ-II): the unwillingness to remain in contact with distressing internal experiences.
• Cognitive fusion (targeted by the CFQ): the tendency to be entangled with the literal content of thoughts, treating them as reality rather than as passing mental events.
• Valued living (targeted by the VLQ): the extent to which a person identifies and acts in accordance with chosen life directions.

These three processes account for a substantial share of the variance in psychological wellbeing across dozens of studies [A-Tjak et al., 2015]. Measuring them repeatedly allows clinicians to detect stalls, celebrate wins invisible on symptom scales, and adjust interventions with precision. For a deeper dive into these mechanisms, see our overview of the Six Core Processes of ACT: Complete Interventions & Worksheets.

The AAQ-II: Measuring Experiential Avoidance and Psychological Inflexibility

The AAQ-II is a 7-item self-report scale that measures psychological inflexibility and experiential avoidance — the unwillingness to stay in contact with painful thoughts and feelings. Scores range from 7 to 49, with higher scores indicating greater inflexibility. It remains the most widely used measure in ACT research despite ongoing debate about what exactly it captures.

The Acceptance and Action Questionnaire-II, developed by Bond and colleagues in 2011, replaced the original 9-item AAQ, which had inconsistent factor structures across samples [Bond et al., 2011].

What does the AAQ-II actually ask?

Respondents rate each of seven statements on a 7-point Likert scale from 1 ("never true") to 7 ("always true"). Items include statements such as "My painful experiences and memories make it difficult for me to live a life that I would value," and "Worries get in the way of my success." Higher scores indicate greater psychological inflexibility.

Scores range from 7 to 49. Population norms suggest a mean of approximately 18–20 in nonclinical samples, with clinical cutoffs often set around 24–28, though researchers have debated the utility of a single cutoff across populations [Bond et al., 2011; Fledderus et al., 2012].

How reliable is the AAQ-II?

The AAQ-II has demonstrated strong internal consistency (Cronbach's alpha typically 0.84–0.88), acceptable test-retest reliability, and predictable relationships with measures of depression, anxiety, and quality of life [Bond et al., 2011]. Meta-analytic work has repeatedly shown that changes in AAQ-II scores mediate the effect of ACT on symptom outcomes across diagnoses [Stockton et al., 2019].

What are the known limitations and controversies?

The AAQ-II is not without critics. A significant body of research has argued that it correlates so strongly with neuroticism and general distress measures that it may capture something closer to general negative affect than a distinct psychological inflexibility construct [Wolgast, 2014; Tyndall et al., 2019]. This does not invalidate its clinical usefulness, but it does mean clinicians should interpret changes cautiously and pair it with other measures.

Newer alternatives such as the Multidimensional Psychological Flexibility Inventory (MPFI) and the Comprehensive Assessment of ACT Processes (CompACT) attempt to address these concerns by measuring each of the six ACT processes separately [Rolffs et al., 2018]. Still, the AAQ-II remains the most common measure because of its brevity, ease of scoring, and enormous comparison database.

How to Use It in Session

• Baseline and every 4–6 sessions. Administering the AAQ-II too frequently can create response fatigue and undermine reflection; too infrequently misses meaningful shifts.
• Look for a change of 5–7 points as clinically meaningful, based on reliable change index calculations in published trials.
• Discuss item-level responses. If a client rates "I'm afraid of my feelings" as a 7, that becomes rich material for defusion and acceptance work.

The CFQ: Untangling Cognitive Fusion

The CFQ is a 7-item scale that measures how tangled a person becomes with the literal content of their thoughts. Scores range from 7 to 49, with clinical samples typically scoring in the mid-30s. Unlike the AAQ-II, the CFQ shows better discriminant validity — it captures fusion as distinct from general distress.

The Cognitive Fusion Questionnaire, developed by Gillanders and colleagues in 2014, addresses one of the most important — and most difficult to measure — ACT processes: fusion with the literal content of thoughts [Gillanders et al., 2014]. Where the AAQ-II measures general inflexibility, the CFQ zeroes in on the extent to which a person becomes hooked by their own mental narratives.

How is the CFQ structured and scored?

The CFQ is a seven-item self-report scale rated on a 7-point Likert scale from 1 ("never true") to 7 ("always true"). Sample items include "My thoughts cause me distress or emotional pain," "I get so caught up in my thoughts that I am unable to do the things that I most want to do," and "I struggle with my thoughts."

Scores range from 7 to 49. Higher scores reflect greater cognitive fusion. Nonclinical samples typically average around 20–24; clinical samples often score in the mid-30s [Gillanders et al., 2014].

