Research—Basic Empirical Research Assessment of body image flexibility: The Body Image-Acceptance and Action Questionnaire Emily K. Sandoz a,n , Kelly G. Wilson b , Rhonda M. Merwin c , Karen Kate Kellum b a University of Louisiana at Lafayette, Psychology Department, Girard 202-A, P.O. Box 43131, Lafayette, LA 70504, USA b University of Mississippi, USA c Duke University Medical Center, USA article info Article history: Received 1 August 2012 Received in revised form 8 February 2013 Accepted 17 March 2013 Keywords: Body image Psychological flexibility Acceptance Mindfulness Eating Assessment abstract Acceptance and mindfulness components are increasingly incorporated into treatment for eating disorders with promising results. The development of measures of proposed change processes would facilitate ongoing scientific progress. The current series of studies evaluated one such instrument, the Body Image-Acceptance and Action Questionnaire (BI-AAQ), which was designed to measure body image flexibility. Study one focused on the generation and reduction of items for the BI-AAQ and a demonstration of construct validity. Body image flexibility was associated with increased psychological flexibility, decreased body image dissatisfaction, and less disordered eating. Study two demonstrated adequate internal consistency and test–retest reliability of BI-AAQ. Study three extended findings related to structural and construct validity, and demonstrated an indirect effect of body image dissatisfaction on disordered eating via body image flexibility. Research and clinical utility of the BI-AAQ are discussed. The BI-AAQ is proposed as a measure of body image flexibility, a potential change process in acceptance- oriented treatments of eating disorders. & 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science. 1. Introduction A number of cognitive behavior therapies (CBTs) focus on teaching clients to behave effectively in the presence of disturbing thoughts and feelings (Hayes, 2004). This is particularly well suited for clinical populations which tend to be cognitively rigid (and therefore have thoughts that are difficult to change) or for whom cognitions are consistent with a preferred self-image (despite being harmful), such as in eating disorders like anorexia nervosa. Acceptance and Commitment Therapy (ACT; Sandoz, Wilson, & DuFrene, 2011), Dialectical Behavior Therapy (DBT; e. g., Safer, Telch, & Chen, 2009), Mindfulness Based Cognitive Therapy (MBCT; e.g., Baer, Fischer, & Huss, 2005b), and Mind- fulness Based Stress Reduction (MBSR; e.g., Kristeller & Hallet, 1999) have all been adapted for treatment of disordered eating. Common to each of these approaches is an emphasis on building awareness and openness toward experience (for example, cues for hunger and satiation and dissatisfaction with the body) while replacing automatic or reactive eating behavior with more inten- tional, committed behaviors. This emphasis seems to be particularly well suited for treating disordered eating (see Baer, Fischer, and Huss (2005a), Kristeller, Quillian-Wolever, and Baer (2006) for reviews), with recent evidence that symptoms are maintained, at least in part, by non- acceptance or experiential avoidance. ACT has recently gathered preliminary support in the treatment of eating disorders. A randomized controlled trial comparing ACT to traditional cognitive therapy (CT) for treatment of comorbid eating pathology found that ACT produced larger reductions in eating pathology than CT (Juarascio, Forman, & Herbert, 2010). A small case series investi- gating ACT as a treatment for unremitting anorexia nervosa showed clinically significant improvement in disordered eating in all three clients (Berman, Boutelle, & Crow, 2009). A randomized controlled trial investigating ACT as a treatment for obesity and obesity-related stigma showed significantly greater improvements in obesity stigma, quality of life, psychological distress, and body mass (Lillis, Hayes, Bunting, & Masuda, 2009). 2. Psychological flexibility and disordered eating In ACT, this combination of openness to experience with constructive behavior is called psychological flexibility. Psycholo- gical flexibility is the ability to fully experience the present moment while engaging in behavior that is consistent with one's chosen values even when the present moment includes difficult emotions, thoughts, memories or body sensations (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). From this perspective, healthy Contents lists available at SciVerse ScienceDirect journal homepage: www.elsevier.com/locate/jcbs Journal of Contextual Behavioral Science 2212-1447/$ - see front matter & 2013 Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science. http://dx.doi.org/10.1016/j.jcbs.2013.03.002 n Corresponding author. Tel.: +1 3373715440. E-mail address: emilysandoz@louisiana.edu (E.K. Sandoz). Please cite this article as: Sandoz, E. K., et al. Assessment of body image flexibility: The Body Image-Acceptance and Action Questionnaire. Journal of Contextual Behavioral Science (2013), http://dx.doi.org/10.1016/j.jcbs.2013.03.002i Journal of Contextual Behavioral Science ∎ (∎∎∎∎) ∎∎∎–∎∎∎