Comparing the effectiveness of acceptance and commitment therapy and schema therapy on tolerance of uncertainty of divorced women referring to welfare

Subject Areas : Islamic-Iranian Family Studies Journal

sajjad  almardani ¹ (PhD student in psychology, Tabriz branch,Islamic Azad University,Tabriz,Iran.)
Masoumeh  Azemoudeh ² (Assistant Professor, Department of Psychology, Tabriz Branch,Islamic Azad University, Tabriz, Iran)
reza  Abdi ³ (Associate Professor, Department of Psychology, Shahid Madani University of Azerbaijan, Iran)
Seyed davoud  Hoseini Nasab ⁴ (. Professor, Department of Psychology, Tabriz branch, Islamic Azad University, Tabriz, Iran)

Received: 2023-08-22 Accepted : 2023-09-22 Published : 2023-08-23

Keywords: acceptance and commitment therapy, Divorced women welfare, Schema Therapy, tolerance of uncertainty,

Abstract :

 Introduction: Divorce is one of the stressful experiences of the family that can lead to conflict and incompatibility between couples. The purpose of this research was to Comparing the effectiveness of acceptance and commitment therapy and schema therapy on tolerance of uncertainty of divorced women referring to welfare. Methods: The method of this research was semi-experimental with a pre-test-post-test design and a control group. The statistical population consists of all the women who referred to the welfare of Tabriz city in the second half of 1402-1401, of which 60 people were randomly assigned to two experimental groups and one control group (20 people in each group) by random sampling. The pre-test and post-test were conducted after the treatment interventions based on acceptance and commitment and schema therapy. McLean's tolerance of uncertainty questionnaire (1993) was used to collect data and multivariate analysis of covariance test was used to analyze the hypotheses. Results: The results showed that both interventions were effective on the tolerance of uncertainty variable (p<0.05). According to the results of the present study, there was a difference between the effectiveness of acceptance and commitment therapy and schema therapy in the dependent variable, and the effectiveness of acceptance and commitment therapy was more than schema therapy. Conclusion: The results of the present study show that the treatment based on acceptance and commitment plays a role in increasing the tolerance of uncertainty and improving the condition of divorced women.Extended AbstractIntroductionDivorced women are among the most vulnerable groups in society, who face mental, psychological, social, economic and cultural difficulties and disabilities. Divorce is the most common manifestation of severe conflict, and more than half of the couples who seek counseling end up getting divorced. According to official statistics in Iran, out of every 1000 marriages, about 200 cases lead to divorce. According to the statistics of the Civil Registration Organization of the country in 2019, the growth rate of divorce in Iran was about 3.6% compared to 2018. Therefore, divorce is the most important threat to the foundation of the family, and it is very important to pay attention to issues related to divorce and women who suffer from it. It is clear that divorce is one of the factors that cause disruption and confusion in people's lives. The decision to divorce is the result of intense internal pressure (such as ambiguity tolerance) on at least one spouse, which may occur through unmet needs. Divorce occurs when couples fail to meet the attachment needs of security, safety, and satisfaction of each other, that is, the ambiguity and confusion of marital relations represents the failure of couples to establish a relationship with a secure attachment style. In this regard, one of the variables that is important in divorced people is tolerance of ambiguity. Ambiguity tolerance is defined as how people process, interpret and react to information from stimuli that are considered ambiguous. A person who has a high tolerance for ambiguity does not feel threatened or difficult in adapting to a new and fresh environment, because he has accepted the existence of a degree of ambiguity as one of the principlesof life and knows that our information is never complete for decision-making, and with patience and Boredom can recognize the ambiguous situation and find a solution, and divorced women probably feel more ambiguity and have less tolerance for ambiguity due to psychological disturbances. Also, most divorced women feel uncertainty and