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Namazi R, Bolook Sahragard S, Pourkaveh H, Homayoon S, Mirniyam S K, seyed jafari J. Effectiveness of Acceptance and Commitment Therapy on Psychological Hardiness, Social Isolation and Loneliness of Women with Breast Cancer. jcbr 2022; 6 (1) :1-10
URL: http://jcbr.goums.ac.ir/article-1-343-en.html
URL: http://jcbr.goums.ac.ir/article-1-343-en.html
Roshanak Namazi1 
, Soolmaz Bolook Sahragard2 , Hoda Pourkaveh3 , Shariat Homayoon4 , Seyyed Kamal Mirniyam * 5, Javad Seyed jafari6
, Soolmaz Bolook Sahragard2 , Hoda Pourkaveh3 , Shariat Homayoon4 , Seyyed Kamal Mirniyam * 5, Javad Seyed jafari6
1- Department of Psychology, Science and Research Branch, Islamic Azad University, Alborz, Iran
2- Department of Psychology, Faculty of Psychology, Islamic Azad University of Tehran Markaz, Tehran, Iran
3- Tehran Medical Branch, Islamic Azad University, Tehran, Iran
4- Department of Psychology, Shiraz Branch, Islamic Azad University, Shiraz, Iran
5- Department of Psychology, Khorasgan Branch, Islamic Azad University, Isfahan, Iran , mirniyamkamal@gmail.com
6- Allameh Tabataba'i University, Tehran, Iran
2- Department of Psychology, Faculty of Psychology, Islamic Azad University of Tehran Markaz, Tehran, Iran
3- Tehran Medical Branch, Islamic Azad University, Tehran, Iran
4- Department of Psychology, Shiraz Branch, Islamic Azad University, Shiraz, Iran
5- Department of Psychology, Khorasgan Branch, Islamic Azad University, Isfahan, Iran , mirniyamkamal@gmail.com
6- Allameh Tabataba'i University, Tehran, Iran
Keywords: Acceptance and Commitment Therapy, Psychological Hardiness, Social Isolation, Loneliness, Breast Cancer
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INTRODUCTION
According to the World Health Organization, breast cancer is the most common cancer in women and the second leading cause of cancer death worldwide (1). Compared to developed countries, women in Iran develop breast cancer a decade earlier (1-4). In many cancers, radiotherapy either alone or in combination with chemotherapy, hormone therapy, immunotherapy, and surgery is a crucial component of curative treatment. More than half of cancer patients suffer from psychosocial dysfunctions (5).
A fundamental concept of psychological hardiness is the ability of a person to resist the physical decline and improve when facing a disease (6). In a study by Farahbakhsh Beh et al. (2019), hardiness traits in women with breast cancer appear to act as a buffer against perceived stress (7).
A high level of hardiness may improve tolerance to unpleasant events. The coping capacity of these people accounts for their resistance to illness, which may stem from understanding life changes as less stressful events or from having less stress tolerance (8). Hardiness has a positive relationship with greater hope (9) and is associated with using the problem-oriented comparative strategies (10). In the absence of adequate treatment, patients may experience a variety of physiological problems. The lack of hardiness causes people to display excessive anxiety since they are unable to remain positive when hardships occur. However, hardiness is influenced by social support, parenting patterns, family, and self-confidence (11).
Cancer patients with an established social network after treatment were less likely to die from cancer recurrences than those without one (12). A research on 10,000 breast cancer cases concluded that women with more isolation are 40% more likely to experience cancer relapse (13). Another study also found that solitary women have
60% higher chance of developing breast cancer and 70% increased chance of death from any cause (14). Overall, there is strong
evidence suggesting a link between social isolation and cancer-specific mortality (13, 15, 16).
It is well-established that psychosocial support interventions such as acceptance and commitment therapy (ACT) could contribute to patient survival and improved quality of life (18). Cognitive and behavioral therapy using acceptance and mindfulness, such as dialectical behavior therapy (19) or mindfulness-based cognitive therapy has become increasingly popular in recent years (4, 20). In contrast to trying to alter the physiological events themselves, these interventions aim to change the emotional functions and relationships between psychological events (21).