What does the psychometric evidence show?

The CFQ has shown excellent internal consistency (alpha typically above 0.88), strong test-retest reliability at four weeks, and good convergent validity with measures of rumination, thought suppression, and psychological distress [Gillanders et al., 2014]. Importantly, factor analysis has consistently supported a single-factor structure across diverse populations, including chronic pain, cancer, and general clinical samples [China et al., 2018].

Unlike the AAQ-II, the CFQ appears to have somewhat better discriminant validity — meaning it captures something distinguishable from general negative affect. Studies have shown that CFQ scores predict outcomes above and beyond depression severity, suggesting fusion is not merely a proxy for feeling bad [Bardeen & Fergus, 2016].

Interpreting CFQ Change

In clinical practice, look for these markers of meaningful progress:

• A drop of 6–8 points across a course of therapy suggests reliable change.
• Reduced endorsement of items about "struggle" often indicates the client is applying defusion techniques rather than fighting thoughts.
• Stable fusion scores despite improved mood may signal that the client is feeling better for external reasons (a life change, a new relationship) but has not built durable defusion skills — a relapse risk.

Pairing the CFQ with In-Session Defusion Work

Because the CFQ is content-focused, it pairs beautifully with defusion interventions. A clinician might administer it after a run of sessions using techniques like "I'm having the thought that…", the leaves-on-a-stream exercise, or physicalizing thoughts. If scores drop, the therapist has empirical evidence that defusion is landing; if not, it may be time to try more experiential approaches or explore whether fusion is showing up in other domains.

The Valued Living Questionnaire: Measuring What Matters

The VLQ measures how much a client values ten life domains and how consistently they act in line with those values. It is the only widely used ACT measure that captures the "toward" moves of values and committed action — making visible the meaningful behavior changes that symptom scales cannot detect.

If the AAQ-II and CFQ measure the barriers to psychological flexibility, the Valued Living Questionnaire (VLQ), developed by Wilson and colleagues in 2010, measures the compass [Wilson et al., 2010].

How does the VLQ work?

The VLQ is a two-part instrument covering ten life domains: family relationships, marriage/couples/intimate relations, parenting, friendships/social relations, work, education/training, recreation/fun, spirituality, community life, and physical self-care.

For each domain, respondents rate:

1. Importance — how important this area is to them on a 1-to-10 scale.
2. Consistency — how consistently they have lived in accordance with their values in this area over the past week, again on a 1-to-10 scale.

A common summary score is the Valued Living Composite: the average of importance × consistency across the ten domains, divided by 10. Higher scores indicate greater alignment between what matters and how one is actually living.

Why is the VLQ clinically powerful?

The VLQ makes visible what symptom scales miss entirely. A client may show minimal change on the PHQ-9 but demonstrate that they have moved from a consistency score of 2 to a 7 in the domain of "friendships" — meaning they are, in real terms, showing up for people they love. That is ACT working, even if the sadness has not fully lifted.

Research supports the VLQ's utility as a treatment outcome measure. Studies have shown that increases in VLQ consistency scores predict long-term wellbeing and reduced relapse in depression, independent of symptom change [Trompetter et al., 2013]. For guidance on translating values into daily behavior, see our companion guide to Committed Action in ACT: Turn Values Into Daily Habits.

Limitations to Keep in Mind

The VLQ has weaker psychometric documentation than the AAQ-II or CFQ. Internal consistency varies by domain, and the ten domains do not always map cleanly onto individual clients' actual value structures. A person may have no interest in "parenting" or "spirituality," which can distort composite scores if not interpreted thoughtfully.

Newer measures such as the Valuing Questionnaire (VQ) [Smout et al., 2014] have been developed to address these limitations by capturing two dimensions — progress and obstruction — without requiring domain-by-domain scoring. Many clinicians now use the VQ alongside or instead of the VLQ.

Using the VLQ Clinically

• Focus on discrepancy scores. The gap between importance and consistency in each domain is where suffering often lives — and where committed action interventions are most useful.
• Don't average away meaning. A composite score can hide huge domain-by-domain variation. Always review individual domains with the client.
• Use it as a conversation starter. The VLQ is not just a measure; it is a values clarification exercise disguised as a questionnaire.

Combining the Three: A Triangulated View of Flexibility

Used together, the AAQ-II, CFQ, and VLQ create a three-dimensional picture: willingness, unhooking, and valued action. CFQ scores typically drop first, AAQ-II next, and VLQ consistency rises last — a sequence that mirrors how skills build in ACT.

