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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 205-211

Effectiveness of group-based acceptance and commitment therapy on the difficulty emotional regulation and distress tolerance patients with essential hypertension


1 Department of Psychology, Isfahan(Khorasgan) Branch, Islamic Azad University, Iran
2 Lecturer School of Psychology and Counseling, Faculty of Health, Engineering and Sciences, University of Southern Queensland, Australia
3 Associate Professor of Cardiology, Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication29-Nov-2017

Correspondence Address:
Ms. Mahboobeh Boostani
Department of Psychology, Isfahan(Khorasgan) Branch, Islamic Azad University, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-2296.204118

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  Abstract 


AIM: The aim of this study is to evaluate the effectiveness of acceptance and commitment therapy (ACT) on two factors difficult emotion regulation and distress tolerance in women with essential hypertension.
METHODS: Research was semi-experimental while the statistic society of this research was women with hypertension in Isfahan. Forty patients were selected and randomly placed into control and experimental groups. Questionnaires used were difficulty in emotion regulation, distress tolerance scale. The intervention group received 8 sessions of 2 h acceptance and commitment group-based therapy.
RESULTS: Multivariate analysis of covariance indicated that the intervention group after receiving the intervention, showed a significant decrease in terms of emotion regulation difficulties compared to the control group (P ≤ 0.04). Furthermore, regarding distress tolerance scores improved significantly in the intervention group (P ≤ 0.00).
CONCLUSION: The results indicated that ACT is an effective method to improve difficult emotion regulation and distress tolerance in patients with essential hypertension.

Keywords: Acceptance and commitment therapy, difficult emotion regulation, distress tolerance, hypertension


How to cite this article:
Boostani M, Ezadikhah Z, Sadeghi M. Effectiveness of group-based acceptance and commitment therapy on the difficulty emotional regulation and distress tolerance patients with essential hypertension. Int J Educ Psychol Res 2017;3:205-11

How to cite this URL:
Boostani M, Ezadikhah Z, Sadeghi M. Effectiveness of group-based acceptance and commitment therapy on the difficulty emotional regulation and distress tolerance patients with essential hypertension. Int J Educ Psychol Res [serial online] 2017 [cited 2024 Mar 29];3:205-11. Available from: https://www.ijeprjournal.org/text.asp?2017/3/3/205/204118




  Introduction Top


High blood pressure hits the first and the fourth rankings in deaths and disabilities, respectively, in the world.[1] It is also considered as a primary factor for cardiovascular diseases throughout the world.[2] Primary hypertension (essential) as chronic increase of systolic blood pressure is higher or equal to 140 mmHg while diastolic blood pressure is higher or equal to 90 mmHg.[3] This is a common, asymptomatic disease which has no detectable organic cause and is usually a combination of physiological and psychological factors.[4] The World Health Report in 2012 shows that one in three adults has high blood pressure, half of deaths caused as a result of heart and stroke attacks.[5] Since high blood pressure remains a global challenge, and about one billion people suffering from it and also four million people die as a direct result of high blood pressure a year, the World Health Organization declared the slogan of “hypertension” for 2013. Similarly, the Iran's Ministry of Health announced that one in five Iranians above 30 years of age is suffering from blood pressure.

Today, researchers' attempts are to examine emotional components of behavior such as anxiety, anger, and depression, especially in the field of physical reactions, cardiovascular diseases, and blood pressure.[6] From the viewpoint of psychosomatic approach, personality traits and individual's emotional status play an essential role in etiology of hypertension. It is essential to say that even social-economic conditions and stress indirectly effective in adolescence hypertension through the increase of negative emotions and risky behaviors. Furthermore, emotions through affecting different body's systems, especially cardiovascular or autonomic nervous system trigger hypertension disease process.[7] Harrison (2008) recommends changes in life pattern and promoting health in people with prehypertension as adjunct to pharmacotherapy in patients with hypertension. Therefore, by considering the impact of psychological factors such as individual's personality type on symptoms of blood pressure and its control, the results of studies around the world have emphasized on assessing psychological and social factors to optimize the treatment of hypertension.[8]

