Introduction
Fibromyalgia syndrome is a chronic musculoskeletal disease [1]. Pain and automatic negative thoughts in these patients play an important role in their mental health and quality of life (QoL) [2]. Fibromyalgia syndrome is associated with high levels of psychological distress [5]. One of the third-wave therapies is cognitive-behavioral therapy based on mindfulness [8], in which the person is watching his thoughts in the present moment [9]. As an effective treatment, this treatment reduces pain and automatic negative thoughts, and psychological symptoms and thus increase the QoL[11]. Compassion therapy is also effective in controlling pain; Self-compassion involves being kind to oneself. Regarding the effectiveness of this treatment in improving the QoL, it helps people to enjoy greater flexibility and QoL [24, 25, 26]. According to the mentioned materials in relation to the subject of the present study, no study has been done so far, and an attempt has been made to compare these two interventions and fill the research gap. This study seeks to answer whether there is a difference between these similar treatment methods on the mentioned variables in patients with fibromyalgia.
Materials and Methods
This research is an interventional study (due to the lack of control of all variables) with a pretest-posttest design with two experimental groups and one control group. The statistical study population consisted of all individuals with fibromyalgia symptoms, of which 30 were randomly divided into three groups: experimental group 1, experimental group 2, and control. The inclusion criteria were as follows: diagnosis of fibromyalgia based on the American College of Rheumatology (ACR), female gender, the satisfaction of participating in research, and not receiving any psychological intervention in the last 6 months. The criteria for diagnosing fibromyalgia are generalized pain for three months and pain in the elbows, buttocks, chest, knees, back, neck, chest, shoulders, and thighs. The exclusion criteria were unwillingness to continue attending, having a psychiatric disorder, and reporting any musculoskeletal pain outside the fibromyalgia criteria. After forming the groups, cognitive-behavioral education based on mindfulness and compassion therapy were administered for the experimental groups. No education was presented for the control group. In the present study, the analysis of covariance and the Chi-square test were used for analysis using SPSS 26 software. The research instruments were WHO QoL questionnaires, the severity of pain, psychological symptoms, and automatic negative thoughts.
Results 
The effectiveness of the interventions was evaluated and compared using a univariate analysis of covariance. Homogeneity of demographic characteristics of gender, age, and education in groups was assessed and confirmed using the Chi-square test (P<0.05). Assumptions of analysis of covariance, including normality of data distribution, homogeneity of variance, and homogeneity of regression slopes with appropriate tests, including tilt and elongation statistics, Levene’s test, and interactive effects of pretest and group, were examined. The analysis of covariance showed that both therapeutic interventions, namely cognitive therapy based on mindfulness and compassion therapy, were effective on variables of the severity of pain, psychological symptoms, automatic negative thoughts, and QoL (P<0.05) (Table 1).


Effect size values ​​ranged from a minimum of 0.646 for the severity of pain to a maximum of 0.788 for psychological symptoms. Bonferroni post hoc test to compare the mean of the three groups showed that the two cognitive-therapy interventions based on mindfulness and compassion therapy had an almost equal effect on the three variables of the severity of pain, psychological symptoms, and automatic negative thoughts (P<0.05) (Table 2).


However, mindfulness-based cognitive therapy had a greater effect on the QoL variable than compassion therapy intervention (P<0.05).
Discussion
Therapeutic interventions were effective on these variables, and the effect has been equal. The results are consistent with the results of some studies [41, 42]. Mindfulness helps to identify situations that lead to discomfort and to learn coping strategies for coping [42].
Regarding the effect of compassion therapy on the severity of pain, these findings are consistent with some studies [43]. When patients have compassion for themselves, they accept that the individual deserves kindness.
Regarding therapeutic interventions on psychological symptoms, the findings are consistent with some studies [44, 45, 46, 47]. Mindfulness teaches how to prepare habitual skills out of the rigid state and direct information processing resources toward attention goals such as breathing or the momentary sense of the situation. These activities reduce psychological symptoms [45].
Regarding the effect of compassion therapy on the reduction of psychological symptoms, these findings are consistent with the results [48, 49, 50]. This treatment acts as a positive emotional regulation style and reduces negative emotions, and replaces positive emotions with stress [48].
Regarding the effectiveness of mindfulness-based cognitive therapy on spontaneous thoughts, the results are consistent with some studies [17, 21, 51, 52, 53]. In this treatment, cognitive reconstruction is performed.
