Volume 23, Issue 2 (June & July 2020)                   J Arak Uni Med Sci 2020, 23(2): 138-149 | Back to browse issues page

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Esfahani A, Zeinali S, Kiani R. Effect of Acceptance and Commitment Therapy On Pain-Related Anxiety and Cognitive Emotion Regulation in Breast Cancer Patients: A Clinical Trail. J Arak Uni Med Sci 2020; 23 (2) :138-149
URL: http://jams.arakmu.ac.ir/article-1-6144-en.html
1- Hematology and Oncology Research Center, Medical Science Department, Faculty of Medical science, Tabriz University of Medical Science, Tabriz, Iran.
2- Department of Psychology, Faculty of Human Science, Urmia University, Urmia, Iran. , sh.zeinali@urmia.ac.ir
3- Department of Psychology, Tabriz Branch, Islamic Azad University, Tabriz Iran.
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Breast cancer accounts for 31% of all women’s cancers in the United States [1]. Feeling of pain is common in breast cancer [3]. Pain-related anxiety refers to the combination of cognitive, psychological, and behavioral reposnses to pain or pain-related events [4]. In patients with cancer, emotion regulation are impaired [6]. Emotional regulation refers to actions that are used to modify an emotional state [7]. In the context of chronic pain, Acceptance and Commitment Therapy (ACT) targets ineffective control and avoidance strategies by fostering techniques that lead to psychological resilience [11]. It helps people to accept pain (to experience pain or unpleasant events without trying to control them) or pain-related thoughts, promote meaningful aspects of life, and increase valuable activities [12]. In this method, the patient is taught that any action to avoid or control these unwanted mental experiences is ineffective or has adverse effects, and that the experiences must be fully accepted without any attempt to eliminate them [15, 16]. The aim of this study is to examine the effect of group therapy based on ACT method on pain-related anxiety and cognitive emotion regulation in patients with breast cancer.

Materials and Methods

 This is a quasi-experimental study with pretest/postest design. The study population consists of all patients with a diagnosis of breast cancer referred to Shahid Ghazi Hospital in Tabriz, Iran. of these, 68 eligible patients were selected using a convenience sampling method and randomly divided into two groups of intervention (n=34) and control (n=34). The intervention group received 8 weeks of ACT, while controls recived 8 weeks of routine training with no ACT content. Treatment sessions were conducted by an expert in psychology. Data collection tools were: (a) Pain Anxiety Symptom Scale-Short Form (PASS) developed by McCracken and Dhingra [22] which has 20 items and 4 subscales of cognitive, escape/avoidance, fear, and physiological anxiety symtomps; and (b) Cognitive Emotion Regulation Questionnaire (CERQ) developed by Garnefski et al. [23] which has 36 items measuring two negative and postive affects. Their validity and reliability have been already confirmed in different studies. 


Subjects in the experimental and control groups were homogenous in terms of age (t=-2, P=0.6) and marital status (x2=0.4, P=0.7). Analysis of the main and interaction effects of the factors using Wilks’ lambda statistic showed that the ACT intervention has made a significant difference in the cognitive emotion regulation model (F=47.5, P=0.001). The results of Levene’s test used for testing the equality of variances of pain-related anxiety and cognitive emotion regulation, was not significant (P>0.05). Table 1 presents the results of comparing the mean scores of pain-related anxiety and cognitive emotion regulation for the two study groups.

In order to investigate the differences between the mean scores of the two groups, after controling the effects of the pretest scores, one-way ANOVA was used for pain-related anxiety and MANCOVA was used for cognitive emotion regulation variables. Results presented in Table 2 showed that ACT reduced pain-related anxiety and cognitive regulation of negative affect, and increased cognitive regulation of positive affect.


ACT reduced pain-related anxiety and cognitive regulation of negative affect, and increased cognitive regulation of positive affect. This is consistent with the results of Fish et al. and Cho et al. [24, 25]. The use of some adaptive emotion regulation strategies, such as cognitive reappraisal, to cope with stress, can increase positive emotions by reducing negative emotions [26]. Due to the effect of ACT on different dimensions of pain, it is a suitable alternative to other treatment methods [27]. With its techniques, ACT aims to accept the present conditions and take active and committed actions. Techniques such as considering thoughts as an imaginary thing, not real [28], reducing experiential avoidance and increasing flexibility [25], correction and strengthening of self-compassion, reduction of misplaced judgments [29], increasing the acceptance of existing conditions and the commitment to action, observing life events and seeing oneself as part of it [30] are some techniques used in this method. In other words, it helps patient accept pain-related anxiety as part of his/her life by accepting pain and related thoughts [15].

The limitations of this study was the absence of some patients in some treatment sessions, difficulty in selecting subjects with the disease knowledge and finding a standard location. In future studies, the case study method should be used to investigate the trend of changes based on treatment techniques. The ACT is recommended for patients with mastectomy due to their tangible physical changes.


ACT allows patients to become familiar with their feelings and thoughts and to be able to observe and identify their negative emotions, and learn ways to reduce judgmental look to these thoughts.

Ethical Considerations

Compliance with ethical guidelines

The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish. This study ethically approved by the Medical Ethics Committee of Tabriz University of Medical Sciences (Code: 1397.287 IR.TBZMED.REC) and registered in Iranian Registry of Clinical Trials (IRCT2017100615590N5).


This research was conducted with the financial support of the Hematology and Oncology Research Center of Tabriz University of Medical Science.

Authors' contributions

All authors contributed in preparing this article.

Conflicts of interest

The authors declared no conflict of interest.


The authors would like to thank the esteemed colleagues and staff of Shahid Ghazi Hospital in Tabriz, as well as the management of the Aramesh Andisheh Counseling Center in Tabriz, who cooperated in the implementation of this project



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Type of Study: Original Atricle | Subject: psychology
Received: 2019/09/5 | Accepted: 2020/01/25

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