Emotion regulation is a process through which individuals adjust their emotions consciously or unconsciously and based on different studies emotion regulation improves physical health and difficulty in emotion regulation leads to physical and psychosomatic diseases.[9] Researchers also found that people not having the power to express and discharge their negative emotions and using avoidance and submission mechanisms in life-threatening situations are more prone to high blood pressure.[10] Similarly, researchers have found that emotional avoidance as a negative strategy in emotion regulation leads to cardiovascular diseases and cognitive reassessment of emotions as a positive strategy in emotion regulation leads to lower blood pressure.[11] In recent years, distress tolerance is considered as a major component of emotion regulation and studies have shown a significant relationship between distress low distress tolerances and difficulty emotional regulation.[12],[13] Distress tolerance is defined as the ability to tolerate psychological and unpleasant emotions.[14] Furthermore, low distress tolerance is appeared as high emotional vulnerability and inability to regulate emotions. Recent studies in psychopathology have shown that the impact of stress on physical and mental disorders is associated with individual differences of people in distress tolerance.[15] In addition, treatment strategies for reform and change should reduce avoidance and develop emotional management skills.[16] Researchers have come to the conclusion that distress tolerance and experiential avoidance are coping strategies and people with low distress tolerance, increased anxiety, and avoidance show experiences in encountering with different events.[17] According to these findings, acceptance and commitment therapy (ACT) treatment might be an appropriate goal for increasing distress tolerance of patients with high blood pressure. ACT approach was created in 1986 by Hayes and Strosahl. The main purpose of ACT is to increase mental flexibility or the ability to flex with living conditions.[18] In this treatment, a therapist attempts to change reference behaviors in life by drawing one's attention to move toward value rather than moving for relief and getting rid of a situation or unpleasant emotions.[19] Specific processes used during the treatment are diffusion, acceptance, self as context, self as background, values, and committed action.[20] In view of ACT, human widespread suffering is caused by limiting effects of word in two traumatic processes of cognitive fusion and experiential avoidance. These processes lead to cognitive inflexibility that is introduced as inability and weakness of behavior regulation to achieve the objectives and inadequate response to inner experiences.[21] On the other hand, Eifert and Forsyth investigated ACT approach on how to tackle and manage negative emotions and showed that ACT teaches people the choice and commitment to personal values to behave based on reality not emotional and behavioral motives of fleeting emotions.[22] To date, in other treatments such as CBT in improving emotion regulation, scientists have dealt with cognitive change and reduction in emotion level, but in ACT, references are encouraged to directly experience unpleasant emotions in a way that language does not increase negative consequences of these emotions. In this case, unpleasant emotions rather than being obstacles are life services and in consequence of this emotional acceptance and tendency to discomfort and not avoiding them, emotions reach a balanced and consistent level that is considered as the ultimate goal.[23] Since hypertension as a result of high prevalence and dangerous side effects imposing high costs to the health system and regarding that the majority of psychological therapies have paid less attention to reduce psychological problems of patients with hypertension, the aim of the ACT is to improve emotional performance of patients with initial hypertension by increasing psychological flexibility and to increase their distress tolerance by decreasing emotional problems.


