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Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: https://www.tandfonline.com/loi/sbeh20

Acculturative stress and experiential avoidance:
relations to depression, suicide, and anxiety
symptoms among minority college students

Michael J. Zvolensky, Charles Jardin, Lorra Garey, Zuzuky Robles & Carla
Sharp

To cite this article: Michael J. Zvolensky, Charles Jardin, Lorra Garey, Zuzuky Robles & Carla
Sharp (2016) Acculturative stress and experiential avoidance: relations to depression, suicide, and
anxiety symptoms among minority college students, Cognitive Behaviour Therapy, 45:6, 501-517,
DOI: 10.1080/16506073.2016.1205658

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Published online: 22 Jul 2016.

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Cognitive Behaviour therapy, 2016
voL. 45, no. 6, 501–517
http://dx.doi.org/10.1080/16506073.2016.1205658

Acculturative stress and experiential avoidance: relations to
depression, suicide, and anxiety symptoms among minority
college students

Michael J. Zvolenskya,b, Charles Jardina, Lorra Gareya, Zuzuky Roblesa and
Carla Sharpa,c

aDepartment of psychology, university of houston, houston, tX, 77204, uSa; bDepartment of Behavioral
Sciences, university of texas MD anderson Cancer Center, houston, tX, uSa; cadolescent treatment program,
the Menninger Clinic, houston, tX, uSa

ABSTRACT
Although college campuses represent strategic locations to address
mental health disparity among minorities in the US, there has been
strikingly little empirical work on risk processes for anxiety/depression
among this population. The present investigation examined the
interactive effects of acculturative stress and experiential avoidance in
relation to anxiety and depressive symptoms among minority college
students (n  =  1,095; 78.1% female; Mage  =  21.92, SD  =  4.23; 15.1%
African-American (non-Hispanic), 45.3% Hispanic, 32.5% Asian, and
7.1% other races/ethnicities. Results provided empirical evidence of an
interaction between acculturative stress and experiential avoidance
for suicidal, social anxiety, and anxious arousal symptoms among the
studied sample. Inspection of the significant interactions revealed that
acculturative stress was related to greater levels of suicidal symptoms,
social anxiety, and anxious arousal among minority college students
with higher, but not lower, levels of experiential avoidance. However,
in contrast to prediction, there was no significant interaction for
depressive symptoms. Together, these data provide novel empirical
evidence for the clinically-relevant interplay between acculturative
stress and experiential avoidance in regard to a relatively wide array
of negative emotional states among minority college students.

College students have historically been viewed by society as a privileged population, but
there is an increased recognition that mental health problems are common among this
group (Hunt & Eisenberg, 2010). Aside from well-publicized cases of homicide on college
campuses attributed, in part, to mental illness (e.g. Virginia Tech, Northern Illinois), empir-
ical work suggests mental health problems, particularly anxiety/depressive symptoms, are
highly common and personally impairing to life functioning (Mackenzie et al., 2011). For
example, major survey studies involving thousands of college students consistently report
findings of elevated anxiety and depressive symptoms and suicidal ideation (American
College Health Association [ACHA], 2008; Drum, Brownson, Burton Denmark, & Smith,

KEYWORDS
Mental health; anxiety;
depression; suicide; health
disparity; college students

ARTICLE HISTORY
received 23 March 2016
accepted 21 June 2016

© 2016 Swedish association for Behaviour therapy

CONTACT Michael J. Zvolensky [email protected] Department of psychology, university of houston,
houston, tX, 77204, uSa

mailto:[email protected]

502 M. J. ZvoLenSky eT AL.

2009; Weitzman, 2004). Some work has found that approximately 50% of college students
meet criteria for a DSM axis I dis in the past year (Blanco et al., 2008). Many scholars
have theorized that the transition to college and greater independence may represent a
vulnerable developmental period (Blanco et al., 2008; Kisch, Leino, & Silverman, 2005).
Because higher-education institutions offer health services and are designed to facilitate
individual and societal growth, they offer a unique “strategic portal” from a public health
perspective wherein evidenced-based programming can be delivered to offset disparity in
mental health (Erdur-Baker, Aberson, Barrow, & Draper, 2006).

