International Journal of Educational and Psychological Researches

: 2018  |  Volume : 4  |  Issue : 2  |  Page : 71--77

The effectiveness of group application of acceptance and commitment therapy on anxiety, depression, and stress among high school female students

Mahnaz Karimi, Asghar Aghaei 
 Department of Educational Science and Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran

Correspondence Address:
Ms. Mahnaz Karimi
Department of Educational Science and Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan


AIM: The aim of this study was to determine the effectiveness of the method is based on acceptance and commitment therapy (ACT) on anxiety, depression, and perceived stress among girls (18–15 years) in Isfahan. METHODS: Semi-experimental study with pre- and post-test and follow-up with the control group. Multi-stage random cluster sampling from three training and education of 30 students with the highest scores on three scales of anxiety, depression, and stress were selected and randomly assigned into two groups (n = 15) and control group (15 subjects). Training as a group in eight sessions (one session a week for 60 min) was performed on the experimental group. Moreover, all the participants before the start of training, after training and after 45 days as a follow-up period, Lavyb and Depression Anxiety Stress Scale 21 questionnaire (1995) was completed. To analyze the data, analysis of variance with repeated measures was used. RESULTS: The results showed that the subjects' perceived stress in the track slightly increased, but the increase was not statistically significant. Therefore, based on ACT group therapy in reducing depression, anxiety, and perceived stress and posttraining follow-up period had an impact. Moreover, perceived stress levels have increased significantly in the little track time, but was not statistically significant. CONCLUSION: Based on ACT group therapy on depression, anxiety and posttraining follow-up period have been reduced (P > 0.05). The results of this study, based on ACT group therapy to improve rates of depression, anxiety, and perceived stress among girl student (18–15 years) of treatment is recommended.

How to cite this article:
Karimi M, Aghaei A. The effectiveness of group application of acceptance and commitment therapy on anxiety, depression, and stress among high school female students.Int J Educ Psychol Res 2018;4:71-77

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Karimi M, Aghaei A. The effectiveness of group application of acceptance and commitment therapy on anxiety, depression, and stress among high school female students. Int J Educ Psychol Res [serial online] 2018 [cited 2019 Mar 24 ];4:71-77
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Stress and depression are among those disorders which have a notable increase in young adults.[1] American psychology Institute defines “The Diagnostic and Statistical Manual of Mental Disorders” (DSM-5) as an intense arousal of mental state which key traits are fear, dilemma and intense anxiety.[2] This state often causes some problems such as heart beat, shortness of breath, headache, upset stomach, and inquietude.[3] Anxiety is an unpleasant emotional state which is a result of pressure and mental tension, and its primary symptom is the fear of what is happening in future.

Depression is one of the mood disorders which according to DSM-5 standards, it is often followed by its symptoms such as sadness, hopelessness, feeling of guilt, thinking about death, lack of concentration, and lack of energy.[2] Another threatening factor for young adults is stress. Folkman believes that perceived stresses in difficult situations could affect the psychological welfare. Whatever that affects and disturbs the normal organism is called perceived stress.[4] What really matters here is not only the cause of stress but also what is more important in this case is the way the stress is perceived, and it can be either positive or negative. In positive perception, stress factors are perceived as something positive and under control while negative perception causes the negative pulses and ideas in our minds which may end in a feeling of helplessness against stress factors. In these situations, people show negative reactions such as fear and anxiety.[4] Severe and long lasting stresses such as changes in the way we live,[5] may affect the adaptation ability, cause depression, affect our health, and eradicate the joy of life.[6]

All specialists who are working in consultation centers, schools, and welfare centers are really concerned with finding the best methods for different disorders and also reaching new cognitive-behavioral treatments (CBTs). Almost everyone believes in one unique method, but sometimes, there are some obstacles that cause the progress cease. Such cases are not just restricted to Iran, but we can see them in all countries. Therefore, specialists are always trying to optimize and adopt new treatment methods, and as a result, treatments will vary in different situations.[7]

The 20th century could be considered to be the century of development and evolution of behavior therapy.[8] Recently, there have been lots of discussions about mindfulness interventions, especially about those who hardly respond to therapies. These therapies have caused the third wave of behavior therapy which among them we can name; dialectic behavior therapy, psychotherapy performance analysis, mindfulness based cognitive therapy and acceptance and commitment based therapy. These methods focus on accepting beliefs in facing their challenges, mindfulness, cognitive fault or describing feelings and thoughts without giving meaning to them and living in accordance with personal spiritual values. Furthermore, the main focus of these methods is on the acceptance of symptom and more flexible ways of facing the undesirable inside drive, instead of reducing the signs of symptoms.[9] The main emphasis of third wave therapies is on making a change in structure or operation using tissue hypothesis such as relation therapy.[2]