uncertainty about their future life and feel weak in the face of problems. This research uses treatment based on commitment and acceptance and schema therapy. Considering the importance of the ambiguity tolerance component in divorced women and considering that the psychological damage caused by divorce in women occurs chronically; This raises the need for psychological interventions. According to the above researches, the present study wants to answer the question that among the methods of treatment based on acceptance and commitment (ACT) and schema therapy, which one is more effective in tolerating the ambiguity of divorced women who refer to welfare?MethodologyThe method of this research was semi-experimental with a pre-test-post-test design and a control group. The statistical population consists of all the women who referred to the welfare of Tabriz city in the second half of 1402-1401, of which 60 people were randomly assigned to two experimental groups and one control group (20 people in each group) by random sampling. (Matched by gender, age range and educational and economic conditions). The pre-test and post-test were conducted after the treatment interventions based on acceptance and commitment and schema therapy. McLean's tolerance of uncertainty questionnaire (1993) was used to collect data and multivariate analysis of covariance test was used to analyze the hypotheses.ResultsThe number of 20 people in the intervention group of acceptance and commitment therapy and 20 people in the intervention group of schema therapy and 20 control people with mean (standard deviation) age of 28.87 (2.71) and 29.24 (2.93) respectively. and 31/63 (3/32) participated in this research. The default check of homogeneity of variances is established to tolerance of uncertainty (F=0.420, P=0.659). The Mbox test value was equal to 2.71, the corresponding significance level was equal to 0.51, and the assumption of homogeneity of variance-covariance matrices was established (p<0.001). Table 1: Mean and standard deviation of tolerance of uncertainty by group and timeTable 1 showed that the average tolerance of uncertainty in the acceptance and commitment group was 22.85 in the pre-test, which increased to 47.50 in the post-test. In the schema therapy group, the average score in the pre-test was 28.95, which increased to 42.90 in the post-test. In the control group, the average in the pre-test was 24.25, which increased to 26.55 in the post-test.Table 2: The results of the analysis of covariance in order to compare the effectiveness of the two interventions of acceptance and commitment and schema therapy on the scale of tolerance of uncertaintyThe results of Table 2 showed that there was a significant difference in the effectiveness of the two intervention methods of acceptance and commitment and schema therapy on tolerance of uncertainty (p<0.05). The significance level of the analysis of covariance test showed the difference in the effectiveness of the two intervention methods on tolerance of uncertainty.Table 3: Comparison of the adjusted means of the tolerance of uncertainty scale in the groups with the LSD testThe results showed that the adjusted average of tolerance of uncertainty in the acceptance and commitment group was 48.24 and in the schema therapy group it was 42.15, and the average of the acceptance and commitment group was 6.09 points higher than the schema therapy group and this difference was statistically significant and showed that the effectiveness of the acceptance and commitment intervention on tolerance of uncertainty was greater than the schema therapy intervention (p<0.05). DiscussionExamining the findings of the research showed that there is a difference between the effectiveness of acceptance and commitment therapy and schema therapy on the tolerance of uncertainty of divorced women referring to welfare, and the effectiveness of acceptance and commitment therapy was more than schema therapy. The findings of the present study are consistent with previous studies (Aghili, kashiri, 2022).ConclusionThe results of the present study show that the treatment based on acceptance and commitment plays a role in increasing the tolerance of uncertainty and improving the condition of divorced women and can have implications for social support for these people.Finally, non-implementation of follow-up due to time constraints, small number of samples and targeted sampling method were among the limitations of the present study. It is suggested that in order