Among college students, ethnic minorities appear to be a particularly at-risk group for
anxiety and depressive problems (Benton, Robertson, Tseng, Newton, & Benton, 2003;
Blanco et al., 2008; Hunt & Eisenberg, 2010), as they are forced to adapt to both the demand-
ing intellectual environment and social pressures associated with college life as a minority
student (Neville, Heppner, Ji, & Thye, 2004). Here, a clinically important construct to mental
health among minority college students is acculturative stress; reflecting stress reactions
to intercultural contact or the cultural adaptation process (Lonner, Wong, & Wong, 2007).
Acculturative stress reflects the emotional reaction to life events and activities associated
with acculturation whereas acculturation pertains to the process of cultural change (Lonner
et al., 2007). Acculturative stressors may involve such activities as learning a new language,
balancing differing cultural values, and managing the demands between living in a majority
culture and being a minority (Dawson & Panchanadeswaran, 2010). There is rich and diverse
empirical literature indicating that greater acculturative stress is related to discrimination
(Dawson & Panchanadeswaran, 2010) and negative mood states as well as psychopathology
(Crockett et al., 2007; Torres, 2010). For instance, acculturative stress may help explain rela-
tions between racial discrimination and poorer physical health status (Finch, Hummer, Kol,
& Vega, 2001). Other work suggests acculturative stress is related to depression and anxiety
symptom severity (Baker, Soto, Perez, & Lee, 2012; Revollo, Qureshi, Collazos, Valero, &
Casas, 2011; Walker, Wingate, Obasi, & Joiner, 2008). Integrative models of mental health,
however, posit that acculturative stress by itself is not solely apt to lead to greater anxiety/
depressive symptoms (LaFromboise, Coleman, & Gerton, 1993). Rather, this construct may
likely interact with various, more specific psychological factors (e.g. thinking styles, genetic
history) or socio-environmental experiences (e.g. trauma, discrimination) to confer risk
for anxiety/depressive conditions, much as similar work has reported that coping resources
moderate the impact of experienced racism on anxiety symptoms (Graham, Calloway, &
Roemer, 2015; Graham, West, & Roemer, 2013). Despite the theoretical and clinical appeal,
research testing interactive models of acculturative stress in relation to anxiety/depressive
symptoms among minority college students is highly limited.

Experiential avoidance is one promising, clinically-relevant risk candidate for further
understanding linkages between acculturative stress and “emotional vulnerability” among
minority college students. Experiential avoidance reflects individual differences in the ten-
dency to be willing to experience or remain in contact with aversive internal experiences
(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Hayes et al., 2004). At the core of expe-
riential avoidance conceptualizations of anxiety/depressive psychopathology is inflexible
responding functionally directed at altering the form or frequency of aversive internal
experiences (e.g. negative thoughts, bodily sensations) and the contexts that occasion them
(Hayes et al., 1996). Such inflexible responding to internal states can be a toxic process that
distinguishes normal from dis ed experiences of emotion (Zvolensky & Forsyth, 2002).

CoGnITIve BeHAvIoUR THeRApy 503

Indeed, experiential avoidance is theorized to be a broad-based diathesis for affective psy-
chopathology that is culturally invariant (see review by Chawla & Ostafin, 2007) and distinct
from other emotion-regulatory vulnerability factors (e.g. worry, distress intolerance, neg-
ative affectivity; Hayes et al., 2004). In line with this perspective, numerous studies among
predominately European-American samples, and to a much lesser extent specific minority
groups (e.g. African-Americans; Naifeh, Tull, & Gratz, 2012), have found that experien-
tial avoidance is related to depression (Adams, Tull, & Gratz, 2012; Tull & Gratz, 2008),
non-suicidal self-injury (Anderson & Crowther, 2012), and anxiety symptoms (Bardeen,
Tull, Stevens, & Gratz, 2014; Feldner, Zvolensky, Eifert, & Spira, 2003; Forsyth, Parker, &
Finlay, 2003; Karekla, Forsyth, & Kelly, 2004), along with negative mood more generally
(Kumpula, Orcutt, Bardeen, & Varkovitzky, 2011). Yet, to the best of our knowledge, expe-
riential avoidance has not been comprehensively explored in relation to anxiety/depressive
states among minority college students from different racial/ethnic groups. One unpublished
study found experiential avoidance moderated the relationship between acculturative stress
and psychological distress among Asian-American college students (Lee, 2013). Thus, there
is a clear need to further our understanding of the interplay of acculturative stress and
experiential avoidance among minority college students.