As part of a trans-diagnostic model that looks at the pathogenic mechanisms of human suffering, ACT combines acceptance and mindfulness processes with commitment and behavior change processes (22). According to research, ACT is effective for treating depression in individual, self-help, and group settings (23, 24). As a major element of ACT, increasing awareness of the psychopathology functioning beneath subclinical and clinical suffering is key to building the capacity for individuals to act as they see fit (21). By targeting physical health, well-being, and mental health, ACT is more than just treating symptoms (21).
Psychological flexibility is achieved through six central processes in the ACT therapeutic approach. Each of the six processes consists of acceptance, cognitive diffusion, contact with the present moment, self-in-context, values, and committed action. The name ACT is derived from its original message, namely accepting that you can't control everything and committing to taking actions that enrich your life (25). Many studies in Iran have examined psychological hardiness and its relationship with quality of life (7), social support (8), hope for the future (9), and optimism (11) in women with breast cancer; however, no research has examined psychological hardiness, social isolation, and loneliness from an ACT perspective. Thus, the objective of the present study was to determine effectiveness of ACT in reducing depression, increasing pain acceptance, and improving psychological flexibility in a population of Iranian women with breast cancer.
MATERIALS AND METHODS
The present study was a quasi-experimental research with a pretest-posttest design. The study population consisted of all women with breast cancer who had been referred to the oncology ward of Shohada Tajrish Hospital in Tehran (Iran) in 2020. The subjects were selected through purposive sampling and then randomly assigned to an experimental group (n=15) and a control group (n=15). Furthermore, the estimated sample size was between 15 to 20 individuals for each study group (28).
Inclusion criteria were being a woman with breast cancer (based on medical records and diagnosis) and willingness to participate in the study. Attending other psychotherapy sessions, having a history of psychiatric disorders, and being absent for more than a session were considered as exclusion criteria. The intervention group received eight sessions of 90-minute ACT therapy [according to the protocol described by Hayes et al. (21)], two sessions a week, for four consecutive weeks. The control group received three sessions of ACT therapy approximately one month after the end of the study.
The Lang and Goulet Psychological Hardiness Scale was first designed in 2003 (30). The questionnaire consists of 42 questions and three subscales of control, commitment, and challenge. The questions were scored based on a five-point Likert scale from completely disagree (score of 1) to completely agree (score of 5). The total score was obtained by determining the sum scores in each of the questions. Scores of 42-84, 84-126 and above 126 indicated low, moderate and high psychological hardiness, respectively. Reliability of the Persian version of the scale was verified by obtaining Cronbach's alpha scores of 0.86, 0.75 and 0.61 for the subscales of control, commitment, and challenge, respectively (31). In the present study, a Cronbach's alpha score of 0.71 was obtained for the scale.
The social isolation questionnaire consists of 20 items (10 negative and 10 positive) (32) that are scored from 1 (never) to 4 (always). The overall score is calculated by summing the numbers of the selected items, which is inverted by the number related to the positive tone sentences (5, 6, 9, 10, 15, 16, 19, 20). The questionnaire has three subscales including loneliness due to family relationships (2, 4, 9, 12, 16, 18, 20), communication with friends (1, 3, 5, 10, 11, 15, 19), and emotional sign questions (6, 7, 8, 13, 14, 17). The reliability of the social isolation questionnaire has been confirmed previously (33). In the present study, a Cronbach's alpha score of 0.77 was obtained for the questionnaire.
The University of California, Los Angeles, Loneliness Scale (UCLA) is the most frequently used loneliness assessment tool. The Persian adaptation of the scale consists of 20 original items that are scored based on a five-point Likert scale ranging from never (1) to always (5). The maximum score is 100 and the minimum score is 20. The UCLA uses a diagnostic cut-off score of greater than 70, identical to the Young cut-off score. It must be noted that this cut-off score has not been independently assessed clinically (34). The exploratory factor analysis on the original UCLA revealed three factors (online preoccupation, adverse effects and social interactions) explaining 50% of the variance (34, 35).
Data were analyzed first using descriptive statistical methods including mean and standard deviation. Inferential statistics including one-way analysis of variance (ANOVA) with repeated measures were used to determine the stability and effect size in three stages pre-test, post-test, and two-month follow-up. The normality of data was confirmed using the Shapiro-Wilk test. Data analysis was carried out in SPSS software (version 23), and statistical significance was set to 0.05.
