Psychological inflexibility as main factor associated with emotional symptomatology and suicide risk: Two trans-diagnostic models for risk in young adults from Cundinamarca

Marge Alejandra Sierra, Eliana Ortiz, Bertha Lucia Avendaño-Prieto


Introduction: Psychological inflexibility is the systematic use of ineffective behavioral regulation strategies that in the long-term worsen psychological distress and quality of life. Evidence suggests that psychological inflexibility is a trans-diagnostic process essential to mental-health that predicts “emotional and affective disorders”. This study proposes two trans-diagnostic models of risk based on experiential avoidance, cognitive fusion, repetitive negative thinking, and values obstruction and generalized pliance as part of a “psychological inflexibility” super-ordinated factor using available instruments which already have psychometric properties and factor structure analyses, along with evidence of validity and reliability in Colombia. Said super-ordinated factor is expected to be associated to the outcome variables in the current sample and have some relationship with other latent super-ordinated factors deemed “sociodemographic variables”, “sexuality”, “mental health history” and “suicide risk”.

Method: There was a cross-sectional correlational design and a non-randomized convenience sampling. The sample was 541 young adults from Cundinamarca aging from 18 to 39 (M=28.86; SD=5.66), most of them cisgender (98%; n=530), assigned female at birth (81.9%; n=443) and identified as women (81.5%; n=441). They responded to an online survey inquiring sexuality, sociodemographic and mental health history aspects and including emotional symptomatology, experiential avoidance, cognitive fusion, repetitive negative thinking, values obstruction and generalized pliance assessment. Structural Equation Modelling was used to adjust the aforementioned models.

Results: Both models had a good fit. Psychological inflexibility (β= .70) and suicide risk (β= .33) had a moderate relationship (r= .66) and were associated with emotional symptomatology. Emotional symptomatology (β= 1.56) and psychological inflexibility (β=-.77) had a strong relationship (r= .95) and were associated with suicide risk. 

Discussion: There is preliminary evidence for the role of psychological inflexibility and sexuality related variables as potential risk factors associated with emotional symptomatology and suicide risk, supporting some of the assumptions from the ACT model.


Clinical Psychology; Psychological Inflexibility; Emotional Symptomatology; Contextual Behavioral Science; Structural Equation Modeling; Risk Factors.

Full Text:



Antony, M.M., Bieling, P.J., Cox, B.J., Enns, M.W., & Swinson, R.P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales (DASS) in clinical groups and a community sample. Psychological Assessment, 10, 176-181.

Aparicio-García, M., Díaz-Ramiro, E., Rubio-Valdehita, S., López-Núñez, M., & García-Nieto, I. (2018). Health and Well-Being of Cisgender, Transgender and Non-Binary Young People. International Journal of Environmental Research and Public Health, 15(10), 2133.

Aranmolate, R., Bogan, D.R., Hoard, T., Mawson, A.R. (2017) Suicide Risk Factors among LGBTQ Youth: Review. JSM Schizophr 2(2): 1011.

Ato, M., López-García, J. J., & Benavente, A. (2013). Un sistema de clasificación de los diseños de investigación en psicología. Anales de Psicología, 29(3).

Avendaño-Prieto, B. L., Betancort Montesinos, M., Bernal-Aguirre, A., González-Martínez, L. A., Gómez-Sánchez, S. M., & Villalobos-Sánchez, C. F. (2019). Celos, desesperanza e ideación suicida en población con orientación sexual diversa. Universitas Psychologica, 18(4), 1-12.

Baca, G, E., & Aroca, F. (2014). Factores de riesgo de la conducta suicida asociados a trastornos depresivos y ansiedad. Salud Mental, 37(5), 373-380.

Bahraini, N. H., Devore, M. D., Monteith, L. L., Forster, J. E., Bensen, S., & Brenner, L. A. (2013). The role of value importance and success in understanding suicidal ideation among Veterans. Journal of Contextual Behavioral Science, 2(1), 31–38.

