THE EFFECTIVENESS OF ACCEPTANCE AND COMMITMENT THERAPY APPROACH (ACT) IN RESPONSIBILITY AND SOCIAL ISOLATION OF OBSESSIVE COMPULSIVE PATIENTS

1 Bahareh Bakhtiari

1 M.A. in General Psychology, Islamic Azad University, Borujerd Branch, Borujerd, Iran

Corresponding Author: Bahareh Bakhtiari

ABSTRACT

INTRODUCTION

Humans are inherently social beings, and to meet a significant portion of their needs, they must engage in communication with others in society. Thus, establishing these relationships in a healthy, purposeful, and lasting way can greatly influence individual development and facilitate personal advancement in life. Social interactions involve forming relationships between two or more individuals, resulting in mutual responses that both parties recognize. Naturally, various definitions of social interaction exist; for instance, it can encompass physical presence, eye contact, conversation, and interpersonal connections, all of which require defining events, activities, and, consequently, individuals' roles within spaces, as well as their participation in groups and social networks (Azodo et al., 2021). The absence of social connections adversely affects the brain's structural development. Studies on young mice and monkeys have demonstrated that severe social isolation profoundly impacts the brain due to the lack of social interactions and relationships (Weiner et al., 2019). Consider an individual who struggles significantly to establish social connections and cannot engage with society; such difficulty may lead to social isolation and withdrawal. Social isolation occurs when a person has entirely or nearly entirely disconnected from others in society. Unlike loneliness, which is a temporary and involuntary lack of interaction, social isolation represents a more profound disconnection. Regardless of age, social isolation can pose a serious challenge for anyone, though its symptoms may manifest differently across age groups (Glaster et al., 2020). Various factors, including mental health, lifestyle, illness, unemployment, lack of a job, and family crises, can contribute to social isolation in an individual. Another key factor that plays a dual role as both a cause and a consequence of social isolation is responsibility. Responsibility involves accepting accountability and taking timely action (Hashemi et al., 2022). An absence of responsibility can lead to outcomes such as unemployment, educational discontinuation, financial dependence, decreased social interactions, and ultimately, social isolation. Responsibility encompasses multiple aspects, with social and individual responsibility being the most significant. A lack of responsibility can indirectly diminish social interactions through factors like unemployment and financial dependence, ultimately leading to withdrawal and isolation (Stockton et al., 2019).

As previously mentioned, illness can be a significant factor in reducing social interaction and even leading to social isolation across different age groups. Physical illnesses contribute to this issue by lowering self-esteem, often due to changes in physical appearance and reduced physical attractiveness. However, certain mental health conditions, such as obsessive- compulsive disorder (OCD), may not alter a person’s physical appearance but can still diminish social interactions and potentially result in isolation. OCD is characterized by persistent intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that an individual feels compelled to perform. When these two symptoms coexist, the condition is identified as obsessive-compulsive disorder (OCD) (Linda et al., 2002).

In treating OCD, pharmacological approaches such as clomipramine or serotonin reuptake inhibitors like fluoxetine and sertraline are considered the most effective biological treatments (Tindall et al., 2019). However, these treatments are generally recommended only in severe cases due to their high risk of side effects and the likelihood of symptom recurrence if medication use is discontinued. In less severe cases, psychological treatments are the preferred approach. Psychological interventions can act as either a complementary or an effective alternative to medication for treating OCD (Brown et al., 2009). To address OCD, as well as the related issues of social interactions and social isolation, various psychological approaches are available. One such approach is Acceptance and Commitment Therapy (ACT). ACT integrates four key elements: mindfulness, acceptance, commitment, and behavior change with the ultimate goal of fostering psychological flexibility. This approach focuses on helping individuals engage in appropriate behaviors despite experiencing negative emotions. Introduced by Steven Hayes in 1982, ACT is classified as part of the third wave of behavioral therapies (Aswaina et al., 2015). The primary objective of this therapy is to break the cognitive

fusion between cause and effect, thereby enhancing the ability to regulate goal-directed behavior.

