The effectiveness of acceptance and commitment group therapy on social anxiety in female dormitory residents in Isfahan university of medical sciences
Zahra Toghiani1, Farzane Ghasemi2, Rahele Samouei3
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Information Technology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||03-May-2018|
|Date of Acceptance||05-Aug-2018|
|Date of Web Publication||15-Feb-2019|
Ms. Rahele Samouei
Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
AIM AND BACKGROUND: Social anxiety can interfere with performance and academic success in students. One of the third-generation treatments for social anxiety is acceptance and commitment therapy. Therefore, the current study aims to determine the effectiveness of acceptance and commitment group therapy on social anxiety of female dormitory residents of Isfahan University of Medical Sciences.
METHODS: This was a semiempirical study with pre- and posttest conducted on 71 female students living in the dormitory of Isfahan University of Medical Sciences. The study was carried out in five training sessions using the Liebowitz Social Anxiety Scale and second version of acceptance and commitment scale whose validity and reliability were confirmed. Data were analyzed using Student's t-test.
RESULTS: The findings showed that acceptance and commitment group therapy has affected the social anxiety in female dormitory residents of Isfahan University of Medical Sciences (P < 0.0001).
CONCLUTIONS: The findings of this study can be used by student deputies of universities, consultation centers, as well as counselors and psychologists to improve the conditions for students.
Keywords: Acceptance, commitment, group therapy, Isfahan University of Medical Sciences, social anxiety
|How to cite this article:|
Toghiani Z, Ghasemi F, Samouei R. The effectiveness of acceptance and commitment group therapy on social anxiety in female dormitory residents in Isfahan university of medical sciences. J Edu Health Promot 2019;8:41
|How to cite this URL:|
Toghiani Z, Ghasemi F, Samouei R. The effectiveness of acceptance and commitment group therapy on social anxiety in female dormitory residents in Isfahan university of medical sciences. J Edu Health Promot [serial online] 2019 [cited 2019 Jul 23];8:41. Available from: http://www.jehp.net/text.asp?2019/8/1/41/252321
| Introduction|| |
Social anxiety is a common behavioral disorder, for which several medicinal and psychotherapy treatment methods have been proposed over the years. The third-generation treatments are those based on the acceptance models. Acceptance and commitment therapy (ACT) is a type of behavioral therapy which uses mindfulness, acceptance, and cognitive defusion to increase psychological flexibility. In the ACT, psychological flexibility includes increased ability of people for connecting in their current experiences and acting based on their selected values.
The main and basic processes of psychological flexibility in ACT include acceptance, defusion, self as context, connection to present, values, and action commitment. These processes are related to each other and together affect the strengthening of psychological flexibility.
Various studies have been conducted regarding the effectiveness of different treatment methods, some of which are mentioned. One study showed that self-value training is a good predictor for reducing social anxiety symptoms. The results of other studies showed that cognitive behavioral therapy can result and improve the social anxiety.,,,,,,, Other findings showed that a mixture of group cognitive-behavioral therapy and teaching of social skills can significantly improve the symptoms of social anxiety. Another study reported that ACT is effective in improving social anxiety disorder in students. Studies conducted in Iran have shown that training self-expression can lead to a reduction of social anxiety. Furthermore, training of courage has led to an improvement of social skills, self-expression, and reduced social anxiety in high school students. Another study showed that exposure therapy can lead to a general decrease in anxiety in patients with social anxiety disorder. Another study showed that teaching communication skills can lead to reduced social anxiety and its components (social avoidance and stress and fear of negative evaluation) in students during an intervention.
A study reported that metacognitive therapy has significantly reduced the symptoms in social anxiety disorder patients in the intervention group., In another study, evaluation of therapeutic proxies and effectiveness of ACT in reducing the symptoms of widespread anxiety disorder showed the effectiveness of these treatments. The results also showed that acceptance and value-based living act as therapeutic proxies. The results of another study showed that exposure therapy is effective in reducing fear of negative evaluation in social anxiety disorder. In another study, the results showed that eclectic therapy can be an effective intervention method for reducing social anxiety and improving self-expression. Another study showed that teaching of anger management and self-discipline skills can reduce social anxiety in male high-school students. The findings of another study showed that group training in courage can reduce the symptoms of social anxiety as well as shyness. The results of another study indicated that group training of social skills can reduce the symptoms of social anxiety. Furthermore, the results of another study showed the effectiveness of group hybrid therapies (exposure therapy and stress control) in treating of social anxiety disorder. In this regard, the sheer number of studies with related factors and different statistical population indicate the importance of this topic. Furthermore, to achieve academic development, students require social interactions and are therefore one of the groups vulnerable to this disorder which can significantly reduce their performance. In this regard, some studies have reported that the prevalence of psychological disorders is higher in female students compared to male students, and in dormitory residents compared to other students. Negative consequences of social anxiety in students can lead to reduced academic success, performance interference, and feelings of self-blame and dissatisfaction. This will in turn reduce their ability in using their knowledge and abilities, and losing these opportunities can lead to avoidance and mental health problems. Therefore, given the special needs of female students for mental health and given the important effects of social anxiety disorder on future performance of female students which can affect their work, family life, and the next generation, this study aimed to investigate the effectiveness of acceptance and commitment group therapy on female dormitory residents of Isfahan University of Medical Sciences.