Bardeen, J. R., & Fergus, T. A. (2016). The interactive effect of cognitive fusion and experiential avoidance on anxiety, depression, stress and posttraumatic stress symptoms. Journal of Contextual Behavioral Science, 5, 1–6.

Barnes, S. M., Smith, G. P., Monteith, L. L., Gerber, H. R., & Bahraini, N. H. (2017). ACT for Life: Using Acceptance and Commitment Therapy to Understand and Prevent Suicide. In U. Kumar (Ed) Handbook of Suicidal Behaviour (pp. 485–504). Springer

Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15(1).

Bentler, P. M., & Bonett, D. G. (1980). Significance tests and goodness of fit in the analysis of covariance structures. Psychological Bulletin, 88(3), 588–606.

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D. (2011). Preliminary Psychometric Properties of the Acceptance and Action Questionnaire–II: A Revised Measure of Psychological Inflexibility and Experiential Avoidance. Behavior Therapy, 42(4), 676–688.

Borges, G., Benjet, C., Medina-Mora, M. E., Orozco, R., & Nock, M. (2018). Suicide ideation, plan, and attempt in the Mexican adolescent mental health survey. Journal of the American Academy of Child and Adolescent Psychiatry, 47(1), 41-52.

Bostwick, J. M., & Pankratz, V. S. (2000). Affective Disorders and Suicide Risk: A Reexamination. American Journal of Psychiatry, 157(12), 1925–1932.

Bullis, J. R., Boettcher, H., Sauer‐Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). What is an emotional disorder? A transdiagnostic mechanistic definition with implications for assessment, treatment, and prevention. Clinical Psychology: Science and Practice, 26(2), e12278.

Byrne, B. M. (2016). Structural Equation Modeling with AMOS: Basic Concepts, Applications, and Programming (3rd edn). Routledge.

Cantão, L., & Botti, N. C. L. (2016). Comportamento suicida entre dependentes químicos. Revista Brasileira de Enfermagem, 69(2), 389–396.

Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology, 63(9), 871–890.

Chen, F. F. (2007). Sensitivity of goodness of fit indexes to lack of measurement invariance. Structural Equation Modeling, 14(3), 464–504.

Chiappini, S., Mosca, A., Miuli, A., Santovito, M. C., Orsolini, L., Corkery, J. M., … Schifano, F. (2021). New Psychoactive Substances and Suicidality: A Systematic Review of the Current Literature. Medicina, 57(6), 580.

Cookson, C., Luzon, O., Newland, J., & Kingston, J. (2019). Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression. Psychology and Psychotherapy: Theory, Research and Practice.

Dalgleish, T., Black, M., Johnston, D., & Bevan, A. (2020). Transdiagnostic approaches to mental health problems: Current status and future directions. Journal of Consulting and Clinical Psychology, 88(3), 179–195.

Dávila-Cervantes, C. A. (2022). Suicide burden in Latin America, 1990-2019: findings from the Global Burden of Disease Study 2019. Public Health, 205, 28–36.

Departamento Administrativo Nacional de Estadística (DANE) (2022) Preguntas frecuentes estratificación.

Dereix-Calonge, I., Ruiz, F. J., Suárez-Falcón, J. C., & Flórez, C. L. (2019). Adapting the Perseverative Thinking Questionnaire for measuring repetitive negative thinking in clinical psychology trainees. Training and Education in Professional Psychology, 13(2), 145–152.

Dionne, F., Ngô, T.-L., & Blais, M.-C. (2013). Le modèle de la flexibilité psychologique : une approche nouvelle de la santé mentale. Numéro Thématique, 38(2), 111–130.

dos Santos, H. G. B. D., Marcon, S. R., Espinosa, M. M., Baptista, M. N., & Paulo, P. M. C. D. (2017). Factores asociados a la presencia de ideación suicida entre universitarios1. Revista Latino-Americana de Enfermagem, 25.