RESULTS
The mean age of subjects and mean duration of marriage were 34.23±6.12 years and 8.46±5.14 years, respectively. Psychological hardiness scores improved in the experimental group compared to the control group in the post-test and follow-up periods, whereas social isolation and loneliness scores decreased (Table 2).
According to the World Health Organization, breast cancer is the most common cancer in women and the second leading cause of cancer death worldwide (1). Compared to developed countries, women in Iran develop breast cancer a decade earlier (1-4). In many cancers, radiotherapy either alone or in combination with chemotherapy, hormone therapy, immunotherapy, and surgery is a crucial component of curative treatment. More than half of cancer patients suffer from psychosocial dysfunctions (5).
A fundamental concept of psychological hardiness is the ability of a person to resist the physical decline and improve when facing a disease (6). In a study by Farahbakhsh Beh et al. (2019), hardiness traits in women with breast cancer appear to act as a buffer against perceived stress (7).
A high level of hardiness may improve tolerance to unpleasant events. The coping capacity of these people accounts for their resistance to illness, which may stem from understanding life changes as less stressful events or from having less stress tolerance (8). Hardiness has a positive relationship with greater hope (9) and is associated with using the problem-oriented comparative strategies (10). In the absence of adequate treatment, patients may experience a variety of physiological problems. The lack of hardiness causes people to display excessive anxiety since they are unable to remain positive when hardships occur. However, hardiness is influenced by social support, parenting patterns, family, and self-confidence (11).
Cancer patients with an established social network after treatment were less likely to die from cancer recurrences than those without one (12). A research on 10,000 breast cancer cases concluded that women with more isolation are 40% more likely to experience cancer relapse (13). Another study also found that solitary women have
60% higher chance of developing breast cancer and 70% increased chance of death from any cause (14). Overall, there is strong
evidence suggesting a link between social isolation and cancer-specific mortality (13, 15, 16).
It is well-established that psychosocial support interventions such as acceptance and commitment therapy (ACT) could contribute to patient survival and improved quality of life (18). Cognitive and behavioral therapy using acceptance and mindfulness, such as dialectical behavior therapy (19) or mindfulness-based cognitive therapy has become increasingly popular in recent years (4, 20). In contrast to trying to alter the physiological events themselves, these interventions aim to change the emotional functions and relationships between psychological events (21).
As part of a trans-diagnostic model that looks at the pathogenic mechanisms of human suffering, ACT combines acceptance and mindfulness processes with commitment and behavior change processes (22). According to research, ACT is effective for treating depression in individual, self-help, and group settings (23, 24). As a major element of ACT, increasing awareness of the psychopathology functioning beneath subclinical and clinical suffering is key to building the capacity for individuals to act as they see fit (21). By targeting physical health, well-being, and mental health, ACT is more than just treating symptoms (21).
Psychological flexibility is achieved through six central processes in the ACT therapeutic approach. Each of the six processes consists of acceptance, cognitive diffusion, contact with the present moment, self-in-context, values, and committed action. The name ACT is derived from its original message, namely accepting that you can't control everything and committing to taking actions that enrich your life (25). Many studies in Iran have examined psychological hardiness and its relationship with quality of life (7), social support (8), hope for the future (9), and optimism (11) in women with breast cancer; however, no research has examined psychological hardiness, social isolation, and loneliness from an ACT perspective. Thus, the objective of the present study was to determine effectiveness of ACT in reducing depression, increasing pain acceptance, and improving psychological flexibility in a population of Iranian women with breast cancer.
MATERIALS AND METHODS
The present study was a quasi-experimental research with a pretest-posttest design. The study population consisted of all women with breast cancer who had been referred to the oncology ward of Shohada Tajrish Hospital in Tehran (Iran) in 2020. The subjects were selected through purposive sampling and then randomly assigned to an experimental group (n=15) and a control group (n=15). Furthermore, the estimated sample size was between 15 to 20 individuals for each study group (28).
