Volume 27, Issue 4 (Autumn 2021)                   Intern Med Today 2021, 27(4): 534-549 | Back to browse issues page

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Mirmoeini P, Bayazi M H, Khalatbari J. Comparing the Effectiveness of Acceptance and Commitment Therapy and Compassion Focused Therapy on Worry Severity and Loneliness Among the Patients With Multiple Sclerosis. Intern Med Today 2021; 27 (4) :534-549
URL: http://imtj.gmu.ac.ir/article-1-3555-en.html
1- Department of Psychology, Torbat-e-Jam Branch, Islamic Azad University, Torbat-e-Jam, Iran.
2- Department of Psychology, Torbat-e-Jam Branch, Islamic Azad University, Torbat-e-Jam, Iran. , bayazi123@gmail.com
3- Department of Psychology, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran.
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1. Introduction
Multiple Sclerosis (MS) is a chronic disease of the central nervous system that affects the brain and spinal cord [1]. MS’s age of onset is mostly between 20 and 40 years. According to the World Health Organization, the prevalence of the disease in Iran is 20-60 per 100000 people, and the rate in women is 3 to 4 times that in men [2]. The disease does not affect all people in the same way and has different manifestations [3]. The physical structure of the individual, disorders in the regulation and balance of the immune system, environmental and racial factors, exposure to viruses during life, vaccination, and stress are among the factors that affect the development of MS [4]. Also, many psychological factors, including coping, creation, self-efficacy, and perceived support, contribute more than biological factors to the quality of life of MS patients. Therefore, interventional studies should consider the psychological factors associated with the health of these patients and go beyond physical damages and their disabilities [5]. 
Depending on the level of disability after the first 5 or 10 years of the disease, the future course of the disease can be determined to an acceptable extent [6]. MS is an incurable brain disease that strongly causes worries, decreases self-esteem, and forces the patients to adapt to disease disabilities. According to many sufferers, there is a strong association between anxiety and disease recurrence. During worries, more energy is needed to think and solve daily living problems, and this energy depletion causes fatigue and disruption of patients' daily functioning [7]. Psychological stresses are mentioned as a possible factor for disease recurrence and progression [8]. Loneliness is a risk factor for increased complications and mortality. People with MS are subject to an increased risk of loneliness [9]. The studies on the relationship between loneliness and physical and mental health show that loneliness affects the various aspects of the social life of individuals. The sense of loneliness is predictive of symptoms of depression [10]. MS also causes severe anxiety in patients and forces them to adapt to the disabilities caused by the disease. According to many patients with MS, there is a strong association between anxiety and disease recurrence. Most of the patients report that the symptoms of the disease worsen during times of stress and anxiety [11]. Statistics show the ascending course of the disease in the world, so in our country, it is necessary to take serious action to control and treat the disease. Psychological problems in MS are more common than in healthy populations and other chronic diseases [12]. Empirical research suggests a high rate of depression and loneliness, an increase in anxiety, and problems related to relationships and social roles in MS patients, so it is necessary to find appropriate and effective solutions for the better life of these patients. 
Compassion means having a positive attitude towards oneself when things go wrong. Compassion itself is considered an effective trait and a protective factor in cultivating emotional flexibility. Compassion includes kindness to oneself in the face of self-judgment and criticism, human communication in the face of isolation, and mindfulness in the face of over-imitation of others. Compassion leads to a sense of self-care, self-awareness, an unbiased view of one's inadequacies and failures, and the acceptance that one's experiences are also part of ordinary human experiences. Compassion requires the acceptance that suffering, failure, and inadequacy are part of the condition of life and that all human beings, including the individual, deserve kindness and compassion [13]. Kindness to oneself is self-understanding instead of self-judgment and a kind of support for one's shortcomings and inadequacies. Acknowledging that all human beings are flawed, make mistakes, and engage in unhealthy behaviors is characteristic of shared human emotions [14]. In self-compassion focused therapy, clients are helped by creating or enhancing a client's inner compassionate relationship with themselves, rather than blaming, condemning, or self-criticizing. The results of self-compassion focused therapy include the importance of well-being, understanding and empathy, empathy, non-judgment and not blaming others, tolerance or resilience to turmoil, and suffering, through attention, thinking, behavior, imagery, feeling, and compassion [15]. 
Also, creating a rich and meaningful life while accepting its inevitable suffering is an effective way to build a meaningful life through its most deeply guided values while being fully prepared and committed only through a conscious action [16]. Acceptance and commitment-based therapy has been developed as an alternative to more traditional forms of psychotherapy, such as classical cognitive-behavioral therapy. This treatment emphasizes reducing the intensity and the frequency of emotions and annoying thoughts. Instead of trying to alleviate recent annoying thoughts, Acceptance and Commitment Therapy (ACT) emphasizes increasing behavioral efficiency in the presence of unpleasant thoughts and feelings. In other words, the ACT therapist does not attempt to alter the client's disturbing thoughts or reduce his or her unpleasant emotions [17]. Studies show different treatments to change and reduce the psychological consequences of diseases. Research has proven the effectiveness of psychological therapies on mental health problems caused by chronic diseases. ACT therapy is one of the new and effective therapies in solving psychological problems and disorders, the basic principles of which are as follows: 1) acceptance or desire to experience pain or other disturbing events without trying to control them and 2) action based on value or commitment is accompanied by a desire for meaningful personal goals before the elimination of unwanted experiences. Therefore, ACT is very appropriate by focusing on the current situation and the paths leading to acceptance and personal growth in crises. According to the circumstances in the individual's situation, acceptance is gradually created to achieve a sense of self as a socially, sexually, and occupationally appropriate person [18].
 A variety of studies on the effectiveness of ACT on improving quality of life [19] have studied reducing pain intensity in MS patients [20], reducing anxiety and dysfunctional attitudes [21], anxiety and depression in women with MS [22], resilience [23], logical memory, problem-solving skills [24], cognitive conflicts, and negative spontaneous thoughts [25].
Compassion Focused Therapy (CFT) teaches people not to let go of their painful feelings but accept them. Therefore, in the first step, they know their experience and feel compassion for it [26]. Compassion acknowledges that not all pain can be resolved or cured, but all suffering can be alleviated with a hug of compassion. In fact, with mindfulness based on cognition, we can face the problems and sufferings of life. With compassion, we can deal effectively with them [27]. Since no research has been done on the effectiveness of CFT and ACT on loneliness and anxiety in patients with MS, in the current study, we seek to answer whether the ACT and CFT are effective on loneliness and the severity of worry in patients with multiple sclerosis. Also, if there is a significant difference between these two intervention methods in the effectiveness on the mentioned variables.
2. Materials and Methods
The present quasi-experimental study has a pretest-post-test design with a control group. The study population includes all patients with multiple sclerosis under treatment by MS clinic physicians in Tehran City, Iran. The study sample was selected by purposive sampling from 2500 MS patients during the second 6 months of 2019.
The study questionnaires were presented to 166 patients of the statistical population. Among them, 92 people with the highest scores in loneliness and anxiety were identified. Then, 45 people were randomly selected and assigned into three groups of 15: the first experimental group went under CFT, the second experimental group consisted of 15 patients treated based on ACT, and the third group was the control group. According to Dr Delavar, for experimental and comparative studies, a sample size of 30 people in each group is recommended. However, sometimes experimental research is conducted with 15 people in each group under controlled conditions. After the intervention (CFT and ACT groups), the independent variables were observed, measured, and re-evaluated in the post-test.
3. Results
The study sample was 45 patients with MS. Of these, 15 were randomly selected and assigned into the first experimental group (ACT), 15 in the second experimental group (CFT), and 15 in the control group. The age range of the participants was between 20 and 40 years, with an average of 28.84 years. The number of females was 0.33 times that of males.
There was no statistically significant difference between the three groups after analyzing qualitative data through descriptive statistics using the indicators of central tendency, dispersion, and frequency distribution of age and education variables. The scores of the subjects in the pretest for all three groups were at a significant level for testing the normality of the data in all the variables under study was greater than 0.05, and the assumption of the normality of the distribution of scores was accepted.
Before the intervention, in the pretest, the scores of loneliness and severity of worry were equal in the three groups, but after the intervention, the mean scores of loneliness and the severity of worry decreased in the two experimental groups compared to the control group while no significant change was observed in the control group. Comparing the effect of these two therapies, according to Tables 1 and 2, ACT is more effective than CFT.