| Methods|| |
Since it was impossible to randomly select dormitory students, the study was carried out using semiempirical approach with two groups and pre- and posttest on female dormitory residents of Isfahan University of Medical Sciences in 2015. Sampling was carried out using convenient sampling. A notice was posted and students who desired to participate in social anxiety group therapy were asked to register with dormitory's consultation office. After explaining the study's aims and gaining necessary consent, pretest (social anxiety test) was carried out. Based on the scores of social anxiety test (a total of 55 scores), students were randomly divided into experiment and control groups. This resulted in 31 students in experiment group and 40 in control group. Data gathering was carried out using questionnaires including the Liebowitz Social Anxiety Scale (1987), which included 24 items and two subscales for performance anxiety (13 items) and social anxiety (11 items). The reported Cronbach's alpha coefficient was equal to 95 for the entire scale, while it was equal to 82 for performance anxiety subscale and 91 for social anxiety subscale.
The Acceptance and Action Questionnaire version II (AAQ-II) is used to evaluate psychological flexibility and is proposed by Heise and Bond. The items in AAQ-II are scored based on the 7-option Likert scale. The average score of university students in this scale was 50.72, while the average scale for people with drug abuse was 39.80. Internal consistency and smoothing factor of the questionnaire is 71%–89%.
After the pretest, experiment group students underwent five group therapy sessions, with each session lasting for 2 h and taught by a clinical psychologist. These sessions consisted of discussions, group work, role playing, personal assignments, group assignments, and homework. Control group students were only offered a set of informative scientific nonpsychological brochures to that they could ethically gain something from their participation in the study. Posttest was performed 2 months after the last group therapy session.
The content of therapy sessions included definition of social anxiety, symptoms and signs, pharmacological and nonpharmacological treatments, measuring a person's desire for change, help in understanding control over personal events, thoughts, and memories, determination of ineffective control strategies and understanding their futility, acceptance of painful personal events without resistance and not trying to control them through examples, feedbacks and assignments, avoiding painful experiences and understanding the consequences of this avoidance, discovery of avoided situations and connecting with them through acceptance, teaching acceptance steps and explaining enthusiasm and barrier concepts, explaining the concept of evaluation and description through examples, changing language concepts through analogies, teaching of relaxation, accepting feedback and giving assignments, explanation of role and context concepts, seeing self as a substrate and connecting with self, awareness of different sensual inputs and separation of those that are part of mental content based on their thoughts, emotions and contents, explanation of concept of values and difference between values, goals and needs, determination of basic values, creating the motivation for change and development of references for a better life, concentration on breathing, eating, commitment training, identification of behavioral patterns following values and commitment for using these behaviors, review of assignments, and a summary of sessions. After gathering the necessary data, the results were entered into SPSS 18 software and analyzed using Student's t-test.
| Results|| |
The majority of participants were 21 years old (21.7%), single (90.1%), studying in bachelor's degree (48.6%), part of regional quota (61.8%), and from other cities (81.8%).
According to the results presented in [Table 1], the changes in social anxiety score of experiment group during treatment period are significantly higher than that in control group (P < 0.0001). Therefore, ACT is effective in total score of social anxiety and can reduce this score. Furthermore, the score for components of performance anxiety (P < 0.0001), social anxiety (P < 0.0001), performance avoidance (P < 0.0001), and social avoidance (P < 0.0001) also showed a significant decrease in experiment group.
|Table 1: Comparing the effectiveness of acceptance and commitment group therapy on average total social anxiety score of experiment and control groups|
Click here to view
| Discussion|| |
The results showed that ACT can significantly reduce total social anxiety and its components including performance anxiety, social anxiety, performance avoidance, and social avoidance.
These results are similar to the results of other studies. a study showed that a hybrid of group exposure therapy and teaching of stress avoidance skills can significantly affect the levels of social anxiety in students. Another study confirmed the effects of acceptance and commitment-based therapy on anxiety and depression. The results showed that using this method can lead to significant reduction of social fears in children and adolescents. Another study showed that exposure therapy with emphasis on reducing fear of negative evaluation can improve social anxiety disorder. Moreover, another study showed that acceptance of changes and value-based living can act as proxies for treatment of social fear.