to increase the generalizability of the findings, similar researches should be conducted considering long-term follow-up periods, with a larger number of samples and using possible sampling. According to the findings, it is suggested that therapeutic intervention based on acceptance and commitment be used as a beneficial intervention to improve and increase tolerance of uncertainty of divorced women in welfare and treatment centers. AcknowledgmentsWe hereby express our thanks and appreciation to the honorable directorate of Tabriz welfare admission, and all those who helped us in this research. FundingThe present research is taken from the doctoral thesis of the second author "Sajjad Alamardani Someeh" and without financial support.Ethics Approval and Consent to Participate"This article is extracted from the specialized doctoral thesis of the first author in Tabriz Branch, Islamic Azad University, Tabriz, Iran" and has the code of ethics IR.IAU.TABRIZ.REC.1401.307 from the Ethics Committee of Tabriz Islamic Azad University Medical Sciences Branch. Conflict of interestsThe authors declare that there is no conflict of interest in this article. RefferencesAbu-Ras, R.,  & Itzhaki-Braun, Y. (2023). The complex role of the community in the determination of well-being and hope among divorced Muslim women.  Journal of Community Psychology, 32(5), 21-32. https://doi.org/10.1002/jcop.23037Abbasi, M. and Omidvar, p. (2021). Statistical Yearbook of June 1401. Tehran: Publications of the Civil Registration Organization of the country. https://www.sabteahval.ir/homeAghili M, kashiri S. (2022). The Effectiveness of Acceptance and Commitment-Based Therapy on Uncertainty Intolerance, Turmoil Tolerance, and Sexual Function in Betrayed Women. Shefaye Khatam; 10 (3) :57-67. URL: http://shefayekhatam.ir/article-1-2279-en.htmlAllen, S., Hawkins,  A. J., Harris, S. M., Roberts, K., Hubbard, A., & Doman, M. (2022). Day-to-day changes and longer-term adjustments to divorce ideation: Marital commitment uncertainty processes over time, Family Relations, 71(2), 611-629.https://doi.org/10.1111/fare.12599Arntz A, Jacob GA, Lee CW. (2022). Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial. JAMA Psychiatry;79(4):287–299. doi:10.1001/jamapsychiatry.2022.0010Babaei, A., Maktabi, G., Behrouzi, N., & Atashafrouz, A. (2018). The impact of successful intelligence on academic achievement motivation and teacher efficacy in student teachers of Farhangyan Univercity. 2. Psychological Methods and Models, 8(30), 159-176.  https://jpmm.marvdasht.iau.ir/article_2723.htmlBratton, S., Ray, de., Rhine, Ta., & Jones, Le. (2015). The Efficacy of Play Therapy with Children: A Meta-Analytic Review of Treatment Outcomes. Professional Psychology: Research and Practice. 36(4): 376-390.  https://doi:10.1037/0735-7028.36.4.376Chen, I., Niu, Sh., Yeh, Y., Chen, I., &  Kuo, Sh. (2022). Psychological distress among immigrant women who divorced: Resilience as a mediator, Archives of Psychiatric Nursing, 39(2), 1-6. DOI:10.1016/j.apnu.2021.11.006De Klerk, N., Abma, T., Bamelis, L., & Arntz, A. (2017). Schema Therapy for Personality Disorders: A Qualitative Study of Patients’ and Therapists’ Perspectives. Behavioural and Cognitive Psychotherapy, 45(1), 31-45. doi: https://doi.org/10.1017/S1352465816000357Dosti, P., Gudari, G., Ebrahimi, M. (2017). Guide to group therapy based on acceptance and commitment therapy (ACT), Tehran: Amin Negar Publications. https://www.gisoom.com/book/11480943Dugas, M. J., Sexton, K. A., Hebert, E.A., Bouchard, S., Gouin, J., & Shafran, R. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder, Behavior Therapy, 53(6), 47-60. https://doi.org/10.1016/j.beth.2022.05.003Eilenberg, T., Hoffmann, D., Jensen, J.S., Frostholm, L. (2017). Intervening variables in group-based acceptance & commitment therapy for severe health anxiety, Behaviour Research and Therapy, 92, 24–31. https://doi.org/10.1016/j.brat.2017.01.009Eastwood, B. J., doering, L., Roper, J. (2008). Uncertainty and Health-Related Quality of life 1 years after Coronary Angiography. American journal of critical care, 17, 3. https://pubmed.ncbi.nlm.nih.gov/18450680/Farrell, Y., Shaw, I. (2016). Group schema therapy. Translated by Leila Porthamer. Tehran: Arjmand Publications.Foster, B, A., Zhou, Ch., Canty, E., Ralston, Sh., & ; Rooholamini, S. N. (2023). Association of Tolerance of Uncertainty With Outcomes in a Quality Improvement Collaborative, Hospital Pediatrics, 13 (1): 55–60. https://doi.org/10.1542/hpeds.2022-006674Forman, E. M., Herbert, J. D. (2008). New directions in cognitive behavior therapy: acceptance based therapies, cognitive behavior therapy: Applying empirically supported treatments in your practice,Hoboken, new jersy: wiley, 3(1): 263-265. https://www.academia.edu/13771758Flujas-Contreras, J.M., Gomez, I. (2018). Improving flexible parenting with Acceptance and Commitment Therapy: A case study. Journal of Contextual Behavioral Science, 8: 29-35. https://psycnet.apa.org/doi/10.1016/j.jcbs.2018.02.006Groot, I.Z., Venhuizen, AS.S.M., Bachrach, N. et al.  (2022). Design of an RCT on cost-effectiveness of group schema therapy versus individual schema therapy for patients with Cluster-C personality disorder: the QUEST-CLC study protocol. BMC Psychiatry 22, 637. https://doi.org/10.1186/s12888-022-04248-9Hakim, E . & Crouch , T. (2017). Adaptation of behavioral activation in the treatment ofchronic pain. American Psychological Association; 54, 3: 237–244. https://doi.org/10.1037/pst0000112Hayes, S C, Strosahl, K D. (2010).  A practical guide to acceptance and commitment ‎therapy, New York: Springer Press.Hojatkhah, S. M., & golmohammadian, M. (2018). Effectiveness of group therapy based on acceptance and commitment on Resilience mothers of children with mental retardation. Psychology of Exceptional Individuals, 8(29), 85-109. doi: 10.22054/jpe.2018.24311.1613Kennedy, A.E., Whiting, S.W., Dixon, M.R. (2014). Improving novel food choices in preschool children using acceptance and commitment therapy. Journal of Contextual Behavioral Science, 3(4): 228-235. https://psycnet.apa.org/doi/10.1016/j.jcbs.2014.10.002Mahoney, A.E., Hobbs, M.J., Newby, J.M., Williams, A.D., Sunderland, M., & Andrews, G.A., (2016). The Worry Behaviors Inventory: Assessing the Behavioral Avoidance Associated with Generalized Anxiety Disorder. Journal of Affect Disorder, 203: 256–264. https://doi.org/10.1016/j.jad.2016.06.020Mohammadi Nezhady, B., Rabiei, M. (2015). The effect of schema therapy on quality of life and psychological well-being in divorced women. Journal of Police Medicine; 4(3): 179-190. [Persian] http://jpmed.ir/article-1-389-en.htmlMcClure, J. B., Bricker, J., Mull, K., & Heffner, J. L. (2020). Comparative Effectiveness of GroupDelivered Acceptance and Commitment Therapy versus Cognitive Behavioral Therapy for Smoking Cessation: A Randomized Controlled Trial. Nicotine and Tobacco Research, 22 (3), 354-362. https://doi.org/10.1093/ntr/nty268McLain, D. L. (1993). The MSTAT-1: A New Measurement of an Individual’s Tolerance for Ambiguity. Educational and Psychological Measurement, 53, 183-189. http://dx.doi.org/10.1177/0013164493053001020McLain, D, L., Kefallonitis, E., & Armani, K. (2015). Ambiguity tolerance in organizations: Definitional clarification and perspectives on future research. Frontiers in Psychology, 6, 344. https://doi.org/10. 3389/fpsyg.2015.00344Osmont, A., & Cassotti, M. (2023). Development of ambiguity aversion from early adolescence to adulthood: New insights from the Ellsberg paradox. International Journal of Behavioral Development, 47(1), 47–58. https://doi.org/10.1177/01650254221104056Ost LG.(2014). The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis. Behav Res Ther; 61: 105-21. https://doi.org/10.1016/j.brat.2014.07.018Ong, C.W., Lee, E.B., Twohig, M.P. (2018). A meta-analysis of dropout rates in acceptance and commitment therapy. Behavior Research and Therapy, 104: 14-33. https://doi.org/10.1016/j.brat.2018.02.004Pleger, M., Treppner, K., Diefenbacher, A., Schade, C., Dambacher, C., Fydrich, T. (2018). Effectiveness of Acceptance and Commitment Therapy compared to CBT+: Preliminary results. The European Journal of Psychiatry, 32 (4): 166-173. https://doi.org/10.1016/j.ejpsy.2018.03.003Pilkington PD, Younan R, Karantzas GC. (2023). Identifying the research priorities for schema therapy: A Delphi consensus study. Clin Psychol Psychother;30(2):344-356. doi: 10.1002/cpp.2800. Epub 2022 Nov 22. PMID: 36369615.Perczel-Forintos, D. & Kresznerits, S. (2017). Social anxiety and self-esteem: Hungarian validation of the Brief Fear of Negative Evaluation Scale Straightforward Items . ORV Hetil; 843-850. DOI: 10.1556/650.2017.30755Radmehr, F., & Karami, J. (2019). The examination of the role tolerance of ambiguity and flourishing in predicting academic engagement in students. Educational Psychology, 15(52), 203-216. doi: 10.22054/jep.2019.32890.2275Renner, F., Arntz, Ar., Peeters, P. M. L., Lobbestael, Ji. Huibers, J. & Marcus. H. (2016). Schema therapy for chronic depression: Results of a multiple single case series. Journal of Behavior Therapy and Experimental Psychiatry. 