Now, in this study, we aim to investigate the problem of isolation and reduced social responsibility in OCD patients in Boroujerd County, using the Acceptance and Commitment Therapy (ACT) approach, to determine whether this therapeutic approach can improve social responsibility and social isolation in OCD patients and prepare them for a better life.

METHOD:

This study is categorized as applied research based on its objective. It also follows a semi- experimental research design with a pre-test and post-test format, incorporating an unequal control group. The statistical population includes all individuals diagnosed with obsessive- compulsive disorder (OCD) at the Royan Counseling and Psychology Center in Boroujerd County, as determined by a psychiatrist or clinical psychologist, meeting the study’s inclusion criteria in the second half of 2023, totaling 367 individuals. The study employed a convenience sampling method. Since semi-experimental research with a pre-test and post-test requires group homogenization, and in accordance with previous research records and established research methodology sources (Kardeloi, 2014), a total of 40 individuals were selected through convenience sampling. These participants were then randomly assigned to two groups: an experimental group (20 individuals) and a control group (20 individuals).

Table 1. Content of Sessions and Acceptance and Commitment Therapy Protocol

Sessions	Objectives	Duration
Session 1	Establish a therapeutic relationship, familiarize individuals with the research topic, explain headaches, symptoms and signs, pharmacological and non-pharmacological treatments, assess individual readiness for change, respond to questionnaires, and sign a therapeutic contract.	90 minutes
Session 2	Discover and examine the patient’s treatment methods and score them, assess the effectiveness of treatment methods, create a sense of helplessness regarding temporary and less effective treatments using metaphors, receive feedback, and assign tasks.	90 minutes
Session 3	Help participants identify control over personal events, thoughts, and memories, identify ineffective strategies, explore the futility of control, accept painful personal events without struggling with them, and refrain from controlling them using metaphors, receive feedback, and assign tasks.	90 minutes
Sessions 4 and 5	Explain avoidance of painful experiences and awareness of the consequences of avoidance, identify avoided situations, and confront them through acceptance, teach acceptance steps by explaining the concepts of eagerness and obstacles, define evaluation and description using metaphors, change conceptual language using metaphors, teach relaxation techniques, receive feedback, and assign tasks.	90 minutes
Session 6	Explain the concepts of role and context, observe the self as a foundation, and establish contact with the self-using metaphors, become aware of different sensory perceptions and differentiate them from mental content. In these exercises, group members are trained to focus on their activities (such as breathing, walking) and be aware of their condition at any given moment. When emotions, sensations, and cognitions are processed, they are observed without judgment. When participants realize their mind is wandering in	90 minutes

	thoughts, memories, or fantasies, they are taught to redirect their focus to the present moment, regardless of the content and nature of those thoughts. This helps them learn to pay attention to their thoughts and feelings but not attach themselves to the content. Receive feedback and assign tasks.
Session 7	Explain the concept of values and the difference between values, goals, and needs, clarify the client's values, create motivation for change, and empower the client for a better life. Practice mindfulness (focus on breathing, walking, eating, brushing teeth, environmental sounds, etc.), receive feedback, and assign tasks.	90 minutes
Session 8	Teach commitment to action, identify behavioral patterns aligned with values, and create commitment to act on them, review tasks, and summarize the sessions with group members, and conduct post- test.	90 minutes

The experimental group underwent Acceptance and Commitment Therapy (ACT) in eight 90- minute sessions over two months (one session per week) based on the therapeutic program by Wills et al. (2007). At the conclusion of the intervention, both groups completed the post-test, and the data were analyzed using multivariate analysis of covariance (MANCOVA).

MEASUREMENT TOOLS:

Responsibility Scale (Gaf, 1984): This scale was first introduced along with 14 other scales in the "California Psychological Inventory" by Gaf (1984). The 42-item Responsibility Scale is used to measure traits such as conscientiousness, sense of commitment, hard work, seriousness, reliability, rule-based behavior, logic, and sense of responsibility (Dansa et al., 2016). The reliability and validity coefficients of the Responsibility section were assessed using split-half and Cronbach’s alpha methods in a study by Lewis (2001) on a sample of 619 students, with values of 0.70 and 0.81, respectively. In another study by Kaladinski et al. (2010) on a sample of 92 participants, the values were 0.50 and 0.55, respectively. In a further investigation, the reliability and validity of this test in Iran, using the test-retest method, were found to be 0.81 and 0.76, respectively (Shirinzadeh Dasgiri et al., 2008). The scale is scored such that responses are given a score of 0 or 1.