Social anxiety is among disorders which can have negative effects on lives and performance of students. Even when people understand the illogical nature of their fears which can lead to shame, predicting the confrontation with these situations creates an immediate anxiety response. This means that people will avoid these situations, which results in disturbances in their performance and social relations. These people with social anxiety need to lead that instead of cognitively and actively avoiding thoughts and situations leading to social anxiety, increased psychological flexibility regarding their internal experiences, they can accept their thoughts and emotions in social situations. Then, people can choose what is possible for them at the current moment and act in a way that fit their values. These characteristics are created during ACT and help people remove their need for avoidance through increased mindfulness, being in the present and better acceptance and commitment.
Furthermore, having access to better tools and improved social skills can help people better show their abilities and merits in the society, facilitates better self-introduction, and leads to better interactions and social capital. Trust in these skills can help people develop the factors of mental health in their psyche. Moreover, access to factors of mental health leads to more constructive social interactions, as well as better chances for development and success among people. This is especially important in students who need constructive and purposeful social interactions before graduation.
The limitation of this study was the inability for random selection of participants among dormitory students and the lack of possibility for follow-up on the results, 6 months after the study due to sample drop. One of the strengths of this study is that its subject matter which was selected with the help of advising psychologist is one of the most common problems among female dormitory resident students according to the university's consultation center. The findings of this study helped participants understand the advantages of group therapy for overcoming their social anxiety.
| Conclusion|| |
The nature of student life means that they are faced with situations and assignments in which they require social relations and interactions. In the current study, students with symptoms of social anxiety disorder managed to overcome their social anxiety using acceptance and commitment group therapy. The results of this study can be used by student deputies and consultation centers of universities as well as counselors and psychologist and other related disciplines to use in private and group consultation sessions as well as training workshops. Furthermore, these results help universities to achieve a better evaluation of students' academic capabilities by overcoming their social anxiety. Offering quality services in majority of medical disciplines requires social and interpersonal skills for students to make full use of their skills and knowledge. Therefore, medical service recipients and students are the main beneficiaries of this study.
Given the demonstrated role of acceptance and commitment group therapy in improving the performance and symptoms of different groups of people with social anxiety, especially in students, we recommend that an acceptance and commitment workshop be offered to all new university students in their first semester along with their normal lessons.
We hereby wish to thank all the students participating in this study. This study is the result of a research proposal approved by Isfahan University of Medical Sciences with ethics code of 1395.2.131.
Financial support and sponsorship
It is approved by Isfahan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tavangar L, YazdKhasti F. Effectiveness of eclectic intervention (cognitive restructuring, cognitive coping skills and role playing approaches) on self-assertiveness and social anxiety among Isfahan university students. J Med Sci Zanjan Univ2013;21:76-85.
Omran P. The effectiveness of acceptance and commitment group therapy in social phobia of students. Orig Artic Knowledge Health 2011;6:1-5.
Izadi R, Abedi M. Treatment Based on Admission and Commitment. Isfahan: Jangal Publishing; 2014.
Gaudiano B, Herbert JD. Preliminary psychometric evolution of a new self – Efficacy scale and its relationship to treatment outcome in social anxiety disorder. Cogn Ther Res 2003;27:567-70.
Melyani M, Shairi MR, Ghaedi G, Bakhtirari M, Tavali A. The effectiveness of cognitive-behavioral group therapy based on Heimbergs model on the decrease of social anxiety symptoms. Iran J Psychiatry Clin Psychol 2009;15:42-9.
Rahmanian Z, Mirzaeen B, Hassanzadeh R. the effect of cognitive-behavioral therapy Rohi on social anxiety of student girls. J Shahed Univ 2011;8:2-11.
Dadashzadeh H, Yazdandoost R, Gharraee B. Asgharnejad A, Comparison of the effectiveness of group cognitive-behavioral therapy and exposure therapy in social anxiety disorder. Q J Psychol Tabriz Univ 2009;4:102-130.
Dadashzadeh H, Yazdandoost R, Gharraee B, Asgharnejad A. Effectiveness of cognitive – Behavioral group therapy and exposure therapy on interpretation bias and fear of negative evaluation in social anxiety disorder. Iran J Psychiatry Clin Psychol 2012;18:40-51.