Ducasse, D., René, E., Béziat, S., Guillaume, S., Courtet, P., & Olié, E. (2014). Acceptance and Commitment Therapy for management of suicidal patients: A pilot study. Psychotherapy and Psychosomatics, 83, 374-376.

Eaton, N. R., Rodriguez-Seijas, C., Carragher, N., & Krueger, R. F. (2015). Transdiagnostic factors of psychopathology and substance use disorders: a review. Social Psychiatry and Psychiatric Epidemiology, 50(2), 171–182.

Ehring, T., Zetsche, U., Weidacker, K., Wahl, K., Schönfeld, S., & Ehlers, A. (2011). The Perseverative Thinking Questionnaire (PTQ): Validation of a content-independent measure of repetitive negative thinking. Journal of Behavior Therapy and Experimental Psychiatry, 42(2), 225–232.

Ehring, T., & Watkins, E. R. (2008). Repetitive Negative Thinking as a Transdiagnostic Process. International Journal of Cognitive Therapy, 1(3), 192–205.

Ellis, T. E., & Rufino, K. A. (2016). Change in experiential avoidance is associated with reduced suicidal ideation over the course of psychiatric hospitalization. Archives of Suicide Research, 20, 426-437.

Fan, X., Thompson, B., & Wang, L. (1999). Effects of sample size, estimation methods, and model specification on structural equation modeling fit indexes. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 56–83.

Faustino, B. (2020). Transdiagnostic perspective on psychological inflexibility and emotional dysregulation. Behavioural and Cognitive Psychotherapy, 49(2), 233–246.

Faustino, B., Vasco, A. B., Farinha-Fernandes, A., & Delgado, J. (2021). Psychological inflexibility as a transdiagnostic construct: relationships between cognitive fusion, psychological well-being and symptomatology. Current Psychology.

Ferrando, L., Franco-Alfonso, L., Soto, M., Bobes-García, J., Soto, O., Franco, L., & Heinze, G., (2000). The Mini-International Neuropsychiatric Interview (M.I.N.I.): Spanish Version.

Field, A. P. (2009). Discovering statistics using SPSS: and sex and drugs and rock 'n' roll (3rd edn). SAGE Publications.

Gil-Luciano, B., Calderón-Hurtado, T., Tovar, D., Sebastián, B., & Ruiz, F. J. (2019). How are triggers for repetitive negative thinking organized? A relational frame analysis. Psicothema, 31(1), 53-59.

Gillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., … Remington, B. (2014). The Development and Initial Validation of the Cognitive Fusion Questionnaire. Behavior Therapy, 45(1), 83–101.

Gómez, A.S. (2020). Psychosocial Factors and Clinical Predictors of Suicide Risk in College Students. Mediterranean Journal of Clinical Psychology, 8(3).

Gómez, A. S., Núñez, C., Agudelo, M. P., & Grisales, A. M. (2020). Riesgo e Ideación Suicida y su Relación con la Impulsividad y la Depresión en Adolescentes Escolares. Revista Iberoamericana de Diagnóstico y Evaluación – e Avaliação Psicológica. RIDEP, 54 (1), 147- 163.

Gómez, A. S., Núñez, C., Caballo, V. E., Agudelo, M. P., & Grisales, A. M. (2019). Predictores psicológicos del riesgo suicida en estudiantes universitarios. Behavioral Psychology / Psicología Conductual, 27 (3), 391-413.

Gómez, C., Rodríguez, N., Bohórquez, A., Díazgranados, N., Ospina, M. B., & Fernández, C. (2002). Factores asociados al intento de suicidio en la población Colombiana. Revista colombiana de psiquiatría, 31(4), 271-283.

Gómez-Romero, M. J., Limonero, J. T., Toro, J., Montes, J., & Tomas, J. (2018). Relación entre inteligencia emocional, afecto negativo y riesgo suicida en jóvenes universitarios. Estrés y ansiedad, 24, 18-23. 1134-7937

Gómez-Tabares, A.S., Mogollón-Gallego E.M., Muñoz-Vanegas, A., Landinez-Martinez, D.A., Carmo, J.P. (2022). The effect of coping strategies on the risk for suicidal ideation and behavior in adolescents. Mediterranean Journal of Clinical Psychology, 10(2).