Regarding the effect of compassion therapy on automatic thoughts, the findings are consistent with some studies [31, 52, 53]. By creating a fault, the components of self-efficacy cause the person to observe them without any judgment, instead of identifying themselves with negative thoughts [53]. The effect of mindfulness intervention was more than compassion therapy intervention. This finding is in line with the results of some studies [11, 12, 13, 29, 54, 55, 56]. The presence of the mind increases the QoL through self-regulation and care activities [12, 54, 55].
Regarding the effectiveness of compassion therapy on QoL, these findings are consistent with some studies [56, 57, 58, 59]. Self-compassion reduces pain and helps improve QoL by creating acceptance and kindness. It is suggested that this research be performed in other medical centers and on a larger sample.
Cognitive therapy based on mindfulness and compassion therapy has had almost the same and quite an effective effect on the variables.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Arak Branch, Islamic Azad University (Code: IR.IAU.ARAK.REC.1400.005). 

Funding
This article is taken from the doctoral dissertation of Naghme Shekohinjad in the field of general psychology in the psychology department of the Faculty of Psychology and Educational Sciences, Arak Branch, Islamic Azad University.

Authors' contributions
All authors contributed equally in preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.


References

1. Conversano C, Carmassi C, Bertelloni CA, Marchi L, Micheloni T, Carbone MG, et al. Potentially traumatic events, PTSD and post - traumatic stress spectrum in patients with fibromyalgia. Clin Exp Rheumatol. 2019; 116(1):39-43. [PMID]
2. Pardos-Gascón EM, Narambuena L, Leal-Costa C, van-der Hofstadt-Román CJ. Differential efficacy between cognitive-behavioral therapy and mindfulness-based therapies for chronic pain: Systematic review. Int J Clin Health Psychol. 2021; 21(1):100197. [DOI:10.1016/j.ijchp.2020.08.001] [PMID] [PMCID]
3. CF Kuok K, Li L, Xiang YT, Nogueira BO, Ungvari GS, Ng CH, et al. Quality of life and clinical correlates in older adults living in the community and in nursing homes in Macau. Psychol. 2017; 17(3):194-9. [DOI:10.1111/psyg.12214] [PMID]
4. Manshaee G, Haji Mohammad Kazemi S, Ghamarani A. [The effectiveness of therapy based on quality of Life promotion model on pain catastrophizing in female patients with fibromyalgia (Persian)]. J Anesthesiol Pain. 2019; 10(2):42-54. [Link]
5. Corrêa MS, Vedovelli K, Giacobbo BL, De Souza CE, Ferrari P, de Lima Argimon II, et al. Psychophysiological correlates of cognitive deficits in family caregivers of patients with Alzheimer disease. Neuroscience. 2015; 286:371-82. [DOI:10.1016/j.neuroscience.2014.11.052] [PMID]
6. Gillen CT, Barry CT, Bater L R. Anxiety symptoms and coping motives: Examining a potential path to substance use-related problems in adolescents with psychopathic traits. Subst Use Misuse. 2016; 51(14):1920-9. [DOI:10.1080/10826084.2016.1201510] [PMID]
7. Mc Crachen LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain. Am Psychol. 2014; 69(2):178-87. [DOI:10.1037/a0035623] [PMID]
8. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: A systematic review and metaanalysis. Pain. 2011; 152(3):533-42. [DOI:10.1016/j.pain.2010.11.002] [PMID]
9. Crane R. Mindfulness-based cognitive therapy distinctive features by Rebecca Crane. London: Routledge; 2008. [DOI:10.4324/9780203882344]
10. Parsons CE, Crane C, Parsons LJ, Fjorback LO, Kuyken W. Home practice in mindfulness-based cognitive therapy and mindfulness-based stress reduction: A systematic review and meta-analysis of participants’ mindfulness practice and its association with outcomes. Behav Res Ther. 2017; 95(8):29-41. [DOI:10.1016/j.brat.2017.05.004] [PMID] [PMCID]