Atri Fred MR, Rasoulzadeh Tabatabai K, Janbozorgi K, Azad Fallah P, Banopour A. Examination of efficacy of cognitive behavioral therapy based on Hofmann's model for decreasing symptoms of social anxiety disorder. Quarterly Journal of Counseling and Psychotherapy 2012;3:23-51.
SHareh H, Roeinfard M, Haghhi E. The effectiveness of Heimberg and Becker cognitive behavioral group therapy in improving female adolescents social anxiety and cognitive flexibility. Journal of Sabzevar University of Medical Sciences 2014;21:226-40.
Hasanvandamouzadeh M, Aghili M. The effectiveness of cognitive-behavioral self-esteem group training on social anxiety and mental health in social anxious adolescent. Knowledge Res Appl Psychol 2013;14:26-37
Zargar E, Saknajad C, Akhlaghi jami L, Zamastani M. Comparison of the effect of social group skills training and cognitive-behavioral group therapy on reducing social anxiety in students. Urmia Med J 2014;25:172-81.
Herbert JD, Rheingold AA, Goldetein SG. Brief cognitive behavioral group therapy for social anxity disorder. Cogn Behav Pract 2005;9:1-8.
Naesi A, SHahni Yeylagh M. The effect of assertiveness training on self-esteem, self-esteem, social anxiety and mental health of socially distressed students. J Educ Sci Psychol Shahid Chamran Univ Ahvaz 2001;8:11-30.
Rahimi G, Hagheghi G, Mehrabizadeh Honarmand M, beaghleda K. The effect of dare training on social skills, social anxiety and assertiveness in high school boys. J Educ Sci Psychol Shahid Chamran Univ Ahvaz 2006;3:111-24.
Kewand F, Shafiabadi A, Sudanese M. The Effectiveness of communication skills on social anxiety in high school students in district 4 of Ahwaz education. J Appl Psychol Free Univ Khorasgan Branch (Isfahan) 2009: 42:1-24.
Bahadori M, Jahanbakhsh M, Jamshidi A. The effect of metacognitive therapy on anxiety symptoms in patients with social phobia disorders. J Sci Res Appl Psychol 2011;12:12-9.
Soltani S, Mickeyli Manea F. The comparison of the effectiveness of metacognitive therapy and problem-based treatment on reducing social anxiety in Urmia university girl students. Q J Adv Psychol Res 2012;7:89-110.
Mogdehi MR, Atamadi A, Falsafey Najad MR. Assessment of treatment mediums and the efficacy of treatment and acceptance therapy in reducing the symptoms of generalized anxiety disorder. Q J Couns Psychother 2011;2:1-30.
Hassanwand Amouzadeh M, Hassanavand Amouzadeh A, Hassanwand Amouzadeh M, Ghadam Pour M. The effectiveness of anger management skills on social anxiety and self-regulatory anger skills in high school social anxiety boys. J Appl Psychol Knowledge Res 2013;14:74-84.
Asdenia S, Sefarian Azar F, Saadatmand S, Feyzipour A, Zarei F, Hashemi B, et al
. The effectiveness of grassroots group training on reducing the symptoms of social anxiety disorder and improving shyness. Med J Urmia Univ Med Sci 2014;24:673-81.
Salajegheh S, Bakhshani NM. Effectiveness of combined group exposure therapy and coping with stress skills training on social anxiety rate of university students. Knowledge Res Appl Psychol 2014;15:96-104.
Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of acceptance and action psychometric properties of Persian version of acceptance and action questionnaire – II. Journal of Psychological Methods and Models 2012;2:65-80. [In Persian].
Omran MP. The effectiveness of acceptance and commitment group therapy in social phobia of students. Knowledge Health J 2011;6:1-5.
Annunziata AJ, Green JD, Marx BP. Acceptance and commitment therapy for depression and anxiety. In: Friedman H, editor. Encyclopedia of Mental Health. Philadelphia: Springer; 2016.
Ghayur Kazemmi F, Sepehri Shamlou Z, Mashhadi A, Ghanaei A, Pasalar F. Compare the effectiveness of meta-cognitive therapy and neuro feedback to help reduce symptoms of anxiety in students girl with social anxiety disorder. J Cogn Psychol 2015;4:19-30.
Annunziata AJ, Green JD, Marx BP. Acceptance and commitment therapy for depression and anxiety. In: Friedman H, editor. Encyclopedia of Mental Health. Philadelphia: Springer; 2016.
Ghayur Kazemmi F, Sepehri Shamlou Z, Mashhadi A, Ghanaei A, Pasalar F. Compare the effectiveness of meta-cognitive therapy and neurofeedback to help reduce symptoms of anxiety in students Girl with social anxiety disorder. Journal of Cognitive Psychology. 2015; 4 (1-2):19-30.