Guz, S., Kattari, S. K., Atteberry-Ash, B., Klemmer, C. L., Call, J., & Kattari, L. (2021). Depression and Suicide Risk at the Cross-Section of Sexual Orientation and Gender Identity for Youth. Journal of Adolescent Health, 68(2), 317–323.

Haas, A. P., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D’Augelli, A. R., … Clayton, P. J. (2010). Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations. Journal of Homosexuality, 58(1), 10–51.

Hawton, K., Casañas, I., Comabella, C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147(1-3), 17–28.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York, NY: Kluwer Academic/Plenum.

Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012a). Contextual Behavioral Science: Creating a science more adequate to the challenge of the human condition. Journal of Contextual Behavioral Science, 1(1-2), 1–16.

Hayes, S. C., Brownstein, A. J., Zettle, R. D., Rosenfarb, I., & Korn, Z. (1986). Rule-Governed Behavior and Sensitivity to Changing Consequences of Responding. Journal of the Experimental Analysis of Behavior, 45(3), 237–256.

Hayes, S. C., Pistorello, J., & Levin, M. E. (2012b). Acceptance and Commitment Therapy as a Unified Model of Behavior Change. The Counseling Psychologist, 40(7), 976–1002.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (2nd edn). New York, USA: The Guilford Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.

Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467.

Hernández-Sampieri, R., Fernández-Collado, C., & Baptista-Lucio, P. (2014). Metodología de la investigación: (6a. ed.). McGraw-Hill.

Herres, J., Shearer, A., Kodish, T., Kim, B., Wang, S. B., & Diamond, G. S. (2019). Differences in Suicide Risk Severity Among Suicidal Youth With Anxiety Disorders. Crisis, 40(5), 333–339.

Hu, L-T., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to under parameterized model misspecification. Psychological Methods, 3(4), 424–453.

Instituto Nacional de Medicina Legal y Ciencias Forenses (National Institute of Legal Medicine and Forensic Sciences [NILMFS]). (2022). Boletín Estadístico Mensual Diciembre 2022. Centro de Referencia Nacional sobre Violencia. CRNV

Instituto Nacional de Medicina Legal y Ciencias Forenses (National Institute of Legal Medicine and Forensic Sciences [NILMFS]). (2023). Boletín Estadístico Mensual Septiembre 2023. Centro de Referencia Nacional sobre Violencia.

Jöreskog, K. G., & Sörbom, D. (1996). LISREL8 User’s reference guide. Mooresville Scientific Software.

Kanwar, A., Malik, S., Prokop, L. J., Sim, L. A., Feldstein, D., Wang, Z., & Murad, M. H. (2013). The association between anxiety disorders and suicidal behaviors: a systematic review and meta-analysis. Depression and Anxiety, 30: 917–929.

Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30(7), 865–878.

Kline, R. B. (1998). Principles and practice of structural equation modeling. Guilford Press.

Kline, R. B. (2005). Principles and practice of structural equation modeling (2nd ed.). Guilford Press.

Krafft, J., Hicks, E.T., Mack, S.A. and Levin, M. (2019), Psychological Inflexibility Predicts Suicidality Over Time in College Students. Suicide Life Threat Behav, 49: 1488-1496.

Krueger, R. F., & Eaton, N. R. (2015). Transdiagnostic factors of mental disorders. World Psychiatry, 14(1), 27–29.

Landi, G., Pakenham, K. I., Crocetti, E., Grandi, S., & Tossani, E. (2021). The Multidimensional Psychological Flexibility Inventory (MPFI): Discriminant validity of psychological flexibility with distress. Journal of Contextual Behavioral Science, 21, 22–29.