Ethical Considerations
 In this research, ethical provisions have been observed in two parts: executive and written. In the executive part, the privacy and confidentiality of the collected data were observed so that the collected information was used in line with the purpose of this research. Also, in this study, the dignity, rights, privacy, secrets, and freedom of the subjects were observed. The researchers explained the study objectives to the patients and obtained informed consent from them. The other ethical principles observed in this study were the optionality of the research, the right to withdraw from the study, the harmlessness of CFT and ACT, answering questions, and providing results to the subjects if they wished.
The inclusion criteria were 1) having MS, 2) informed consent to participate in research, 3) age range between 20 and 40 years, 4) literacy level above the cycle, 5) no drug addiction, and 6) no use of any sedative that can affect the variables studied (antidepressants, anti-anxiety, and sedatives).
The exclusion criteria were 1) psychosis and use of psychiatric and psychotropic drugs, 2) absence from more than two sessions in treatment sessions, 3) personality disorders, 4) severe family problems, and 5) withdrawal of the subject.
Self-compassion focused therapy sessions
 Self-compassion focused therapy sessions are designed based on the concepts of Paul Gilbert (2010). According to Table 3, the content validity of this package has been approved in Iran with a survey of three clinical psychologists and familiar with the third wave therapies in the universities of Al-Zahra and Kharazmi of Tehran [28].