Inclusion criteria were being a woman with breast cancer (based on medical records and diagnosis) and willingness to participate in the study. Attending other psychotherapy sessions, having a history of psychiatric disorders, and being absent for more than a session were considered as exclusion criteria. The intervention group received eight sessions of 90-minute ACT therapy [according to the protocol described by Hayes et al. (21)], two sessions a week, for four consecutive weeks. The control group received three sessions of ACT therapy approximately one month after the end of the study.
The Lang and Goulet Psychological Hardiness Scale was first designed in 2003 (30). The questionnaire consists of 42 questions and three subscales of control, commitment, and challenge. The questions were scored based on a five-point Likert scale from completely disagree (score of 1) to completely agree (score of 5). The total score was obtained by determining the sum scores in each of the questions. Scores of 42-84, 84-126 and above 126 indicated low, moderate and high psychological hardiness, respectively. Reliability of the Persian version of the scale was verified by obtaining Cronbach's alpha scores of 0.86, 0.75 and 0.61 for the subscales of control, commitment, and challenge, respectively (31). In the present study, a Cronbach's alpha score of 0.71 was obtained for the scale.
The social isolation questionnaire consists of 20 items (10 negative and 10 positive) (32) that are scored from 1 (never) to 4 (always). The overall score is calculated by summing the numbers of the selected items, which is inverted by the number related to the positive tone sentences (5, 6, 9, 10, 15, 16, 19, 20). The questionnaire has three subscales including loneliness due to family relationships (2, 4, 9, 12, 16, 18, 20), communication with friends (1, 3, 5, 10, 11, 15, 19), and emotional sign questions (6, 7, 8, 13, 14, 17). The reliability of the social isolation questionnaire has been confirmed previously (33). In the present study, a Cronbach's alpha score of 0.77 was obtained for the questionnaire.
The University of California, Los Angeles, Loneliness Scale (UCLA) is the most frequently used loneliness assessment tool. The Persian adaptation of the scale consists of 20 original items that are scored based on a five-point Likert scale ranging from never (1) to always (5). The maximum score is 100 and the minimum score is 20. The UCLA uses a diagnostic cut-off score of greater than 70, identical to the Young cut-off score. It must be noted that this cut-off score has not been independently assessed clinically (34). The exploratory factor analysis on the original UCLA revealed three factors (online preoccupation, adverse effects and social interactions) explaining 50% of the variance (34, 35).
Table 1. Protocol of treatment sessions based on ACT (21)
| Session details | Meetings |
| Communicating, introducing members, expressing group rules (including confidentiality, respect, listening, etc.). | 1 |
| Familiarity with some of the therapeutic concepts of ACT, including the experience of avoidance, integration, and psychological acceptance. | 2 |
| Review of the previous session, training, and implementation of ACT therapy techniques such as cognitive isolation, psychological awareness, and self-visualization. | 3 |
| Study of homework, teaching therapy techniques, mindfulness, emotional awareness, wise awareness. | 4 |
| Examining homework, teaching therapeutic techniques related to the present, practicing mindfulness techniques, and teaching stress tolerance in order to accept negative emotions. | 5 |
| Assessing homework, identifying the values of lives and measuring values based on their importance. Prepare a list of obstacles in the realization of values and create positive emotions. | 6 |
| Assessing homework, teaching personal value therapy techniques, engaging in action, and increasing interpersonal efficiency. | 7 |
| Review of homework, review and practice of taught therapy techniques with emphasis on regulating emotions and a sense of meaning in real life. | 8 |
Data were analyzed first using descriptive statistical methods including mean and standard deviation. Inferential statistics including one-way analysis of variance (ANOVA) with repeated measures were used to determine the stability and effect size in three stages pre-test, post-test, and two-month follow-up. The normality of data was confirmed using the Shapiro-Wilk test. Data analysis was carried out in SPSS software (version 23), and statistical significance was set to 0.05.
RESULTS
The mean age of subjects and mean duration of marriage were 34.23±6.12 years and 8.46±5.14 years, respectively. Psychological hardiness scores improved in the experimental group compared to the control group in the post-test and follow-up periods, whereas social isolation and loneliness scores decreased (Table 2).