Law 1090 of 2006: Whereby the practice of the profession of Psychology is regulated, the Code of Ethics and Bioethics and other provisions are issued. September 6, 2006. D.O. No. 46.383

Law, K. C., & Tucker, R. P. (2018). Repetitive negative thinking and suicide: a burgeoning literature with need for further exploration. Current Opinion in Psychology, 22, 68–72.

Levin, M. E., MacLane, C., Daflos, S., Seeley, J. R., Hayes, S. C., Biglan, A., & Pistorello, J. (2014). Examining psychological inflexibility as a transdiagnostic process across psychological disorders. Journal of Contextual Behavioral Science, 3(3), 155–163.

Levin, M. E., Twohig, M. P., & Smith, B. M. (2016). Contextual Behavioral Science: An overview. In R. D. Zettle, S. C. Hayes, D. Barnes-Holmes & A. Biglan (Eds.), The Wiley Handbook of Contextual Behavioral Science (pp. 17-36).New York: Wiley-Blackwell.

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343.

Luciano, C. (2017). The self and responding to the own’s behavior. Implications of coherence and hierarchical framing. International Journal of Psychology and Psychological Therapy, 17, 267-275.

Lynch, S. J., Sunderland, M., Newton, N. C., & Chapman, C. (2021). A systematic review of transdiagnostic risk and protective factors for general and specific psychopathology in young people. Clinical Psychology Review, 87, 102036.

MacCallum, R. C., Browne, M. W., & Sugawara, H. M. (1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods, 1(2), 130–149.

Mallot, R. W. (1989). The Achievement of Evasive Goals: Control by Rules Describing Contingencies That Are Not Direct Acting. In S. C. Hayes. (Ed). Rule-Governed Behavior Cognition, Contingencies, and Instructional Control (pp. 269-324) Plenum Press.

Marsh, H. W., & Hocevar, D. (1985). Application of confirmatory factor analysis to the study of self-concept: First- and higher-order factor models and their invariance across groups. Psychological Bulletin, 97(3), 562–582.

Martinotti, G., Schiavone, S., Negri, A., Vannini, C., Trabace, L., De Berardis, D., … Di Giannantonio, M. (2021). Suicidal Behavior and Club Drugs in Young Adults. Brain Sciences, 11(4), 490.

Mascayano, F., Irrazabal, M., D Emilia, W., Vaner, S. J., Sapag, J. C., Alvarado, R., Yang, L. H., & Sinah, B. (2015). Suicide in Latin America: a growing public health issue. Revista de La Facultad de Ciencias Médicas, 72(4), 295–303.

McEvoy, P. M., Watson, H., Watkins, E. R., & Nathan, P. (2013). The relationship between worry, rumination, and comorbidity: Evidence for repetitive negative thinking as a transdiagnostic construct. Journal of Affective Disorders, 151(1), 313–320.

McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49(3), 186–193.

McLoughlin, S., & Roche, B. T. (2022). ACT: A Process-Based Therapy in search of a process. Behavior Therapy.

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56.

Ministry of Health & Colciencias (2015). National mental health survey 2015 - Volume I. Bogotá D.C., Colombia.

Mizock, L., & Hopwood, R. (2016). Conflation and interdependence in the intersection of gender and sexuality among transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 3(1), 93–103.

Monestès, J.-L., Greville, W. J., & Hooper, N. (2018). Derived insensitivity: Rule-based insensitivity to contingencies propagates through equivalence. Learning and Motivation, 59, 55–63.

Monteith, L. L., Pease, J. L., Forster, J. E., Homaifar, B. Y., & Bahraini, N. H. (2015). Values as moderators of the association between interpersonal-psychological constructs and suicidal ideation among veterans. Archives of Suicide Research, 19(4), 122–134.

Mortier, P., Auerbach, R. P., Alonso, J., Bantjes, J., Benjet, C., Cuijpers, P., Ebert, D. D., Green, J., Hasking, P., Nock, M. K., O’Neill, S., Pinder-Amaker, S., Sampson, N. A., Vilagut, G., Zaslavsky, A. M., Bruffaerts, R., Kessler, R. C., & WHO WMH-ICS Collaborators. (2018). Suicidal Thoughts and Behaviors Among First-Year College Students: Results From the WMH-ICS Project. Journal of the American Academy of Child & Adolescent Psychiatry, 57(4), 263–273.