One of the methods proposed in third wave therapies is called “acceptance and commitment therapy (ACT)” which in fact is a type of behavior therapy. Its main subject is action, of course not all actions but those that are value based. This method uses processes such as acceptance, mindfulness and commitment behaviors to create some flexible psychological processes. It contains different techniques from different areas such as acceptance, fault, creating self-heightened sense, leaving in the present, mindfulness, values, and responsibility.[10]

This method helps the patient find out what is the most important thing for him and then taches him how to use it to guide his life and make the changes the way he wants. An action is mindful which is done by paying attention to previous experiences and even the experiences of others.[11] What this method proposes is: “accept what is out of your control and keep doing what makes your life fruitful.” The main goal of this method is to build a meaningful, complete, and fruitful life as well as the ability to cope with those problems which may exist in the life.[7]

Recently, psychological researches have paid a great deal of attention to subjects such as acceptance and commitment and its important roles in adaptability, stress, anxiety, and social mental welfare.[12] For instance, this method could be used in different cases such as: depression,[13] psychosis,[14] drug addiction and miss use,[15] job exhaustion,[16] and chronic pain.[17] Molavi et al. could prove that ACT could result in reduction of anxiety, stress, and social fear of students under examination in comparison to those who were in control groups. Mojtabae and Gholamhoseini found that ACT is so useful in reducing the stress of women who are infected with breast cancer. Act method can make a great deal of positive effects on adaptation and welfare through mixing liveliness and acceptance of different experiences.[18] Teaching ACT resulted in low score of anxiety and psychological distress [19] and increase of psychological flexibility.[20] Considering the fact that the main aim of this research is to determine the effectiveness of the method is based on ACT on anxiety, depression and perceived stress students girls (18–15 years) in Isfahan, and also considering the facts that this method is new and at the same time effective in reduction of psychological disorders, and also by having clues that this method has not been used before in Iran and specially the girls high schools of Isfahan, so the researcher believes that this research can lead in new ideas. Considering what mentioned above, the researcher tries to find out: will the ACT therapy be useful in a group method and will it affect and decrease anxiety, depression, and stress among female students of high school?

Aims of research

Determination of the impact of applying ACT with group method on anxiety signs of girlsDetermination of the impact of applying ACT with group method on depression signs of girlsDetermination of the impact of applying ACT with group method on perceived stress signs of girls.


This study is designed as a research based, semi-pilot containing pre- and post-examination and control group. The target group of this study contains all the 15–18-years-old female students of Isfahan public high schools. The first step is descriptive. A two-stage cluster sampling of six different education zones in Isfahan, we have chosen third area and in this area two high schools were chosen randomly. By choosing two classes from each school and applying the questionnaire of perceived depression, anxiety and stress among 80 students, 30 of them were dismissed because of distortion. Finally, 30 students out of 50 who achieved the highest scores in three scales of anxiety, depression, and stress were chosen equally from both schools and were distributed randomly in two groups of 15. One examination group and one control group. The questionnaire used in this survey is called Depression Anxiety Stress Scale (DASS 21). It contains 21 Likert-scaled questions, 7 of which are dedicated to perceived stress (questions number 1, 6, 8, 11, 12, 14, 18), 7 are related to anxiety (questions number 2, 4, 7, 9, 15, 19, 20) and 7 are related to depression (questions number 3, 5, 10, 13, 16, 17, 21). The subjects must rate the frequency of symptoms using a 4 degree scale (from 0 to 3). The stability of this method in Iran and in a general sample from Mashhad (400) shows 0.70 of depression, 0.66 of anxiety and 0.76 of stress. Too define the credibility of this survey, we have compared it with Beck's depression questionnaire with scale of 0.66 for depression, 0.67 for anxiety, and 0.46 for perceived stress which gives us reliable credibility. Lovibond and Lovibond have also referred to high correlation of this questionnaire compared to other questionnaires (Lovibond and Lovibond, 1995).[21]

The stability of this present survey has been tested according to Cronbach's alpha in a group of 30 people. Cronbach's alpha ratio for three sub scales of questionnaire is 0.56 for depression, 0.61 for anxiety, and 0.62 for stress.