Table 2. Mean scores of psychological hardiness, social isolation and loneliness in different stages of the study
| P-value | Mean ± SD | Group | Stage | Variable |
| 0.563 | 90±3.334.34 | Experimental | pre-test | Psychological hardiness |
| 17±3.519.34 | Control | |||
| 0.005 | 70±4.057.38 | Experimental | Post-test | |
| 65±3.148.34 | Control | |||
| 0.032 | 87±4.015.37 | Experimental | Follow up | |
| 40±4.405.34 | Control | |||
| 0.568 | 60±4.256.56 | Experimental | Pre-test | Social isolation |
| 57.40 ±3.269 | Control | |||
| 0.001 | 121.4 51.87± | Experimental | Post-test | |
| 07±3.058.57 | Control | |||
| 0.001 | 27±4.431.52 | Experimental | Follow up | |
| 27±3.081.57 | Control | |||
| 0.058 | 70±1.720.58 | Experimental | Pre-test | Loneliness |
| 60.60±1.920 | Control | |||
| 0.001 | 997.2 13±.53 | Experimental | Post-test | |
| 59.97±2.326 | Control | |||
| 0.001 | 066.3 60 ±.53 | Experimental | Follow up |
Table 3. The results of one-way ANOVA on the variables in three stages
Table 4. Paired comparison of the mean of research variables in the study groups between different stages of study
| Measure | Source | SS | df | MS | F | P | Eta |
| Psychological hardiness | Steps | 74.491 | 1.847 | 40.325 | 23.474 | 0.001 | 0.456 |
| Groups | 170.019 | 1 | 170.019 | 4.302 | 0.047 | 0.133 | |
| Mauchly’ test of sphericity | 203.583 | 2 | 101.792 | 35.641 | 0.001 | 0618 | |
| Greenhouse-Geisser test | 203.583 | 1.541 | 132.121 | 35.641 | 0.001 | 0618 | |
| Steps * Group | 46.964 | 1.847 | 25.424 | 14.800 | 0.001 | 0.346 | |
| Mauchly’ test of sphericity | 20970. 234 | 2 | 111.312 | 36.460 | 0.001 | 0618 | |
| Greenhouse-Geisser test | 20970.234 | 1.541 | 138.101 | 36.514 | 0.001 | 0618 | |
| Social isolation | Steps | 114.956 | 1.690 | 68.036 | 14.173 | 0.001 | 0.336 |
| Groups | 302.500 | 1 | 302.500 | 8.891 | 0.006 | 0.241 | |
| Mauchly’ test of sphericity | 2356.333 | 2 | 1098.722 | 406.30 | 0.001 | 0.949 | |
| Greenhouse-Geisser test | 2356.333 | 1.515 | 1450.030 | 406.30 | 0.001 | 0.949 | |
| Steps * Group | 92.600 | 1.690 | 54.805 | 11.416 | 0.001 | 0.290 | |
| Mauchly’ test of sphericity | 2197.444 | 2 | 11178.167 | 436.032 | 0.001 | 0.952 | |
| Greenhouse-Geisser test | 2197.444 | 1.515 | 1554.876 | 436.032 | 0.001 | 0.952 | |
| Loneliness | Steps | 169.839 | 1.738 | 97.738 | 27.063 | 0.001 | 0.491 |
| Groups | 598.044 | 1 | 598.044 | 43.194 | 0.001 | 0.607 | |
| Mauchly’ test of sphericity | 575.000 | 2 | 575.500 | 179.935 | 0.001 | 0.891 | |
| Greenhouse-Geisser test | 575.000 | 1.325 | 571.488 | 179.935 | 0.001 | 0.891 | |
| Steps * Group | 119.272 | 1.738 | 68.638 | 19.005 | 0.001 | 0.404 | |
| Mauchly’ test of sphericity | 643.111 | 2 | 321.556 | 152.864 | 0.874 | 0.891 | |
| Greenhouse-Geisser test | 643.111 | 1.325 | 485.509 | 152.864 | 0.874 | 0.891 |
Table 4. Paired comparison of the mean of research variables in the study groups between different stages of study
| Group | Variable | Paired stages | Mean Difference (I-J) | Std. Error | Sig |
| Control | Psychological hardiness | Post-test-pre-test | -0.487 | 0.489 | 0.985 |
| Follow up-pre-test | -0.233 | 0.494 | 1 | ||
| Follow up-Post-test | 0.253 | 0.388 | 1 | ||
| Social isolation | Post-test-pre-test | 0.333 | 0.865 | 1 | |
| Follow up-pre-test | 0.133 | 0.725 | 1 | ||
| Follow up-Post-test | -0.200 | 0.590 | 1 | ||
| Loneliness | Post-test-pre-test | 0.633 | 0.709 | 1 | |
| Follow up-pre-test | 0.267 | 0.705 | 1 | ||
| Follow up-Post-test | -0.367 | 0.506 | 1 | ||
| Experimental | Psychological hardiness | Post-test-pre-test | -3.800* | 0.489 | 0.001 |
| Follow up-pre-test | -2.967* | 0.494 | 0.001 | ||
| Follow up-Post-test | 0.833 | 0.388 | 0.122 | ||
| Social isolation | Post-test-pre-test | 4.733* | 0.865 | 0.001 | |
| Follow up-pre-test | 4.333* | 0.725 | 0.001 | ||
| Follow up-Post-test | -0.400 | 0.590 | 1 | ||
| Loneliness | Post-test-pre-test | 5.567* | 0.709 | 0.001 | |