Nodin, N., Peel, E., Tyler, A., and Rivers, I. (2015) The RaRE Research Report: LGB and T Mental Health – Risk and Resilience Explored. PACE – Project for Advocacy Counselling and Education.

Nolen-Hoeksema, S., Wisco, B.E., & Lyubomirsky, S. (2008). Rethinking Rumination. Perspectives in Psychological Science, 3(5), 400-424.

O’Beaglaoich, C., McCutcheon, J., Conway, P. F., Hanafin, J., & Morrison, T. G. (2020). Adolescent Suicide Ideation, Depression and Self-Esteem: Relationships to a New Measure of Gender Role Conflict. Frontiers in Psychology, 11,1-111.

O’Connor, M., Byrne, P., Ruiz, F. J., & McHugh, L. (2018). Generalized Pliance in Relation to Contingency Insensitivity and Mindfulness. Mindfulness, 10(5), 833–840.

Oquendo, M. A., Galfalvy, H., Russo, S., Ellis, S., & Mann, J. J. (2004). Prospective Study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am Journal Psychiatry, 161(14), 33-41.

Orri, M., Galera, C., Turecki, G., Forte, A., Renaud, J., Boivin, M., Tremblay, R. E., Cote, S. M., & Geoffroy, M.C. (2018). Association of childhood irritability and depressive/anxious mood profiles with adolescent suicidal ideation and attempts. JAMA Psychiatry, 75(5), 465-473.

Park, S., & Jang, H. (2018). Correlations between suicide rates and the prevalence of suicide risk factors among Korean adolescents. Psychiatry research, 261, 143-147.

Pawłowska, B., & Szymańska, J. (2021). Suicidal ideation, plans, and attempts and the use of psychoactive substances by adolescents. Current Problems of Psychiatry, 22(3), 217–224.

Pellicane, M. J., & Ciesla, J. A. (2022). Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clinical Psychology Review, 91, 102113.

Pereira-Morales, A. J., Adan, A., Camargo, A., & Forero, D. A. (2017). Substance use and suicide risk in a sample of young Colombian adults: An exploration of psychosocial factors. The American Journal on Addictions, 26(4), 388–394.

Plöderl, M., Wagenmakers, E.-J., Tremblay, P., Ramsay, R., Kralovec, K., Fartacek, C., & Fartacek, R. (2013). Suicide Risk and Sexual Orientation: A Critical Review. Archives of Sexual Behavior, 42(5), 715–727.

Reisner, S., Greytak, E., Parsons, J., and Ybarra, M. (2015) Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52(3): 243–256.

Rimes, K. A., Goodship, N., Ussher, G., Baker, D., & West, E. (2019). Non-binary and binary transgender youth: Comparison of mental health, self-harm, suicidality, substance use and victimization experiences. International Journal of Transgenderism, 20(2-3), 230–240.

Rojas-Bernal, L. Á., Castaño-Pérez, G. A., & Restrepo-Bernal, D. P. (2018). Salud mental en Colombia. Un análisis crítico. CES Medicina, 32(2), 129-140.

Rolffs, J. L., Rogge, R. D., & Wilson, K. G. (2018). Disentangling Components of Flexibility via the Hexaflex Model: Development and Validation of the Multidimensional Psychological Flexibility Inventory (MPFI). Assessment, 25(4), 458–482.

Ruiz, F. J., Flórez, C. L., García-Martín, M. B., Monroy-Cifuentes, A., Barreto-Montero, K., García-Beltrán, D. M., … Gil-Luciano, B. (2018a). A multiple-baseline evaluation of a brief acceptance and commitment therapy protocol focused on repetitive negative thinking for moderate emotional disorders. Journal of Contextual Behavioral Science, 9, 1–14.