11. Isa Nejad A, Azadbakht F. [Comparison of the effectiveness of two approaches of acceptance, commitment and cognitive therapy based on mindfulness on quality of life and resilience of spouses of veterans with post-traumatic stress disorder (PTSD) caused by war (Persian)]. J Mil Psychol. 2019; 1(38):69-57. [Link]
12. Mohammadpour M, Rafiunia P. Sabahi P, Najafi M. [Comparison of the effectiveness of mindfulness-based cognitive therapy (BMBCT) and acceptance and commitment-based therapy (ACT) on improving quality of life components in patients with focal epilepsy (Persian)]. Psychol Res. 2020; 15(57):1-18. [Link]
13. Nasiri Kalmarzi R, Moradi Q, Asmayed Majd S, Khanpour F. [The effectiveness of mindfulness-based cognitive therapy on quality of life and mindfulness of asthmatics (Persian)]. Shenakht J Psychol Psychiatry. 2018; 5(5):1-14. [DOI:10.29252/shenakht.5.5.1]
14. Sepanta M, Shirzad M, Bamdad S. The effectiveness of mindfulness-based cognitive therapy on catastrophizing and anxiety associated with pain in adolescents with leukemia. Int J Body Mind Cult. 2019; 6(1):1-9. [DOI:10.22122/ijbmc.v6i1.149]
15. Khoshkhatti N, Amirimajd M, Bazzazian S, Yazdinezhad A. [The effectiveness of mindfulness-based cognitive therapy on symptoms of anxiety, depression and stress in renal patients under hemodialysis (Persian)]. Iran J Nurs Res. 2020; 14 (6):9-17. [Link]
16. Tickell A, Ball S, Bernard P, Kuyken W, Marx R, Pack S, et al. The effectiveness of mindfulness-based cognitive therapy (MBCT) in real-world healthcare services. Mindfulness (N Y). 2021; 11(2):279-90. [DOI:10.1007/s12671-018-1087-9] [PMID] [PMCID]
17. Segal ZV, Dimidjian S, Beck A, Boggs JM, Vanderkruik R, Metcalf CA, et al. Outcomes of online mindfulness based cognitive therapy for patients with residual depressive symptoms: A randomized clinical trial. JAMA Psychiatry. 2020; 77(6):563-73. [DOI:10.1001/jamapsychiatry.2019.4693] [PMID] [PMCID]
18. Gu S, Li Y, Liang F, Feng R, Wang F. The mediating effects of coping style on the effects of breath count mindfulness training on depressive symptoms among international students in China. Neural Plast. 2020; 2020:8859251. [DOI:10.1155/2020/8859251] [PMID] [PMCID]
19. Brouwer ME, Williams AD, Forand NR, DeRubeis RJ, Bockting CLH. Dysfunctional attitudes or extreme response style as predictors of depressive relapse and recurrence after mobile cognitive therapy for recurrent depression. J Affect Disord. 2019; 243:48-54. [DOI:10.1016/j.jad.2018.09.002] [PMID]
20. Ebrahimi S, Fakhri M, Hasanzadeh R. [Effect of mindfulness-based cognitive therapy on hope, dysfunctional attitudes and meta-worry in infertile women (Persian)]. J Psychiatr Nurs. 2019; 7(4):32-40. [Link]
21. Nikkhah B, Haqqani R, Ali Tari Sh. [The effectiveness of mindfulness-based cognitive therapy on negative spontaneous thoughts and sleep problems in female students with depressive disorder (Persian)]. Empowering Except Child. 2019; 4(32):1-12. [DOI:10.22034/CECIRANJ.2020.209576.1306]
22. Neff KD. The role of self-compassion in development: A healthier way to relate to oneself. Hum Dev. 2009; 52(4):211-4. [DOI:10.1159/000215071] [PMID] [PMCID]
23. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009; 15(3):199-208. [DOI:10.1192/apt.bp.107.005264]
24. Neff KD, McGehee P. Self-compassion and psychological resilience among adolescents and young adults. Self- Identity. 2010; 9(3):225-40. [DOI:10.1080/15298860902979307]
25. Nasehi N, Moeini F, Rahnjat AM, Taheri N, Rustaei M, Nazemi M, et al. [Evaluation of the effectiveness of group compassion therapy on improving symptoms and quality of life in Bulimia Nervosa (Persian)]. J Paramed Sci Mili Heal. 2020; 15(1):35-42. [Link]
26. Rezaei A, Sharifi T, Ghazanfari A, Aflaki E, Bahredar M. [Effectiveness of treatment based on acceptance and commitment, compassion-based therapy and combination therapy on depression, anxiety quality of life in patients with lupus (Persian)]. Q J Health Psychol. 2020; 9(33):127-44. [Link]