• The AAQ-II tells you how much the client is willing to have their internal experiences.
• The CFQ tells you how entangled they are with the literal content of their thoughts.
• The VLQ tells you whether that willingness and defusion are translating into a life that feels meaningful.

A common pattern in successful ACT is that CFQ scores drop first (defusion tends to be an early skill), followed by AAQ-II decreases (as clients become willing to have what they used to avoid), and finally VLQ consistency scores rise (as behavior aligns with values). Deviations from this pattern often signal important clinical information — for example, VLQ gains without AAQ-II or CFQ changes may indicate white-knuckle compliance rather than genuine flexibility, which tends to be less durable.

A Sample Measurement Schedule

1. Intake: Administer AAQ-II, CFQ, and VLQ alongside symptom measures (PHQ-9, GAD-7).
2. Session 4: Repeat CFQ (defusion is often the first target).
3. Session 8: Repeat AAQ-II and CFQ.
4. Session 12: Full battery, including VLQ.
5. Termination and 3-month follow-up: Full battery.

This schedule mirrors what is used in many published acceptance and commitment therapy research trials and provides enough data points to detect meaningful change without overwhelming the client.

Making Measurement Meaningful, Not Mechanical

Measurement improves outcomes only when it is discussed openly with clients. Handing over forms without reviewing results turns assessment into paperwork. Effective clinicians explain the purpose of each measure, share results, and hold scores lightly as hypotheses rather than verdicts.

Routine outcome monitoring — regardless of the therapy — improves clinical outcomes. A landmark review found that clinicians who systematically tracked client progress had significantly better outcomes, particularly for clients who were not responding [Lambert & Shimokawa, 2011]. The Substance Abuse and Mental Health Services Administration (SAMHSA) has recommended measurement-based care as a core element of quality behavioral healthcare [SAMHSA, 2023].

But measurement can go wrong. Handing a client a stack of forms at the start of each session and never discussing them turns assessment into an administrative task. To keep measurement meaningful:

• Explain the "why." Tell clients that you are tracking flexibility processes, not just symptoms, and that improvements here often precede — or outlast — symptom relief.
• Share results. Show clients their scores over time. Many find it validating to see cognitive fusion drop, even when depression scores lag.
• Use scores as hypotheses, not verdicts. A high AAQ-II may reflect a bad week, not therapy failure.
• Watch for iatrogenic effects. Some clients become fused with their scores ("I got worse this week — I'm failing therapy"). Model defusion by holding the numbers lightly.

Cultural and Language Considerations

All three measures have been translated and validated in multiple languages, including Spanish, Portuguese, Mandarin, Farsi, and Turkish, among others. However, values in particular are deeply cultural — the ten VLQ domains reflect largely Western individualist assumptions. Clinicians working with collectivist, religiously grounded, or non-Western populations may need to adapt the values domains explicitly with clients rather than relying on the standard list [Fung, 2015]. The World Health Organization has emphasized the importance of culturally adapted mental health assessment tools, particularly in low- and middle-income contexts [WHO, 2022].

Beyond the Big Three: Other Useful ACT Measures

Beyond the AAQ-II, CFQ, and VLQ, clinicians can draw on the CompACT, MPFI, Bull's-Eye Values Survey, and MAAS to capture more granular process data. Each covers different aspects of the hexaflex and can complement the core battery.

• CompACT (Comprehensive Assessment of Acceptance and Commitment Therapy Processes) — a 23-item measure assessing openness to experience, behavioral awareness, and valued action [Francis et al., 2016].
• MPFI (Multidimensional Psychological Flexibility Inventory) — a 60-item measure that assesses all six flexibility and six inflexibility processes separately [Rolffs et al., 2018].
• Bull's-Eye Values Survey — a simple graphical tool that asks clients to mark where they are relative to their values in four domains, useful in session as both assessment and intervention [Lundgren et al., 2012].
• Mindful Attention Awareness Scale (MAAS) — often used in ACT research to capture present-moment awareness [Brown & Ryan, 2003].

Common Pitfalls in ACT Measurement

The most common mistakes include treating symptom persistence as failure, ignoring ceiling effects, skipping the VLQ for time reasons, and collecting data without discussing it. Each of these errors undermines the clinical value of process-based measurement.