  Methods Top


This research was a semi-experimental design with pretest–posttest and control group. The study sample consisted of women with primary hypertension who referred to health centers in Isfahan city and cardiovascular center of Sedigh-e-Tahereh. They were diagnosed based on primary hypertension criteria by cardiologists and their inability to manage negative emotions evaluated by clinical interview (based on the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and a psychiatrist. All participants took part in sampling voluntarily and ensured that their personal information will be kept confidential. Acceptance criteria were female gender, age range of 30–60 years, high school education and higher, initial blood pressure, stress, and tension in life. Rejection criteria were having a record of kidney disease and secondary hypertension, using other psychological treatments during this period, severe psychiatric disorders such as schizophrenia or severe depression and an absence of more than two sessions. The total sample size was sixty patients with primary hypertension selected by convenience sampling. After satisfying and regarding criteria for the screened rejection and acceptance, forty people were randomly assigned to an experimental group based on ACT (n = 20) and a control group (n = 20). Both groups answered the demographic questionnaire, difficulty of emotion regulation, and distress tolerance in introductory meeting (pretest). Furthermore, therapy sessions, based on acceptance and commitment by a trained researcher, were held for experimental group in 8 sessions of 2 h weekly and at the end of each session, a pamphlet related to the contents of class and next session homework was given to the patients. After administrating pretest, control group waited for a treatment after the end of the intervention period. However, they were not under any treatment during 2 months. After the eighth session, both groups responded to the mentioned questionnaire (posttest).

For collecting data, a questionnaire was considered as an appropriate method. Questionnaires were demographic information, difficulties emotional regulation scale (DERS), and distress tolerance scale. Demographic information questionnaire was conducted by the researcher and included age, gender, education level, income per month, and duration of disease.

DERS was developed by Gratz and Romer. In this scale, emotion regulation as an issue includes (1) awareness and understanding of emotions, (2) acceptance of emotions, (3) the ability to control impulsive behaviors and behave in accordance with desired objectives to achieve individual goals and situational demands.[24] This questionnaire is a self-report indicator which is conducted to assess difficulties in emotion regulation as a more comprehensive form than existing tools in this area. It contains 36 words and 6 subscales including (1) rejection of emotional responses, (2) difficulties in handling purposeful behavior, (3) impulse control problems, (4) lack of emotional awareness, (5) limited access to emotion regulation strategies, (6) and lack of emotional clarity. The results of the reliability study reveal that this scale has high internal consistency (total score α = 0.93, P < 0.01). Furthermore, in relation to validity, studies indicate construct validity and sufficient predictor for this scale. The consistency reliability of Persian translated form of the scale was obtained over a pilot study on 48 students of Ferdowsi and Medical Science University of Mashhad (31 females and 17 males). The results of this study showed high internal consistency of the total scale (α = 0.86, mean = 91. 31, standard deviation [SD] =17.78) in an Iranian population.[25] In this study, Cronbach's alpha of difficulty emotion regulation (α = 0.88) was obtained by the researcher.

The distress tolerance questionnaire was developed by Simons and Gaher in 2005. Distress tolerance is defined as capacity of experience and endurance of negative psychological states. Distress tolerance taking into account meta-emotional construct that includes evaluation and expectation of a person from experiencing negative emotional states in (1) tolerability and aversiveness, (2) evaluation and capability, (3) tendency to attract attention and performance rupture, (4) emotion regulation specially the force of action tendencies to avoid or weak immediate experience. The questionnaire has 15 questions, four of which measure distress tolerance, attraction by negative emotions, evaluation or assessment of mental estimation of distress, and regulation of efforts to alleviate distress. The alpha coefficients for these scales and the total scale were 0.72, 0.78, 0.82, 0.7, and 0.82, respectively. It has been indicated that this scale has criterion validity and sufficient primary convergence.[14] In a pilot study on 48 students of Medical Sciences and Ferdowsi Universities of Mashhad (31 females and 17 males), high consistency reliability for the total scale (Cronbach's alpha) was calculated.[25] The result of this study showed high internal consistency reliability for the total scale (α = 0.71, mean = 42.47, SD = 8.59) and average reliability for subscales (0.54). For tolerance subscale (SD = 2.73, mean = 7.38), attraction subscale (SD = 2.64, mean = 9.02), and (0.56) for evaluation subscale (SD = 4.24, mean = 18.12) and (0.58) for subscale (SD = 2.96, mean = 7.5), the extent of calculated alpha was α = 0.82.