27. Begian Kolemarzi MJ, Karami J, Mo’meni Kh, Elahi A. [Comparison of the effectiveness of cognitive-behavioral analysis psychotherapy system and integration of dialectical behavior therapy with compassionate mind-based cognitive therapy on reducing mental pain and emotional regulation difficulties of suicidal individuals (Persian)]. Clin Psychol Stud. 2019; 9(34):35-63. [DOI:10.22054/JCPS.2019.34758.1937]
28. Ezzat Panah F, Latifi Z. [The effectiveness of education based on acceptance, commitment and compassion on pain catastrophe, distress tolerance and post-traumatic growth in patients with fibromyalgia syndrome (Persian)]. J Health Psychol. 2019; 8(32):127-42. [DOI; 10.30473/HPJ.2020.43700.4227]
29. Ahmadi R, Sajjadian I, Jaffari F. [The effectiveness of compassion-focused therapy on anxiety, depression and suicidal thoughts in women with vitiligo (Persian)]. J Derm Cosmet. 2019; 10(1):18-29. [Link]
30. Mazi B, Ebrahimi A, Daghaqzadeh L, Aghaee H. The effectiveness of compassion-based therapy (fcft) on perceived stress in patients with irritable bowel syndrome: An experimental study. J Isfah Med Sci. 2020; 38(588):602-8. [DOI:10.22122/jims.v38i588.12305]
31. Gilbert P. Procter S. Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clin Psycol Psychotherapy. 2006; 13(6):323-79. [DOI:10.1002/cpp.507]
32. Andalib S, Abedi MR, Neshat Doost HT, Aghaee A. [Comparison of the effectiveness of experience-based therapy package with compassion-based therapy on happiness and mental well-being in depressed patients (Persian)]. J Clin Psychol. 2020; 12(1):99-110. [DOI:10.22075/jcp.2020.18071.1695]
33. Nejat S, Montazeri A, Holakouie Naieni K, Mohammad K, Majdzadeh S. [The world health organization quality of life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version (Persian)]. J Sch Public Health Inst Public. 2006; 4(4):1-12. [Link]
34. Vonkorff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain. 1992; 50(2):133-49. [DOI:10.1016/0304-3959(92)90154-4] [PMID]
35. Smith HS, Harris R, Clauw D. Fibromyalgia: An afferent processing disorder leading to a complex pain generalized syndrome. Pain Physician. 2011; 14(2):217-45. [DOI:10.36076/ppj.2011/14/E217] [PMID]
36. Shirazi Tehrani A, Mirdrikvand F, Sepahvandi M. [Develop a structural model for predicting chronic musculoskeletal pain through coping skills, catastrophizing, fear, severity and disability (Persian)]. J Anesthesiol Pain. 2017; 8(2):92-106. [Link]
37. Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther. 1995; 33(3):335-43. [DOI:10.1016/0005-7967(94)00075-U] [PMID]
38. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinton RP. Psychometric properties of the 42- item and 21-item version of the depression anxiety stress scale in clinical group and a community sample. Psychol Assess. 1998; 10(2):176-81. [Link]
39. Samani S, Jokar B. [Evaluation of the validity of the short scale of depression, anxiety and stress (Persian)]. J Soc Sci Humanit Shiraz Univ. 2007; 26(3):65-76. [Link]
40. Hollon SD, Kendall P. Development of an automatic thoughts questionnaire. Cognit Ther Res. 1980; 4(1):383-95. [DOI:10.1007/BF01178214]
41. Soleimani P, Kazami R, Taklavi S, Narimani M. [Effectiveness of group acceptance and commitment therapy on perceived stress and pain perception of women with fibromyalgia (Persian)]. J Anesthesiol Pain. 2020; 11(2):68-79. [Link]
42. Eaton E, Swearingen HR, Vakili AZ, Stephanie R J, ones SJ, Greenberg BD. A brief report on an 8-week course of mindfulness-based care for chronic pain in the treatment of veterans with back pain: Barriers encountered to treatment engagement and lessons learned. Med Care. 2020; 58(Suppl 2 9S):S94-100. [DOI:10.1097/MLR.0000000000001377] [PMID]