Application and analysis

In this survey, the sample group (including 30 female students who scored the highest levels in three scales of anxiety, depression, and stress) were randomly divided into two groups (15 experimental and 15 control group). The experimental group has received a group application of ACT in eight 60 min sessions, each of sessions held in 1 week. The control group has received no treatment sessions. The DASS 21 questionnaire have been applied to both groups before and after the treatment sessions and also 45 days after the end of the course.

The content of this group application of ACT was based on Hayes method and all the sources and contents are credible.[7],[22] The application of method will be discussed here: the aim of the consultant in first session was to build up a friendly atmosphere with students and to reach an agreement on the rules with them. They were asked about their most important obsession in life and the consultant asked them to do nothing till the next session. In second and third sessions, the students got more familiarized with their own emotions. Then, they were asked to talk about the ways the face and control their excitement and creative distress. Finally “the hole metaphor” treatment and the situations which cause it were explained to them. The consultant tried to impose the idea that the main thing in this course is to understand and learn how to control the anxiety and stress and to understand that what is important is how to control, not a solution instead of control. Then in fourth session, regarding their performance in reducing anxiety, stress, and depression and reviewing what we talked about in previous session, the main rules and their application in family system were proposed. The consultant also talked about the story of “the beggar” to examine different reactions. Fifth and sixth sessions were dedicated to reviewing previous sessions and analysis of reactions derived from excitement. Some metaphors were used to show different aspects of life. Life values were demonstrated using “heart box” metaphor and those sad moments were shown using “poison box” metaphor. To show goals of life and how close can we get to them the students have played dart. The “show bus” example and its outcomes were used to emphasize more on mindfulness and live the moment ideas. In seventh session by using “chess” example the main focus was on students' behaviors and the way they could be prevented or controlled. In eighth session, the students have talked about their performance and their responsibility. At the very session, the group have concluded the previous sessions and decided on coming sessions.

Finally, all the results were compared with credible statistical tests and inferential statistics such as Kolmogorov–Smirnov test is to test the normal distribution of study and Levin test to check the variance equality in normal score situation. As far as the subjects were tested in three different time spaces, repetitive variance examination was done with special software. In this test, the researcher have studied not only the meaningfulness effect but also the effect of time on variances during the research.


Descriptive indexes such as the mean and standard deviation of variables before, after, and during the test are shown in [Table 1]. This table shows that there is no great difference between variables of examine group and control group on pretest.{Table 1}

It is crucial to test the data to see whether it is normal and in this research the data was tested with Kolmogorov–Smirnov test (P < 0.05). The assumption of all variances equality was approved via Levin test. As it is clear, the equality of group variances in the majority of tested components of control groups is applied as far as P > 0.05. It was also assumed that all variances were equal during three phases of test (pretest, posttest, and during the test). There was a component that was not supposed to have equal variances. This component is: pretest anxiety. The data resulted from inferential statistics are shown in [Table 2].{Table 2}

As it is clear, as far as P < 0.05, the change in amount of anxiety among the girls in this test shows a significant statistics as a result of group instruction and its mutual effect with time. From these results it could be inferred that group application of ACT upon anxiety of 15–18-years old girls may have positive effects.

As we can see in [Table 3], as far as P < 0.05, the change in amount of depression among the girls in this test shows a significant statistics as a result of group instruction and its mutual effect with time. From these results, it could be inferred that group application of ACT on anxiety of 15–18-year-old girls may have positive effects.{Table 3}

As [Table 4] demonstrates, as far as P < 0.05, the change in amount of perceived stress among the girls in this test shows a significant statistics as a result of group instruction and its mutual effect with time. From these results, it could be inferred that group application of ACT on anxiety of 15–18-year-old girls may have positive effects.{Table 4}


In this survey, we have examined the effectiveness of group application of ACT on female student of 15–18-year-old in Isfahan. The results of this survey shows that ACT can be helpful in reducing the amount of stress, anxiety, and depression among experiment group. Finding of this very research was in the same direction with those that have been done before.[12],[23],[24] Among these patients, the most important and fragile group are young adults. Izadi found out that acceptance and commitment interference during the experiment had special effects in reducing depression.[25] Other studies such as Folk, Parling and Melin and Hayse and Masuda have supported the fact that ACT application may be useful in stress reduction, public health, and the quality of society.[26],[27],[28],[29],[30],[31] Hayes et al. proved that ACT will reduce the thoughts of depression faster.[9] A survey about the effect of ACT upon stress and depression done by Forman et al proved that patients have shown a great deal of improvement in amount of depression and stress, performance problems, quality of life, life satisfaction, and overall clinical practice from themselves.[27] Gratz and Gunderson proposed that group interference could be helpful in reducing the signs of stress, anxiety, and depression.[28] Wiley have shown that ACT will effect self-confidence, affection, acceptance, awareness about the present and respecting the values in great deal.[32]