51: 66-73. https://doi.org/10.1016/j.jbtep.2015.12.001Sabbah-Karkabi, M. (2022). Marriage was not an option: Ethnoreligious mixed marriage in Israel. Ethnic and Racial Studies, 45(1), 47– 68. https://doi.org/10.1080/01419870.2021.1905864Sloshower, J., Guss, J., Krause, R., Wallace, R. M., Williams, M. T., Reed, S., & Skinta, M. D. (2020). Psilocybin-assisted therapy of major depressive disorder using Acceptance and Commitment Therapy as a therapeutic frame. Journal of Contextual Behavioral Science, 15, 12-19. https://doi.org/10.1016/j.jcbs.2019.11.002Shadani, B., & Ghorban Shiroudi, S. (2019). Effectiveness of Cognitive Behavioral Therapy on Intolerance of Uncertainty and Dysfunctional Attitudes Among Divorce Applicant Women. Woman and Culture, 11(42), 21-32. https://jwc.ahvaz.iau.ir/article_670991.html?lang=enShokhmgar, Z. (2017). Effectiveness of Schema Therapy on reducing mental health problems due to crossover relationships in couples. Nasim Health, 5, 1 (17), 1-7. https://jfh.sari.iau.ir/article_654229.html?lang=faShorey, R.S., & Stuart, G.L, Anderson S. (2012). The early maladaptive schemas of an opioid-dependent sample of treatment seeking young adults: A descriptive investigation. Journal Substance Abuse Treatment; 42 (3): 271-8. https://doi.org/10.1016%2Fj.jsat.2011.08.004Tapia, G., Perez-Dandieu, B., Lenoir, H., Othily, E., Gray, M. & Delile, J. M. (2018). Treating addiction  ith schema therapy and EMDR in women with co-occurring SUD and PTSD: A pilot study. Journal of Substance Use; 23 (2), 199-205. https://doi:10.1080/14659891.2017.1378743Tahira, I., Sultan, T., Javeed, M., & Afzal, A. (2023). Social Adjustment of Divorced Women: A Study of District Gujrat, Punjab, Pakistan. Journal of Social Sciences Review, 3(2), 940–950. https://doi.org/10.54183/jssr.v3i2.330Tamborini, C. R., Couch, K. A. and Reznik, G. L. (2015). Long-term impact of divorce on women's earnings across multiple divorce windows: A life course perspective. Advances in Life Course Research, 26: 44-59. http://dx.doi.org/10.1016/j.alcr.2015.06.001Twohig, M. P., Abramowitz, J.S., Smith, B.M., Fabricant, L.E., Jacoby, R.J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behavior Research and Therapy, 108: 1-9. https://doi.org/10.1016/j.brat.2018.06.005Twohig, M. P., Vilardaga, J. C. P., Levin, M. E., Hayes, S. C. (2015). Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder. Journal of Contextual Behavioral Science, 4 (3): 196-202. https://psycnet.apa.org/doi/10.1016/j.jcbs.2015.07.001Twohig, M.P., Abramowitz, J.S., Bluett, E.J., Fabricant, L.E., Jacoby, R.J., Morrison, K. L., Reuman, L., Smith, B.M. (2015). Exposure therapy for Obsessive Compulsive Disorder from an acceptance and commitment therapy (ACT) framework. Journal of Obsessive-Compulsive and Related Disorders, 6: 167-173. https://doi.org/10.1016/j.brat.2018.06.005Viskovich, S., & Pakenham, K. I. (2020). Randomized controlled trial of a web‐based Acceptance and Commitment Therapy (ACT) program to promote mental health in university students. Journal of Clinical Psychology, 76 (6), 929-951. https://doi.org/10.1002/jclp.22848Young, J. E, Klosko, J. S &,. Weishaar, M. E. (2015). Translated by Hamidpoor, H & Andoz, Z. Schema Therapy: A Practical Guide, Tehran: Arjmand. [Persian] http://salmandj.uswr.ac.ir/article-1-1320-en.htmlYousefi Rad, A. and Zoghi, L. (2021). Improving the quality of life and psychological well-being of women on the verge of divorce with regard to communication skills and empathy: the mediating role of mindfulness. Police-social researches of women and family, 9, 2, 431-399. SID. https://sid.ir/paper/964176/faZemestani, M., Gholizadeh, Z., & Alaei, M. (2018). Effectiveness of Acceptance and Commitment Therapy on Depression and Anxiety of ADHD Childrens' Mothers. Psychology of Exceptional Individuals, 8(29), 61-84. doi: 10.22054/jpe.2018.25533.1638Zhaleh K, Ghonsooly B, Pishghadam R. (2018). Effects of conceptions of intelligence and ambiguity tolerance on teacher burnout: a case of Iranian EFL teachers. Research in Applied Linguistics. 9(2):118–40. https://dx.doi.org/10.22055/rals.2018.13796Zolfaghari M, Nikooei F, Shahbazi Seyed Ahmadiyani A, Kohanroozamiri S. (2021). The Effectiveness of Acceptance and Commitment-Based Therapy on Psychological Flexibility and Quality of Life of Divorced Women. MEJDS; 11 :208-208. URL: http://jdisabilstud.org/article-1-2737-en.html