From an integrative perspective, experiential avoidance may also impact the association
between acculturative stress and the experience of negative moods by amplifying the intensity
of the emotional experience. Indirect work suggests adaptive emotion regulation strategies
(e.g. emotional acceptance) increase tolerance for aversive emotional states and reduce per-
ceptions of emotional intensity (e.g. Kohl, Rief, & Glombiewski, 2012). Informed by these
empirical observations, acculturative stress and experiential avoidance may operate with one
another to increase the probability of greater expression of anxiety and depressive symptoms.
Accordingly, acculturative stress may be exacerbated by an individual’s degree of experiential
avoidance. Therefore, these psychological processes may function synergistically to confer
greater risk for anxiety and depressive symptoms. From this perspective, a logical next step
in research is to further explore the potential interplay of current acculturative stress and
experiential avoidance as an integrative explanatory process for vulnerability in the expres-
sion of anxiety and depressive symptoms and dis s among minority college students.

With this background, the aim of the current study was to examine the interactive effects
of acculturative stress and experiential avoidance in relation to anxiety and depressive symp-
toms among minority college students. It was expected that there would be an interaction
between acculturative stress and experiential avoidance, such that greater acculturative
stress and experiential avoidance would be associated with increased anxiety and depressive
symptoms, and that this interactive effect would be observed over and above the effect of
sex, age, relationship status, financial strain, and trait negative affectivity. Demographic
covariates were chosen based on their associations with anxiety and depressive symptoms
in past work (Myers et al., 2015; Rosenthal & Schreiner, 2000). In addition, experiential
avoidance and acculturative stress are both correlated with negative affectivity (Kumpula et
al., 2011; Paukert, Pettit, Perez, & Walker, 2006); therefore, negative affectivity was included
as a covariate to demonstrate that the robustness of the interaction effect of acculturative
stress and experiential avoidance. By better understanding the processes that govern the
expression of anxiety/depressive symptoms among minority college students, it will be
possible to explicate malleable risk factors for affective vulnerability needed for targeted
screening protocols and interventions.

504 M. J. ZvoLenSky eT AL.

Method

Participants

College students (n = 1,691; 78.4% female; Mage = 22.21; SD = 4.67; age range: 18–56 years)
were recruited from a large, southwestern university between April 2014 and April 2015.
The university of highly culturally diverse and routinely ranked in the top three most diverse
institutions in the US. Participants received extra credit for a psychology course as com-
pensation. Recruitment occurred via flyers and postings on the university’s extra credit
website. Study exclusion criteria included being under the age of 18 and non-proficient
in English (to ensure comprehension of study questions). There were 341 participants
excluded from analyses for incomplete study measures. Additionally, European-American
participants were excluded (n  =  429) given the study focus on persons from minority
backgrounds. The final sample consisted of 1,095 minority participants (78.1% female;
Mage = 21.92; SD = 4.23; age range: 18–52 years). The final sample was comprised of 15.1%
African-American (non-Hispanic), 45.3% Hispanic, 32.5% Asian, and 7.1% other races/
ethnicities (e.g. 2% Arab/Middle Eastern, 0.3% Pacific Islander, 0.1% Native American,
4.5% interracial).

Materials

Demographics
Sex (coded: female = 0; male = 1), age, race/ethnicity, and relationship status (coded: single/
non-exclusive dating = 0; exclusive relationship = 1) were assessed.

Acculturative stress
The Social, Attitudinal, Familial, and Environmental Scale (SAFE; Mena, Padilla, &
Maldonado, 1987) is a 24-item measure used to assess acculturative stress. The SAFE is
composed of four subscales examining acculturative stress related to social, attitudinal,
familial, and environmental contexts (sample item: “I have more barriers to overcome
than most people”). Response options for each item ranged from 1 (“Not Stressful”) to 5
(“Extremely Stressful”). Internal reliability of the SAFE in previous studies across different
ethnic groups has been good (α = .87 to .89; Fuertes & Westbrook, 1996; Joiner & Walker,
2002; Mena et al., 1987). In the present study, the total scale score was employed and
demonstrated excellent internal consistency in the total sample (α = .94), as well as within
each of the major racial/ethnic groups studied (α’s = .94).