These surveys have proved that the most important role of psychological acceptance are in psychological performances. ACT will improve “self-centeredness.” It is done through building relations such as me/you, here/there, and now/then. This will improve the communication with present time. Patients are taught to foster the ideas in which all the experiences are accepted with positive regard, not with “good” or “bad” regard. Judging without examination and evaluation may cause in a regard in which inner thoughts and experiences have no place. Building such a self-confident and self-centered regard in patients assures them that they are not judged from their obsessive signs or inner experiences. They learn that all the mentioned experiences are needed just to be familiar with them and sometimes look back at them without having any fear.

Hayse believes that ACT method will not try to focus on omitting or removing traumatic factors. It will instead help the patients to accept their controlled excitements and recognitions and get rid of those verbal rules that are the main cause of their problems.[30] It will give them the ability to get rid of struggle and conflict. Therapeutic acceptance and commitment is based on a special procedure which may augment the acceptance of psychological experiences and commitment to more flexible activities. It will not contain the personal psychological experiences of the patient. This trait does not exist in CBT. Another aspect of ACT is the way it increases realistic thinking. It does not aim to encourage the emotions, its goal is to decrease the avoidance from these psychological experiences and increase the knowledge about them, specially the ability to focus on present without using a system with no struggle and no evaluation. In this method, the patient learns to keep himself far from pain and chaos state to lessen their influence on his behavior. The goal of treatment is to improve the performance through increasing the level of psychological flexibility. Through mixing liveliness and realistic view toward personal experiences and their acceptance, ACT can impose a positive change in emotional adjustment. ACT insists on the acceptance of internal events the way they are instead of confronting them. Applying ACT may result in decrease of anxiety, psychological depression, and psychological inflexibility.[31] ACT is basically a procedure-based method which insists on acceptance of psychological experiences and commitment with increase of meaningful, flexible, and adaptive exercises without considering the content of psychological experience. It uses different procedures such as acceptance, mental focus, commitment, and behavior changing processes to increase the flexibility. It causes that the patient want to experience some new thing based on his commitment to treatment. The patient promises to do all the exercises orderly. In this way and by knowing his own values and goals, the patient himself is responsible to create positive changes for himself when the consultant is not present.

In ACT, it is taught that each phenomenon doesn't have a special meaning by itself. What gives it meaning is the way we look at it and the way we assess it. In group application of ACT the instructors use fear hierarchy and the way we should face it, to have a better understanding of cognitive distortions challenges. The patient understands that there is a natural function in every person's mind. They learn the rules of the world they live in which help them to cope with their problems. Sometimes, there is no bad intention behind some actions, but it creates a situation in which the people become obsessive. For instance a mother who without any bad intention repeatedly tells her child to wash his hands. Our mind tries to collaborate with us and we must be thankful to it. The reason is that in this method, the mind have learnt to say “I don't want to fight with it and I don't want to create a new enemy for myself.” Exactly like a sympathetic mother, it does what it is supposed to do. It is told to our mind that “you can do and say whatever you want, I will appreciate it, but your rules are restricted to outside world and my inside world has its own rules which are defined by me.” The mind thinks that it must fight with its supposed monster which is exactly the compatibility obstacles in teenagers. All the patients are encouraged to be what they want to be and will learn how to set their goals in different parts of their life such as family, job, friendship, and personal growth. By using ACT, the patients are taught to act for themselves. They are asked to write a behavior commitment in valuable activities. Acting responsibly may be included in every behavioral method such as skills, comorbid management and communication purification.

There were some restriction for this survey that must be kept in mind. For instance the present survey focuses on anxiety, depression, and stress of female students who study in specific situations. As a result we should be careful in generalizing the results. We suggest that the same survey could be applied on both genders and in different situations and ages to reach a better credibility.