1. Treating high symptom scores as therapy failure. A client whose GAD-7 stays elevated but whose VLQ consistency doubled has made real progress. Rethink what "outcome" means in ACT.
2. Ignoring the ceiling effect on the AAQ-II. Clients scoring at the bottom of the inflexibility range have little room to improve numerically, though they may still be growing.
3. Skipping the VLQ because it's "too long." The VLQ takes 5–10 minutes and yields information no other measure provides. Consider abbreviating or using the VQ if time is tight — but do not skip values assessment entirely.
4. Not using the data. If measures are collected but never discussed, they add burden without benefit. Build 5–10 minutes into every fourth session for shared review.

The Bigger Picture: Why Process Measurement Matters for the Field

Process measurement matters because it reflects a fundamental shift in how the field defines change. Rather than counting symptoms, ACT and other third-wave therapies ask whether people are living fuller, more values-driven lives — and process measures are the tools that make that shift measurable.

ACT belongs to what researchers call the "third wave" of behavioral therapies, which emphasize context and function over content [Hayes, 2004]. This orientation demands measurement tools that capture how people relate to their inner experiences, not just what those experiences are. The National Institute of Mental Health has increasingly emphasized process-based mechanisms of change as a research priority through its Research Domain Criteria (RDoC) framework [NIMH, 2023].

The AAQ-II, CFQ, and VLQ are imperfect. Each has real psychometric limitations. But together they represent something valuable: a serious attempt to measure the ingredients of a life well lived — willingness, unhooking from thought, and moving toward what matters — rather than just the absence of distress. In a mental health landscape often dominated by symptom checklists, that shift in emphasis is itself a form of progress.

Whether you are a clinician, researcher, or thoughtful client, using these measures deliberately can transform ACT from a philosophy into a trackable, teachable, and continuously improvable practice. And when the numbers show a client moving toward a life that looks like their values — even in the presence of pain — you will have measured something that matters far more than symptom scores alone can capture.

Frequently Asked Questions

What is the difference between the AAQ-II and the CFQ?

The AAQ-II measures broad psychological inflexibility, focusing especially on experiential avoidance — the unwillingness to have painful internal experiences. The CFQ narrows in on cognitive fusion, specifically how entangled a person becomes with the literal content of their thoughts. In practice, the AAQ-II answers "how much does this person avoid?" while the CFQ answers "how hooked is this person by what their mind says?"

How often should I administer ACT outcome measures?

Most clinicians administer the full battery (AAQ-II, CFQ, VLQ) at intake, then repeat individual measures every 4–6 sessions. The CFQ is often repeated first because defusion is typically an early therapy target. A full re-administration is recommended at session 12, at termination, and again at 3-month follow-up. Administering too frequently causes response fatigue; too infrequently misses meaningful shifts.

What is a clinically meaningful change score on the AAQ-II?

Based on reliable change index calculations from published trials, a change of 5–7 points on the AAQ-II is generally considered clinically meaningful. Nonclinical means hover around 18–20, while clinical cutoffs are often set between 24 and 28. However, given the AAQ-II's debated discriminant validity, clinicians should interpret score changes alongside other flexibility measures and behavioral observations rather than in isolation.

Can I use ACT measures if my client is on antidepressants?

Yes. ACT outcome measures track process-level change independent of medication status. Many clients use ACT alongside pharmacotherapy, and process measures can reveal flexibility gains even when symptom scores are influenced by medication. If you are considering treatment options, our overview of antidepressants vs therapy examines how these approaches complement each other.

Is the VLQ appropriate for clients from non-Western cultures?

The VLQ's ten predefined domains reflect largely Western individualist assumptions and may not fit collectivist, religiously grounded, or non-Western clients. Clinicians should adapt the domain list collaboratively with the client, adding categories that reflect their actual value structure (e.g., extended family, ancestral duty, communal obligations). The Valuing Questionnaire (VQ) is a domain-free alternative that may travel better across cultures.

What if my client's symptom scores stay high but their VLQ scores improve?

This is a common and important pattern in ACT. From an ACT perspective, meaningful behavior change in service of values is a primary outcome — even in the presence of ongoing pain or distress. Discuss this discrepancy openly with your client and reframe progress in terms of what they are now able to do, not what they no longer feel. This is often when clients experience the biggest "aha" about what ACT is really targeting.

Are there shorter alternatives to the VLQ?

Yes. The Valuing Questionnaire (VQ) is a 10-item measure that captures two dimensions — progress and obstruction — without requiring domain-by-domain ratings. The Bull's-Eye Values Survey is another brief, visual tool that doubles as an in-session intervention. Both take under five minutes and can substitute for the VLQ when session time is tight.

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