Experiential avoidance
The Multidimensional Experiential Avoidance Questionnaire (MEAQ; Gámez,
Chmielewski, Kotov, Ruggero, & Watson, 2011) was used to assess experiential avoid-
ance. The MEAQ is a 62-item self-report measure containing six subscales: behavioral
avoidance (e.g. “I won’t do something if I think it will make me uncomfortable”), distress
aversion (e.g. “If I could magically remove all of my painful memories, I would”), pro-
crastination (e.g. “I tend to put off unpleasant things that need to get done”), distraction/
suppression (e.g. “When something upsetting comes up, I try very hard to stop thinking
about it”), repression/denial (e.g. “I sometimes have difficulty identifying how I feel”),
and distress endurance (e.g. “People should face their fears,” reverse coded in total scale
score). Response options range from 1 (“strongly disagree”) to 6 (“strongly agree”). The

CoGnITIve BeHAvIoUR THeRApy 505

MEAQ total scale has demonstrated excellent internal consistency (α = .91 to .95 across
patient and college student samples) and strong convergent and divergent validity with
other measures of avoidance (Gámez et al., 2011). In the present study, the total scale
score of the MEAQ was used and showed excellent internal consistency in the total sample
(α = .92), as well as within each of the racial/ethnic groups examined (α’s = .90 to .93).
Higher scores denoted greater experiential avoidance.

Depression, suicidality, social anxiety, and panic
The Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007) is a 64-item
self-report measure depression and anxiety symptoms. The IDAS contains 12 subscales:
general depression (20 items), dysphoria (10 items), well-being (8 items), anxious arousal
(8 items), lassitude (6 items), insomnia (6 items), suicidality (6 items), social anxiety (5 items),
ill temper (5 items), traumatic intrusions (4 items), appetite loss (3 items), and appetite gain
(3 items). Some subscales share overlapping items (e.g. items 7 and 15 are both contained in
the general depression and suicidality subscales). In previous work, the IDAS subscales have
shown good internal reliability (α = .80 to .89) and convergent validity with other measures of
depression and anxiety (Watson et al., 2007). The present study utilized the general depression
(total sample: α = .91; racial/ethnic group range: α’s = .90 to .92), suicidality (total sample:
α = .89; racial/ethnic group range: α’s = .87 to .92), anxious arousal (total sample: α = .90;
racial/ethnic group range: α’s = .88 to .91), and social anxiety (total sample: α = .86; racial/
ethnic group range: α’s = .86) subscales.

Trait affect
The Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) is a
self-report measure that assesses the degree to which participants typically experience 20
different positive (e.g. excited, proud) or negative affective states (e.g. afraid, distressed).
Responses are based on a Likert scale ranging from 1 (“very slightly or not at all”) to 5
(“extremely”). The PANAS yields two subscales, positive affect (PA) and negative affect
(NA), which have shown good internal consistency (PA: α = .86; NA: α = .90) and validity
(Watson et al., 1988). The present study utilized the NA subscale (total sample: α = .90; racial/
ethnic group ranges: α’s = .89 to .90) as a covariate to adjust for the broad-based tendency
to experience negative mood states.

Financial stress
The Financial Strain Questionnaire (FSQ; Pearlin, Menaghan, Lieberman, & Mullan,
1981) is an 8-item self-report measure used to assess stress related to financial difficul-
ties. The FSQ operationalizes economic stress via the level of difficulty associated with
obtaining life necessities (e.g. food, clothing, housing) and conveniences (e.g. furniture,
automobiles, recreation) at the present time (sample item: “Are you able to afford a
home suitable for [yourself/your family]?”). Response options are as follows: 1 (“Yes,
I can afford”), 2 (“I can somewhat afford”), and 3 (“No, I cannot afford”). In previous
research, the FSQ has shown excellent internal consistency (α = .91; Williams, Steptoe,
Chambers, & Kooner, 2009). In the current study, the internal consistency of the FSQ
total score was good (total sample: α = .89; racial/ethnic group ranges: α’s = .88 to .90)
and the scale was employed as a covariate.