Considering the outcome of the present survey, the researcher suggests that using group application of ACT will be successful in reducing psychological problems of female student of 15–18-year-old.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Dadsetan P. Psychopathology from Childhood to Adulthood. Tehran: SAMT; 1997.
2Ganji M. Psychopathology Based on DSM-V. Vol. 1, 2. Tehran: Savalan Publication; 2013.
3Kaplan H, Saduk B, Saduk V. The Summary of Behavioral Psychiatry and Clinical Psychiatry. Translated by Farzin, Rezae F. Tabriz: Arjmand Pub; 2011.
4Bashar Pour S, Narimani M, Esa Zadegan E. The relation between coping styles and social support with conceived stress. Psychol Stud Mag 2013;2:30-47.
5Harkness KL, Luther J. Clinical risk factors for the generation of life events in major depression. J Abnorm Psychol 2001;110:564-72.
6Kiecolt-Glaser JK, Speicher CE, Holliday JE, Glaser R. Stress and the transformation of lymphocytes by Epstein-Barr virus. J Behav Med 1984;7:1-12.
7Izadi R, Abedi M. Acceptance and Commitment Therapy. Tehran: Jungle; 2013.
8Palmer A. Counseling and Psychotherapy Theories. Translated by Yousefi N, Rostami M, Houshangi B. Abadan: Parastesh; 2005.
9Hayes SC, Pistorllo J, Bibland A. Acceptance and commitment therapy. Model, data, and extension to the prevention of suicide. J Behav Cogn Ther 2008;1:81-102.
10Hayes SC, Strosahl KD. A Practical Guide to Acceptance and Commitment Therapy. New York: Springer Science and Business Media lnc.; 2010.
11Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy. The Process and Practice of Mindfull Change. New York: Guilford; 2012.
12Molavi P, Mikaeli N, Rahimi N, Sadi M. The effectiveness of ACT on reduction of depression and anxiety among students with social phobia. Ardebil Univ Behav Sci J 2014;40:114, 412-3.
13Adibi Parsa P, Naziri GH, Pour B. The Influence of Group Application of ACT on Curing Depression Among Elderly People. 2015: The First Psychology Conference. ICPC. Islamic Azad University of Shiraz; 1994.
14Bach P, Hayes SC. The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. J Consult Clin Psychol 2002;70:1129-39.
15Gifford EV, Kohlenberg BS, Hayes SC, Antonuccio DO, Piasecki MM, Rasmussen-Hall ML. Acceptance-based treatment for smoking cessation. Behav Ther 2004;35:689-705.
16Bond FW, Bunce D. The role of acceptance and job control in mental health, job satisfaction, and work performance. J Appl Psychol 2003;88:1057-67.
17Dahl J, Wilson KG, Nilsson A. Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behav Ther 2004;35:785-801.
18Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: Evidence of brief mental training. Conscious Cogn 2010;19:597-605.
19Ostafin BD. Acceptance and commitment training and the reduction of psychological distress: A preliminary study. Cogn Behav Pract 2006;13:191-7.
20Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized Arandomized effective of Acceptance and commitment therapy and cognitive therapy for anxiety depression. J Behav Modif 2007;31:772-99.
21Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation; 1995.
22Hayes SC. Climbing our hills: Abeginning conversation on the comparison of ACT and traditional CBT. Clin Psychol Sci Pract 2008;5:286-95.
23Pourfarajomran M. The Effectiveness of Group Application of Acceptance and Commitment on Social Phobia of College Students. Danesh va Tandorosti Periodical. Islamic Azad University of Behshahr; 2011.
24Ashja M. The Effectiveness of Acceptance and Commitment Therapy on Reducing Depression Among Housewives in Tehran (M.A. Dissertation). Islamic Azad University of Khomeini Shahr; 2011.
25Izadi R. Comparing the Influences of ACT and CBT on Symptoms of Obsessive Beliefs, Life Quality, Psychological Flexibility, Depression and Anxiety of Refractory Patients with Practical Obsessions (Doctoral Dissertation). Esfahan University; 2011.
26Follk F, Parling T, Melin L. Acceptance and commitment therapy for depression: Apreliminary Randomized Clinical Trial for Unemployed on long Term Sick Leave. Cogn Behav Pract 2012;19:583-94.
27Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized effective of acceptance and commitment therapy and cognitive therapy for anxiety depression. J Behav Modif 2007;31:772-99.
28Gratz KL, Gunderson JG. Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behav Ther 2006;37:25-35.
29Follk F, Parling T, Melin L. Acceptance and commitment therapy for depression: Apreliminary Randomized Clinical Trial for Unemployed on long Term Sick Leave. Cogn Behav Pract 2012;19:583-94.
30Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther 2004;35:639-65.
31Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes and outcomes. Behav Res Ther 2006;44:1-25.
32Wiley J. Effects of Acceptance and Commitment Therapy (ACT) Training on Clinical Psychology Trainee Stress, Therapist Skills and Attributes, and ACT Processes; 2014.