Ruiz, F. J., García-Martín, M. B., Suárez-Falcón, J. C., & Odriozola-González, P. (2017a). The hierarchical factor structure of the Spanish version of Depression Anxiety and Stress Scale - 21. International Journal of Psychology and Psychological Therapy, 17, 97-105.

Ruiz, F. J., Suárez-Falcón, J. C., Barbero-Rubio, A., & Flórez, C. L. (2018b). Development and initial validation of the Generalized Pliance Questionnaire. Journal of Contextual Behavioral Science, 12, 189-198.

Ruiz, F. J., Suárez-Falcón, J. C., Cárdenas-Sierra, S., Durán, Y., Guerrero, K., & Riaño-Hernández, D. (2016). Psychometric Properties of the Acceptance and Action Questionnaire–II in Colombia. The Psychological Record, 66(3), 429–437.

Ruiz, F. J., Suárez-Falcón, J. C., Riaño-Hernández, D., & Gillanders, D. (2017b). Psychometric Properties of the Cognitive Fusion Questionnaire in Colombia. Revista Latinoamericana de Psicología, 49(1), 80–87.

Ruiz, F.J., Odriozola-González, P., Suárez-Falcón, J.C., Segura-Vargas, M.A. (2022) Psychometric properties of the Valuing Questionnaire in a Spaniard sample and factorial equivalence with a Colombian sample. PeerJ 10:e12670

Ruiz, F. J., Peña-Vargas, A., Ramírez, E. S., Suárez-Falcón, J. C., García-Martín, M. B., García-Beltrán, D. M., Henao, Á. M., Monroy-Cifuentes, A., & Sánchez, P. D. (2020). Efficacy of a two-session repetitive negative thinking-focused acceptance and commitment therapy (ACT) protocol for depression and generalized anxiety disorder: A randomized waitlist control trial. Psychotherapy (Chicago, Ill.), 57(3), 444–456.

Siabato, E., & Salamanca, Y. (2015). Factores asociados a ideación suicida en universitarios. Psychologia: avances de la disciplina, 9(1), 71-81.

Siabato, E., Forero, I. X., & Salamanca, Y. (2017). Asociación entre depresión e ideación suicida en un grupo de adolescentes colombianos. Pensamiento Psicológico, 15(1), 51-61.

Segerstrom, S. C., Tsao, J. C. I., Alden, L. E., & Craske, M. G. (2000). Worry and Rumination: Repetitive Thought as a Concomitant and Predictor of Negative Mood. Cognitive Therapy and Research, 24(6), 671–688.

Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatry interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59 (20), 22-33.

Sierra, M. A., & Ortiz, E. I. (2022). Psychological inflexibility components as trans-diagnostic predictors of emotional symptomatology and suicide risk among young adults. Mediterranean Journal of Clinical Psychology, 10(3)

Skinta, M.D. (2021) Contextual behavior therapy for gender and sexual minority clients: a practical guide to treatment. Routledge

Smout, M., Davies, M., Burns, N., & Christie, A. (2014) Development of the Valuing Questionnaire (VQ). Journal of Contextual Behavioral Science, 3(3), 164-172.

Sorg, S., Vögele, C., Furka, N., & Hans-Meyer, A. (2012). Perseverative thinking in depression and anxiety. Frontiers in Psychology, 3.

Statutory Law 1266 of 2008: Whereby the general provisions of habeas data are issued and the handling of information contained in personal databases is regulated, especially financial, credit, commercial, services and information from third countries, and other provisions are issued. December 31, 2008. D.O. No. 47.219

Statutory Law 1581 of 2012: Whereby general provisions are issued for the protection of personal data. October 18, 2012. D.O. No. 48.587

Stitt, A. (2020) ACT for Gender Identity: A comprehensive guide. Jessica Kingsley Publishers.

Tanaka, J. S., & Huba, G. J. (1985). A fit index for covariance structure models under arbitrary GLS estimation. British Journal of Mathematical and Statistical Psychology, 38(2), 197–201.