43. Luciano JV, Guallar JA, Aguado J, López-Del-Hoyo Y, Olivan B, Magallón R, et al. Effectiveness of group acceptance and commitment therapy for fibromyalgia: A 6-month randomized controlled trial. Pain. 2014; 155(4):693-702. [DOI:10.1016/j.pain.2013.12.029] [PMID]
44. Wardi-Zonna K, Wardi A. Maternal mental health and mindfulness. J Mother Initiat. 2020; 11(1):93-107. [Link]
45. MacKenzie M B, Abbott KA, Kocovski NL. Mindfulness-based cognitive therapy in patients with depression: Current perspectives. Neuropsychiatr Dis Treat. 2018; 14(1):1065-599. [DOI:10.2147/NDT.S160761] [PMID] [PMCID]
46. Abbasi S, Bagheripanah M, Amir Fakhraee A, Khoroshi M, Bidaghi F. [The effectiveness of mindfulness-based cognitive therapy on depression and emotional regulation in patients with multiple sclerosis (Persian)]. J Rehabil Res. 2019; 6(2):90-9. [Link]
47. Razavizadeh Tabadkan B B Z, Jajarmi M. [The effectiveness of mindfulness-based cognitive therapy (MBCT) on depression, rumination and perceived stress in women with type 2 diabetes (Persian)]. Iran J Psychiatry Clin Pscychol. 2019; 24(4):370-83. [Link]
48. Mak WWS, Wong CCY, Chan ATY, Lau JTF. Mobile self-compassion programme for promotion of public mental health: A randomised controlled trial. Hong Kong J Med. 2019; 25(2):15-7. [PMID]
49. Gonzalez-Hernandez E, Romero R, Campos D, Burichka D, Diego-Pedro R, Banos R, et al. Cognitively-based compassion training (CBCT) in breast cancer survivors: A randomized clinical trial study. Integr Cancer Ther. 2018; 17(3):684-96. [DOI:10.1177/1534735418772095] [PMID] [PMCID]
50. Todorov N, Sherman KA, Kilby Ch J. Self compassion and hope in the context of body image disturbance and distress in breast cancer survivors. Psychooncology. 2019; 28(10):2025-32. [DOI:10.1002/pon.5187] [PMID]
51. Saeedmanesh M, Parsaiety R. [Evaluation of the effectiveness of mindfulness-based therapy on cognitive distortions and self-control of addicted adolescents leaving Isfahan (Persian)]. J Disabil Stud. 2020; 10(65). [Link]
52. Sadeghi A, Ilnaz Sajjadian A, Nadi M. [Comparison of the effectiveness of mindfulness-based compassion and cognition-mindfulness-based therapy on dysfunctional attitudes, self-control and mental health (Persian)]. Q Posit Psychol Res. 2020; 6(1):31-48. [DOI:10.22108/ppls.2020.120851.1861]
53. Frostadottir A D, Dorjee D. Effects of mindfulness based cognitive therapy (MBCT) and compassion focused therapy (CFT) on symptom change, mindfulness, self-compassion and rumination in clients with depression, anxiety and stress. front psychol. 2019; 10(1):1099. [DOI:10.3389/fpsyg.2019.01099] [PMID] [PMCID]
54. kabat zinn J. Mindfulness-based intervention in context: Past, present, and future. Clinic Psychol: Sci Prac. 2003; 10:144-56. [DOI:10.1093/clipsy.bpg016]
55. Joshi SS, Sharma MP, Varambally S. Effectiveness of mindfulness-based cognitive therapy in patients with bipolar affective disorder: A case series. Int J yoga. 2018; 11(1):77-82. [DOI:10.4103/ijoy.IJOY_44_16] [PMID] [PMCID]
56. Bojic S, Becerra R. Mindfulness-based treatment for bipolar disorder: A systematic review of the literature. Eur J Psychol. 2017; 13(3):573-98. [DOI:10.5964/ejop.v13i3.1138] [PMID] [PMCID]
57. Sundh J, Wireklint P, Hasselgren M, Montgomery S. Ställberg B, Lisspers K, et al. Health-related quality of life in asthma patients-a comparison of two cohorts from 2005 and 2015. Respir Med. 2017; 132:154-60. [DOI:10.1016/j.rmed.2017.10.010] [PMID]
58. Nery-Hurwit M, Yun J, Ebbeck V. Examining the roles of self compassion and resilience on health-related quality of life for individuals with multiple sclerosis. Disabil Health J. 2018; 11(2):256-61. [DOI:10.1016/j.dhjo.2017.10.010] [PMID]
59. Sheikhyan R, Ghadampour A, Aghabozorgi R. [The effect of self-compassion training in image, body and quality of life on 20 women with cancer without metastasis undergoing chemotherapy (Persian)]. J Clin Psychol. 2019; 9(35):131-45. [Link]