Therapy session headlines based on acceptance and commitment in eight meetings are shown in [Table 1].
Table 1: Therapy session headlines based on acceptance and commitment in eight meetings

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  Results Top


Data were analyzed using SPSS version 20 (IBM Company) and multivariate analysis of covariance (MANCOVA). [Table 2] shows the mean and SD of difficulty emotion regulation. The results of [Table 2] also show that the average score of difficulty emotion regulation of pretest experimental group is equal to 91 which has decreased to 73.7 in the posttest step. The results also suggest that there is a significant difference in the average of difficulty emotion regulation of experimental group in pre-and post-test steps. To evaluate the significant of this difference, ANOVA was employed. Shapiro–Wilk and Levene tests showed that the score and variance of difficulty emotion regulation of groups are normal and equal, respectively. According to the approval of two groups' default in difficulty emotion regulation of patients with high blood pressure, MANCOVA was applied.
Table 2: Mean and standard deviation of difficulty emotion regulation variable in terms of group

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As seen in [Table 3], if we control the variables of age and level of education, there will be a significant difference between adjusted mean scores of difficulty emotion regulation of participants in terms of group membership (P ≤ 0.03) (experiment and control). Therefore, the difference of two difficulty emotion regulation averages of patients with high blood pressure is significant. As shown in [Table 3], 11.1% of the mean difference of pre- and post-test of emotion regulation in experiment group is associated with ACT.
Table 3: A summary of ANOVA for comparing difficulty emotion regulation of patients with hypertension

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Mean and SD of distress tolerance in terms of the group are shown in [Table 4]. The results show that the mean of distress tolerance of the group has increased in comparison to posttest one. The results also show that there is a difference between distress tolerance mean of experiment group in pre- and post-test steps.
Table 4: Mean and standard deviation of distress tolerance in terms of group

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To study the significance of this difference, multivariate analysis of variance was used. [Table 5] shows the results of MANCOVA. The difference of two means of distress tolerance in patients with high blood pressure is significant. As shown in [Table 5], 19.4% of the mean difference of pre- and post-test of distress tolerance in the experimental group is associated with ACT.
Table 5: A summary of multivariate analysis of covariance. A comparison of distress tolerance in patients with high blood pressure

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  Discussion and Conclusion Top


This study discussed ACT on difficulty emotion regulation and distress tolerance of female patients with primary hypertension. The results show that ACT is effective on the improvement of emotion regulation and distress tolerance of patients with hypertension. Since difficulty emotion, regulation and distress tolerance test scores are decreased and increased, respectively, this confirms the effectiveness of ACT therapy. Available studies showed that there is almost no study about the effectiveness of the third wave of the treatment on emotional problems of patients with high blood pressure. Therefore, the innovation of this study is the use of a treatment based on acceptance in reducing emotional problems and improving distress tolerance of these patients. This study is in conformity with the studies conducted by Padashian and Ghafari and Jane et al., who found that ACT is effective on the improvement of emotional control and emotional regulation of patients.[26],[27] On the other hand, McCraty et al. showed that learning to manage stress reduces negative emotions and improves emotional performance of patients with blood pressure.[28]