 Acceptance and Commitment Therapy 
Acceptance and commitment therapy was performed by the researcher, with a degree in acceptance and commitment training, using a treatment protocol whose content and application validity have been validated by psychologists [29]. The sessions are described in Table 3
Social and emotional loneliness scale for adults
This scale was designed and developed by DiTommaso, Brannen, and Best in 2004 based on Weiss›s classification. This scale includes 15 items and three subscales of romantic loneliness (five items), family (five items), and social (five items), and the feeling of emotional loneliness is obtained from the sum of scores of romantic and family subscales. Each item is scored on a 5-point scale from «strongly disagree» with a score of 1 to «strongly agree» with a score of 5. All items except items 14 and 15 are scored in reverse, and obtaining a higher score in each of the dimensions of this scale indicates a greater sense of loneliness. The authors of this scale reported the Cronbach α coefficient of 0.87 to 0.90, which indicates a suitable internal consistency of the scale. In another study by DiTommaso, Brannenn McNally, Ross, and Burgess, the Cronbach α coefficient was reportedly acceptable from 0.81 for romantic loneliness to 0.91 for family loneliness. The validity of this tool has already been confirmed in several studies.
Penn State Worry Questionnaire 
The Penn State worry questionnaire is a 16-item self-report questionnaire that measures severe, extreme, and uncontrollable anxiety. The scale of answering questions is based on the Likert scale. In the research of Dehshiri et al. (2009), the results of factor analysis showed that the two-factor model of this questionnaire (general concern and lack of concern) has a better fit than the one-factor model. The internal consistency and test-retest coefficients (with an interval of 1 month) of the questionnaire were high. Also, a significant correlation between the scores of this questionnaire and the scores of the trait anxiety and depression questionnaire indicates the validity of the questionnaire. The reliability of the questionnaire was calculated using the Cronbach α method. Usually, the range of the Cronbach α reliability coefficient is from 0, meaning instability to +1, meaning complete reliability. The closer the value obtained to the positive number one is, the more reliable the questionnaire is [30].
4. Discussion
This study aimed to compare the effectiveness of ACT and CFT on loneliness and worry in patients with MS and determine which method is more effective. The results showed that ACT and CFT groups were significantly different from the control group, and these therapies effectively improved loneliness and worry intensity. This finding is consistent with other research results in this field [31, 3233, 34, 35363738]. Compared with each other, ACT and CFT showed a significant difference, i.e., treatment based on the ACT was preferable. Acceptance and commitment therapy emphasizes releasing individuals from mental traps and defusion. In the ACT approach, the people are helped to get rid of annoying self-assessments and labeling associated with painful emotions and are used as psychological flexibility. They result from a set of processes such as defusion, commitment to values, and self as the basis for acceptance, committed action, and mindfulness.
Compassion focused therapy seeks to clarify key components of compassion, such as sensitivity with attention, motivation to care, compassion, empathy, distress, and a non-judgmental perspective. In fact, cultivating self-compassion, compassion for others, and acceptance of compassion by others can provide a safe and spiritual psychological home, as a result of which individuals can effectively deal with the harmful events of life. CFT acts as a method of positive emotion regulation, reducing negative emotions and replacing them with positive emotions. It seems that due to this emotional self-regulation, psychological problems are reduced. As a result, a person›s perception of his abilities improves, especially in the emotional field and dealing with stressful situations and conditions.
Study Limitations
One of the limitations of this study is the inability to control all disturbing variables, such as patients› daily problems during treatment due to the coronavirus pandemic conditions and quarantine of these patients, and consequently, lack of follow-up period, lack of research, and similar studies on the subject. The most important limitations of the research were using only the patients with MS referred to Dr Amir Reza Azimi MS Clinic and the use of self-report tools. These limitations should be considered in using the results and generalizing them. Therefore, it is recommended that such research be conducted using interviews instead of questionnaires.
Study Suggestions
According to the study results, it is suggested that long-term follow-up be used in future research to examine the effectiveness of CFT with ACT more accurately. Considering that the living environment, work, social and economic conditions of individuals affect the research results, caution should be exercised in generalizing the results to the whole society. It is suggested that in future research, the third experimental group should also be considered, which will study the combined treatment of ACT and CFT on the research samples.
5. Conclusion
The current study findings compared the effectiveness of CFT with ACT and supported the effectiveness of both treatments in reducing feelings of loneliness and worry in patients with multiple sclerosis. There is also a significant difference in the effectiveness of CFT with ACT, so that ACT is much more effective on patients› feelings of loneliness and worry than CFT. Therefore, it is suggested that special attention be paid to the effectiveness of these two therapies in controlling the psychological symptoms of patients with multiple sclerosis, which was confirmed by various research backgrounds in different fields.

Ethical Considerations
Compliance with ethical guidelines

This study with the ethical code of IR.IAU.TJ.REC.1399.012 has been approved by the Islamic Azad University of Torbat-e-Jam.

This article is extracted from Ms Pardis MirMoeini's PhD  dissertation in Health Psychology.

Authors' contributions
The main idea of ​​implementing the protocol and writing the manuscript: P. MirMoeini; Manuscript Editing: M.H. Bayazi; Data analysis: Javad Khalatbari.

Conflicts of interest
The authors declared no conflict of interest.

We sincerely thank Dr. Amirreza Azimi Saein for his cooperation in all the executive and scientific stages of the current research.

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Type of Study: Original | Subject: Mental Health
Received: 2020/07/7 | Accepted: 2021/07/20 | Published: 2021/10/1

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