Social Isolation Scale (Chalepi & Amirkafi, 2004): This questionnaire consists of 19 closed- ended items, based on a five-point Likert scale. The questionnaire measures dimensions of support types in social networks (cognitive support, emotional support, tangible support, and service support) and the scope of social network relationships (network size and type of relationship). The reliability coefficient of the Social Isolation Questionnaire in Shatyarian et al. (2017) was found to be 0.83 using Cronbach's alpha. The validity of the tool was examined in a study conducted on high school students using content validity, and the content validity index for this questionnaire was found to be 0.88 (Neves et al., 2019). The scoring method follows a five-point Likert scale, with options ranging from "strongly disagree" = 1 to "strongly agree" = 5. A score of 1 indicates the lowest level of social isolation, and a score of 5 indicates the highest level of social isolation. The questionnaire includes four subscales, and some questions are reverse scored. The reliability coefficient of this scale has also been established.

FINDINGS:

In this section of the present research, descriptive statistics for the variables of responsibility and social isolation will be examined (Table 2).

Table 2. Descriptive Statistics for the Variables of Responsibility and Social Isolation

Group	Variable	Test	Number	Mean	Standard Deviation	Minimum Score	Maximum Score
Experiment	Responsibility	Pre- test	20	22.4	6.24	7	35
		Post- test	20	16.6	6.24	7	35
	Social Isolation	Pre- test	20	57.4	13.21	20	80
		Post- test	20	43.65	12.32	20	80
Control	Responsibility	Pre- test	20	21.2	5.75	7	35
		Post- test	20	21.95	8.88	7	35
	Social Isolation	Pre- test	20	55.6	12.34	20	80
		Post- test	20	54.5	15.31	20	80

Table 3. Results of Multivariate Analysis of Covariance to Examine Between-Group Differences in Mindfulness, Health-Oriented Lifestyle, and Its Components

Source of Variation	Variable	Sum of Squares	Degrees of Freedom	Mean Squares	F	Significance Level
Group	Responsibility	327.391	1	327.391	10.888	* 0.002
	Social Isolation	1466.534	1	1466.534	19.828	* 0.001
Error	Responsibility	1052.563	35	30.073
	Social Isolation	2588.703	35	73.963

* P  0 / 05

The results of the multivariate analysis of covariance (MANCOVA) in Table 3 indicate that, after controlling for the pre-test, there is a significant difference between the mean scores of the experimental and control groups in terms of responsibility in the post-test (F (1,35) = 10.886, p = 0.002). Thus, participation in Acceptance and Commitment Therapy (ACT) sessions, while controlling for the pre-test score, is effective in enhancing responsibility in the participants. Similarly, after controlling for the pre-test, a significant difference is observed between the mean scores of the experimental and control groups in terms of social isolation in the post-test (F (1,35) = 19.808, p = 0.001). This finding suggests that participation in ACT therapy sessions, while controlling for the pre-test score, is effective in reducing social isolation in the participants. Therefore, with 95% confidence, it can be concluded that Acceptance and Commitment Therapy (ACT) has a significant impact on increasing responsibility and reducing social isolation in the studied individuals.

DISCUSSION AND CONCLUSION

This study aimed to evaluate the effectiveness of the Acceptance and Commitment Therapy (ACT) approach on responsibility and social isolation in patients with obsessive-compulsive

disorder (OCD). The results show that ACT therapy was effective in improving responsibility and reducing social isolation among OCD patients at the Mazan Rehabilitation and Treatment Center for Psychiatric Patients. Participation in ACT therapy sessions resulted in a notable increase in responsibility and a decrease in social isolation for these patients. These findings are consistent with the research of Hadian et al. (2023), Hashemi et al. (2022), Daghagh & Arab Hashemi (2022), Khatibi & Bagherzadeh Gol Makani (2020), Izadi & Abedi (2013), and Levin et al. (2020). However, they do not align with the studies conducted by Harris et al. (2020) and Ong et al. (2020).