To explain these findings, it can be assumed that emotion regulation in ACT is improved by raising awareness of emotions when they are evoked. Furthermore, in this treatment, metaphors and mindfulness techniques identify emotions and flexibility in reaction to them and thereby emotion acceptance and the increase of emotions is getting positive. Mindfulness techniques in ACT treatment lead to clearly describe emotions and physical sensations as it happens.[29] Due to interpersonal sensitivity, patients with blood pressure usually consider their situations stressful; therefore, they spend time, energy, and high price to get rid of negative internal experiences (experiential avoidance) and thus show maladaptive responses against their emotions.[11] Therefore, mindfulness training makes it possible to see their emotions and physical symptoms and the acceptance of emotions reduces excessive sensitivity to their problems. In fact, mindfulness techniques act like relaxation techniques and meditations in ACT. The practice of breathing with diaphragm and moment to moment awareness of the senses, to see you as an observer in life situations modulate the autonomic nervous system, and it is a sort of calmness to stressful stimuli.[30] Studies have shown that people with high blood pressure have top perfectionism and external locus of control in contrast to healthy people. Due to extreme effort to achieve objectives and rejection of any perfection, these patients might have lower distress tolerance and flexibility than normal people.[31],[32] On the other hand, Blackledge and Hayes showed that psychological flexibility process is equal to emotion regulation skill because emotion regulation among people means appropriate responses to unpleasant emotions to change or get rid of them.[23] Furthermore, Hayes et al. argue that the acceptance-based approaches using cognitive diffusion and self as context can help patients not to give up their thoughts and subjective rules, and instead they find ways to interact more effectively with the world they experience directly (without any evaluation).[33]

On the other hand, in explaining the result of this effect on the treatment of patients with blood pressure, Masedo and Steve studies showed that the ACT treatment is effective on pain tolerance and its resulting distress.[34] Accordingly, this study is in conformity with the study carried out by Mo'tamedi et al., who believed ACT treatment could decrease psychological distress (a kind of increase in distress tolerance) in patients with tension headache.[35] In fact, the decrease in psychological distress is due to the loss of emotional avoidance creating after emotion regulation. Therefore, it could be inferred that ACT treatment is also effective on distress tolerance improvement of patients with blood pressure having high emotional avoidance because these patients turn to avoidance behavior to control existing stressors and respond to stressful situations by escaping or overreaction.[11] In general, Bohlmeijer et al. and Blackledge and Hayes, in conjunction with effects of this treatment on normal communities with no mental problem, found that ACT treatment showed a significant reduction in the symptoms of depression and everyday stress when acceptance of negative emotions is increased. This could be considered as a treatment to prevent medical chronic disorders in the future. It also verifies the effectiveness of this treatment on patients with hypertension.[36],[37]

From the ACT perspective, language, culture, and mind teach human to evaluate internal events such as anxiety badly and supports any attempt to avoid this feeling.[38] In fact, ACT considers stress and worries as causes of rejection, avoidance, and constant struggle with them. Patients with blood pressure like other people in society have learnt to avoid distress, concern, and whatever hurts them. However, control and fight against internal events increase their intensity and frequency. Therefore, through reception of thoughts and unpleasant emotions, ACT targets concern directly, that is, it helps people to experience emotions of daily life events and utilizes separation of thoughts techniques and ideas as background. Furthermore, patients are taught to accept their emotions and try not to avoid immediate negative emotions. In other words, although an individual is unable to change his/her life conditions, he/she could look at problems in a different way and instead of extreme responding to them, he/she can act in whatever serves values.[39] Moreover, this treatment, using mindfulness technique, teaches patients to pay attention to their internal experiences (thoughts, memories, etc.) and observe them without judgment or evaluation. In fact, when attention is drawn from internal world to the surrounding environment, through this, tolerance threshold rises and patient's response to stressful stimuli gets more balanced.[20] Finally, by learning this style of confrontation, people find that inner experiences are less threatening, and they can reduce devastating impacts of emotions on themselves.[18] Therefore, through using behavioral assignments and metaphors, this treatment moderates the impacts of physiological and emotional sensitivity of patients with high blood pressure on maladaptive responses to events due to the relationship of the individual with these experiences. The study was conducted on women patients with hypertension in Isfahan City. Therefore, the result of this study is merely generalizable to women. The main constraints of this study are time and unavailability of patients. Similarly, it is suggested that future research compares traits and personality characteristics of patients with general population (such as the existence of obvious personality traits that could explain the lack of consultation or irregular referral to a specialist and lack of regular use of medication and appropriate diet).

Financial support and sponsorship

This article has been derived from a thesis research project in Azad University, Oloom Tahghighat, Isfahan.

Conflicts of interest

There is no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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