| Follow up-pre-test | 5.100* | 0.705 | 0.001 | ||
| Follow up-Post-test | -0.467 | 0.506 | 1 |
There were significant differences between the study groups in the mean scores of psychological hardiness (p<0.01), social isolation (p<0.01), and loneliness (p<0.01) in the study stages (Table 3). Furthermore, the mean scores of all research variables in the experimental and control groups differed significantly (p<0.01). The results show that 13.3%, 24.1%, and 60.7% of the individual differences between the two groups were related to psychological hardiness, social isolation, and loneliness, respectively. There were significant difference in the mean scores of variable between the study stages (p<0.01) (Table 4). The mean scores of social isolation and loneliness decreased significantly. It appears that the treatment effect is stable over time and does not differ significantly between the pre-test and follow-up stages (p <0.05).
DISCUSSION
The results show that ACT increased psychological hardiness in women with breast cancer. The findings of this study explain how ACT, along with related techniques, metaphors, and corrections, can help people accept the situation, recognize negative thoughts, and acknowledge their partiality for failure. It should be noted that ACT is less focused on reducing symptoms and more focused on increasing quality of life. First, ACT increases acceptance by addressing the control-time costs (creative frustration) that apply to internal events and teaches one to distinguish between choice and reasoned judgments and helps choose values (21).
According to the results, ACT was effective in reducing social isolation in women with breast cancer, which is in line with the results of Bluth et al. (36) and Kocovski et al. (37). It is clear that the goal of ACT is to create a rich, complete, and meaningful life. Although related thoughts are not directly addressed in this type of therapy, it does reduce social isolation in women with breast cancer by examining the components of the mind, such as emotions, memories, desires, thoughts, and physical symptoms, all of which contribute to the formation of social isolation (37).
In addition, the use of fusion techniques will reduce social isolation due to better acceptance (of laws, reasons, judgments, past, future, and self) and mind-awareness (being in the present, without self-judgment). Furthermore, ACT particularly emphasize on reducing cognitive integration (37). When cognitive fusion is reduced, it means that the content of one's thoughts is broken. Cognitive fusion training teaches people to see only thoughts and emotions (21). None of the internal events are inherently harmful to human health when experienced, and their harmfulness comes from trying to eliminate or control experiences (21).
The results show that ACT significantly reduced feelings of loneliness in women with breast cancer, which is in agreement with results of studies conducted by Abosaidi Moghadam et al. (38) and Samadi and Doustkam (39). In this regard, it can be argued that the acceptance component in the ACT allows an individual to accept his/her unpleasant inner experiences, which ultimately reduces their impact on the individual’s life. Interventions involving ACT seem to be effective in reducing avoidance patterns (22, 38, 39). In addition, ACT teaches clients the values of their lives, in contrast to their previous avoidance-based behaviors. In this therapeutic approach, the person accepts mental experiences and perceptions without any reactions to eliminate these beliefs, so that his/her psychological awareness is increased to correct wrong thinking patterns. As the individual decides and commits, he/she will plan, end avoidance, and reduce social isolation. Therefore, ACT should respond to internal events in an open, non-defensive, and flexible manner because it replaces the desire with avoidance.