506 M. J. ZvoLenSky eT AL.

Procedures

Study procedures were compliant with the Institutional Review Board. All measures were
self-report and completed via the Internet. Each participant provided informed consent
on an introductory web page before being routed to the study survey. No information that
could identify participants was retained.

Data analytic strategy

Data analyses were conducted using SPSS 22.0. Bivariate relations among study variables
were examined using Pearson correlations. Moderation tests were conducted using hierar-
chical linear regression. In hierarchical regression-based moderation models, the unstand-
ardized regression coefficients (bj) for the independent variable (b1) and the moderator
(b2) are estimated while setting the other equal to zero. Because both acculturative stress
(independent variable) and experiential avoidance (moderator) were scaled such that their
range of scores did not include zero, both were mean-centered so that their unstandardized
coefficients would be interpretable (Cohen, Cohen, West, & Aiken, 2003; Hayes, 2013).
For each outcome, study covariates (i.e. age, gender, relationship status, financial strain,
negative affectivity) were entered in step 1 of a hierarchical linear regression, followed by
the mean-centered independent variable (acculturative stress) and theoretical moderator
(experiential avoidance) in step 2, and the interaction variable (calculated as the product
of the mean-centered independent and moderator variables) in step 3. The covariates were
chosen on a theoretical basis, as factors that may covary with the predictor and dependent
variables. Visualization of the interaction was done by estimating the regression line at
specific values of the independent variable and moderator and setting each covariate equal
to its mean. The PROCESS macro, a publicly available syntax package designed to test
moderation effects within a regression framework, facilitated the visualization by producing
the values needed to plot the 10th, 25th, 50th, 75th, and 90th percentiles of the distribution
(Hayes, 2013). Finally, to probe the interaction, regions of significance were determined
using the Johnson–Neyman technique (Bauer & Curran, 2005; Spiller, Fitzsimons, Lynch,
& McClelland, 2013) as calculated by the PROCESS macro (Hayes, 2013). In contrast to
other interaction probing methods, the Johnson–Neyman technique estimates the exact
values of the moderator that will yield the critical value used to determine significance
(Bauer & Curran, 2005).