Tebbe, E. A., & Moradi, B. (2016). Suicide risk in trans populations: An application of minority stress theory. Journal of Counseling Psychology, 63(5), 520–533.

Testa, R. J., Hendricks, M. L. (2015). Suicide risk among transgender and gender-nonconforming youth. In P. Goldblum, D. L. Espelage, J. Chu & B. Bongar (Eds.), Youth Suicide and Bullying: Challenges and Strategies for Prevention and Intervention (pp. 121-133). Oxford University Press.

Tighe, J., Nicholas, J., Shand, F., & Christensen, H. (2018). Efficacy of Acceptance and Commitment Therapy in Reducing Suicidal Ideation and Deliberate Self-Harm: Systematic Review. JMIR Mental Health, 5(2), e10732.

Törneke, N., Luciano, C., & Valdivia-Salas, S. (2008). Rule-Governed Behavior and Psychological Problems. International Journal of Psychology and Psychological Therapy, 8(2), 141-156.

Törneke, N., Luciano, C., Barnes-Holmes, Y., & Bond, F. W. (2016). RFT for Clinical Practice: three core strategies in understanding and treating human suffering. In R. D. Zettle, S. C. Hayes, D. Barnes-Holmes, A. Biglan (Eds.), The Wiley Handbook of Contextual Behavioral Science (pp. 254-272). New York: Wiley-Blackwell.

Tucker, L. R., & Lewis, C. (1973). A reliability coefficient for maximum likelihood factor analysis. Psychometrika, 38(1), 1–10.

Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Pereira, A. (2018). Profiles of Psychological Flexibility: A Latent Class Analysis of the Acceptance and Commitment Therapy Model. Behavior Modification, 44(3), 365–393.

Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in veterans. Behaviour Research and Therapy, 74, 25-31.

Watkins, E. R. (2008). Constructive and Unconstructive Repetitive Thought. Psychological Bulletin, 134, 163-206.

Watkins, E., Moulds, M., & Mackintosh, B. (2005). Comparisons between rumination and worry in a non-clinical population. Behaviour Research and Therapy, 43(12), 1577–1585.

West S. G., Taylor A. B., Wu W. (2012). Model fit and model selection in structural equation modeling. In Hoyle R. H. (Ed.), Handbook of structural equation modeling (pp. 209-231). Guilford Press.

Wilcox, H. C., Arria, A. M., Caldeira, K. M., Vincent, K. B., Pinchevsky, G. M., & O'Grady, K. E. (2010). Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. Journal of Affective Disorders, 127(1-3), 287–294.

Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168(5), 495-501.

Wilson, K. G., & Luciano, C. (2002). Terapia de Aceptación y Compromiso: Un Tratamiento conductual orientado a los valores. Pirámide.

World Health Organization. (2014). Preventing suicide: A global imperative. World Health Organization.

World Health Organization (2017). Depression and other common mental disorders global health estimates.

World Health Organization. (2019). Suicide in the world: Global Health Estimates. World Health Organization.

World Health Organization. (2022a). Mental Disorders. World Health Organization.

World Health Organization. (2022b). News - COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide. World Health Organization.

World Health Organization. (2023a). Depression. World Health Organization.

World Health Organization. (2023b). Suicide. World Health Organization.

World Health Organization. (2022). Global Health Observatory Data Repository. Suicide mortality rate (per 100,000 population). World Health Organization.

World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194.

Wolford-Clevenger, C., Cannon, C. J., Flores, L. Y., Smith, P. N., & Stuart, G. L. (2017). Suicide Risk Among Transgender People: A Prevalent Problem in Critical Need of Empirical and Theoretical Research. Violence and Gender, 4(3), 69–72.

Zettle, R. D., & Hayes, S. C. (1982). Rule-Governed Behavior: A Potential Theoretical Framework For Cognitive–Behavioral Therapy. Advances In Cognitive - Behavioral Research And Therapy, 73–118.



  • There are currently no refbacks.