The short duration of the follow-up period was one of the limitations of the present study. The use of a non-random sampling method and small sample size are other limitations of the study, which make it difficult to generalize the results.
CONCLUSION
It seems that ACT is effective in increasing psychological hardiness and reducing social isolation and loneliness of women with breast cancer.
ACKNOWLEDGEMENTS
Our gratitude goes to the participants who provided their consent and took part in this study. Also, we would like to thank the analyst, the oncologist, and other nursing colleagues who assisted in the fieldwork.
DECLARATIONS
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethics approvals and consent to participate
The study was approved by the Ethical Committee of Islamic Azad university of Medical Sciences (code: IR.KHORASGANUMS.REC.1399.087). Written consent was taken from all participants.
Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
DISCUSSION
The results show that ACT increased psychological hardiness in women with breast cancer. The findings of this study explain how ACT, along with related techniques, metaphors, and corrections, can help people accept the situation, recognize negative thoughts, and acknowledge their partiality for failure. It should be noted that ACT is less focused on reducing symptoms and more focused on increasing quality of life. First, ACT increases acceptance by addressing the control-time costs (creative frustration) that apply to internal events and teaches one to distinguish between choice and reasoned judgments and helps choose values (21).
According to the results, ACT was effective in reducing social isolation in women with breast cancer, which is in line with the results of Bluth et al. (36) and Kocovski et al. (37). It is clear that the goal of ACT is to create a rich, complete, and meaningful life. Although related thoughts are not directly addressed in this type of therapy, it does reduce social isolation in women with breast cancer by examining the components of the mind, such as emotions, memories, desires, thoughts, and physical symptoms, all of which contribute to the formation of social isolation (37).
In addition, the use of fusion techniques will reduce social isolation due to better acceptance (of laws, reasons, judgments, past, future, and self) and mind-awareness (being in the present, without self-judgment). Furthermore, ACT particularly emphasize on reducing cognitive integration (37). When cognitive fusion is reduced, it means that the content of one's thoughts is broken. Cognitive fusion training teaches people to see only thoughts and emotions (21). None of the internal events are inherently harmful to human health when experienced, and their harmfulness comes from trying to eliminate or control experiences (21).
The results show that ACT significantly reduced feelings of loneliness in women with breast cancer, which is in agreement with results of studies conducted by Abosaidi Moghadam et al. (38) and Samadi and Doustkam (39). In this regard, it can be argued that the acceptance component in the ACT allows an individual to accept his/her unpleasant inner experiences, which ultimately reduces their impact on the individual’s life. Interventions involving ACT seem to be effective in reducing avoidance patterns (22, 38, 39). In addition, ACT teaches clients the values of their lives, in contrast to their previous avoidance-based behaviors. In this therapeutic approach, the person accepts mental experiences and perceptions without any reactions to eliminate these beliefs, so that his/her psychological awareness is increased to correct wrong thinking patterns. As the individual decides and commits, he/she will plan, end avoidance, and reduce social isolation. Therefore, ACT should respond to internal events in an open, non-defensive, and flexible manner because it replaces the desire with avoidance.
The short duration of the follow-up period was one of the limitations of the present study. The use of a non-random sampling method and small sample size are other limitations of the study, which make it difficult to generalize the results.
CONCLUSION
It seems that ACT is effective in increasing psychological hardiness and reducing social isolation and loneliness of women with breast cancer.
ACKNOWLEDGEMENTS
Our gratitude goes to the participants who provided their consent and took part in this study. Also, we would like to thank the analyst, the oncologist, and other nursing colleagues who assisted in the fieldwork.
DECLARATIONS
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethics approvals and consent to participate
The study was approved by the Ethical Committee of Islamic Azad university of Medical Sciences (code: IR.KHORASGANUMS.REC.1399.087). Written consent was taken from all participants.
Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Article Type: Research |
Subject:
psychology
References
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