Results

Descriptive statistics and correlations among study variables are presented in Table 1. Of the
outcome variables, the suicidality (skewness = 3.10; kurtosis = 10.64) and anxious arousal
(skewness = 2.40; kurtosis = 6.46) subscales were not normally distributed; therefore, data
were log-transformed. Acculturative stress and experiential avoidance both were signif-
icantly associated with the dependent variables (all p’s  <  .001). Acculturative stress and experiential avoidance were significantly correlated (r = .36; p < .001). Regarding depressive symptoms, the covariates entered in the first step of the regression accounted for 36.2% of the variance (Adjusted R2 = .362; F[5, 1089] = 124.953, p < .001). The covariates with significant effects on depressive symptoms included financial strain CoGnITIve BeHAvIoUR THeRApy 507 Ta bl e 1.  Z er o -o rd er c or re la ti on s am on g s tu d y va ri ab le s. N ot es . a g e = a g e in y ea rs ; g en d er , c od ed fe m al e = 0 a n d m al e = 1 , w it h d es cr ip ti ve s ta ti st ic s fo r n um b er a n d p er ce nt ag e fe m al e; r el at io n sh ip S ta tu s = ro m an ti c re la ti on sh ip s ta tu s, c od ed a s si n g le / n on -e xc lu si ve d at in g = 0 a n d e xc lu si ve re la ti on sh ip = 1 , w it h d es cr ip ti ve s ta ti st ic s fo r n um b er a n d p er ce nt ag e in a n e xc lu si ve re la ti on sh ip ; F in an ci al S tr ai n , t ot al s ca le s co re o f t h e Fi n an ci al S tr ai n Q ue st io n n ai re ; n eg at iv e a ff ec t = t ra it n eg at iv e aff ec t, re p or te d a s th e to ta l s co re fo r th e po si ti ve a n d n eg at iv e a ff ec t Sc h ed ul e n eg at iv e a ff ec t su b sc al e; S oc ia l, a tt it ud in al , F am ili al , a n d e nv ir on - m en ta l S ca le = S a Fe a cc ul tu ra ti ve S tr es s to ta l s ca le s co re ; e xp er ie nt ia l a vo id an ce = to ta l s ca le s co re o f t h e M ul ti d im en si on al e xp er ie nt ia l a vo id an ce Q ue st io n n ai re ; D ep re ss io n = g en er al D ep re s- si on s ub sc al e sc or e of th e in ve nt or y of D ep re ss io n a n d a n xi et y Sy m p to m s (iD a S) ; S ui ci d al it y = S ui ci d al it y su b sc al e sc or e of th e iD a S; a n xi ou s a ro us al = a n xi ou s a ro us al s ub sc al e sc or e of th e iD a S; So ci al a n xi et y = S oc ia l a n xi et y su b sc al e sc or e of th e iD a S. a C ov ar ia te s; b pr ed ic to r; c M od er at or ; d o ut co m e va ri ab le s; † p < .0 5; * p < .0 1; ** p < .0 01 . va ri ab le 1 2 3 4 5 6 7 8 9 10 11 1. a g e (y ea rs )a – .0 23 –. 20 7* * –. 25 1* * –. 11 4* * –. 09 3* –. 10 2* –. 06 5 –. 05 1 –. 12 1 –. 08 2* 2. g en d er a – –. 13 3* * .0 57 .0 27 –. 01 6 .0 83 * .0 26 –. 08 5 –. 02 5 –. 00 2 3. re la ti on sh ip s ta tu sa – .1 18 ** .0 82 ** .0 92 * .1 10 ** .0 85 .0 59 .0 19 .0 96 * 4. Fi n an ci al s ta in a – .1 08 ** .1 20 * .1 64 ** .1 23 .0 56 .0 39 .0 92 * 5. n eg at iv e aff ec ta – .4 19 * .4 06 ** .6 00 .3 67 ** .4 61 ** .4 81 ** 6. a cc ul tu ra ti ve s tr es sb – .3 62 ** .3 71 .2 51 ** .3 37 ** .3 61 ** 7. ex p er ie nt ia l a vo id an ce c – .4 04 .1 92 ** .2 65 ** .3 46 ** 8. D ep re ss io n d – .5 65 ** .5 96 ** .6 10 ** 9. Su ic id al it yd – .6 12 ** .4 57 ** 10 . a n xi ou s ar ou sa ld – .6 28 ** 11 . So ci al a n xi et yd – D es cr ip ti ve M ea n (n ) 21 .9 2 85 5 53 0 16 .6 9 21 .3 0 52 .9 5 20 7. 53 42 .5 8 7. 48 10 .9 7 8. 86 St at is ti cs SD (% ) 4. 23 78 .1 0 48 .4 0 4. 64 7. 84 18 .6 9 37 .1 2 13 .9 3 3. 38 4. 90 4. 41 508 M. J. ZvoLenSky eT AL. (β = .060; t = 2.375, p = .018) and negative affectivity (β = .593; t = 24.246, p < .001). In step 2, significant main effects were observed for both acculturative stress (β = .104; t = 3.900, p < .001) and experiential avoidance (β = .163; t = 6.109, p < .001), which together accounted for an additional 3.5% of variance in depressive symptoms (Adjusted R2 = .397). However, contrary to expectations, the interaction of acculturative stress and experiential avoidance in step 3 was not significant (β = .014; t = .594, p = .552). Table 2 presents model statistics and all variable effects. For suicidality symptoms, the study covariates entered in step 1 accounted for 15.9% of variance (Adjusted R2 = .159; F[5, 1089] = 42.491, p < .001). Among the covariates, gender (β  =  –.109; t  =  –3.902, p  <  .001) and negative affectivity (β  =  .387; t  =  13.804, p  <  .001) demonstrated significant effects on suicidality symptoms. Acculturative stress (β  =  .125; t = 4.004, p < .001) demonstrated a significant main effect on suicidality in step 2, but the main effect of experiential avoidance was not significant. Step 2 accounted for an addi- tional 1.4% of the variance (Adjusted R2  =  .173). The interaction of acculturative stress with experiential avoidance (β = .061; t = 2.199, …

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