Therefore, in explaining the effectiveness of Acceptance and Commitment Therapy (ACT) in enhancing responsibility and reducing social isolation, it can be argued that individuals with Obsessive-Compulsive Disorder (OCD) often struggle to tolerate anxiety and the subsequent social isolation, particularly when engaging in exposure and response prevention. However, ACT, through defusion and acceptance techniques, helps reduce the distress associated with these experiences. Although this therapeutic approach does not directly address the frequency or content of obsessive thoughts, the reduction in social isolation achieved through defusion and acceptance ultimately contributes to a decrease in obsessive thoughts and compulsive behaviors (Khatibi et al., 2020). Furthermore, in ACT therapy, there were in-depth discussions on values and personal goals, with a focus on clarifying these values. One possible reason for the reduction in OCD symptoms could be the emphasis on values and meaningful life goals, rather than focusing on obsessive thoughts and compulsive behaviors. In other words, ACT therapy aims to help individuals recognize an obsessive thought as simply a thought, rather than reacting to it, and instead, engage in meaningful activities that align with their values. Through this process, OCD patients learned that obsessive thoughts are not inherently harmful; the problem lies in their attempts to respond to these thoughts through compulsive behaviors. ACT therapy taught them how to choose the most appropriate course of action from available options, fostering flexibility in responsibility. As a result, this therapeutic approach effectively reduced social isolation (Hadian et al., 2023).

Furthermore, Acceptance and Commitment Therapy (ACT) plays a crucial role in promoting acceptance and commitment to taking effective actions. By fostering acceptance and encouraging value-based actions, ACT facilitates therapeutic changes, including the reduction of maladaptive thoughts (Harris et al., 2020). In addition, by incorporating acceptance techniques and encouraging individuals to confront difficulties or distressing events without attempting to suppress them, ACT enhances situational awareness and improves coping skills in the face of life's challenges. As a result, this process leads to a reduction in social isolation among individuals with Obsessive-Compulsive Disorder (OCD). Through ACT therapy, individuals begin to believe in their ability to handle life's challenges, including obsessive thoughts, while also taking responsibility for their actions. Ultimately, ACT therapy reduces fear and avoidance of confrontation, lessens psychological distress, and promotes acceptance, commitment, and effective engagement with problems and maladaptive beliefs. This process not only enhances responsibility but also reduces social isolation.

On the other hand, Acceptance and Commitment Therapy (ACT) has effectively encouraged OCD patients to stop justifying or making excuses, cease blaming external factors and past events, and accept reality. It has helped them develop rational optimism and overcome common tendencies to avoid responsibility, allowing them to reconcile with their past and make more effective choices in the present to meet their fundamental needs (Hadian et al., 2023). In this context, during ACT therapy sessions, OCD patients were trained to identify and appropriately fulfill their basic needs, as meeting these needs in a healthy manner leads to increased responsibility (Khatibi et al., 2020). ACT therapy teaches that individuals are responsible for choosing their behaviors and that the only behavior they can fully control is their own. Through this approach, individuals learn to break free from the victim mentality and stop blaming fate, luck, or others. They come to realize that they are the primary individuals responsible for

meeting their own needs.

Following their behavioral choices, patients discover whether the resulting outcomes are pleasant or unpleasant, helping them determine whether their behaviors are effective or ineffective in meeting their needs. Additionally, they recognize that various aspects of the external world can be pleasurable (fulfilled need), painful (unfulfilled need), or neutral (Asli- Azad et al., 2021).

This therapeutic approach teaches individuals to confront and manage their disorder by enhancing psychological and cognitive acceptance of their inner experiences, such as thoughts and emotions related to social interactions and public speaking, rather than avoiding stressful social situations. Additionally, it encourages them to set more socially engaged goals and commit to achieving them (Levin et al., 2020). Essentially, active and effective acceptance in ACT therapy—avoiding social isolation, altering self-perception, shifting the narrative of seeing oneself as a victim, reevaluating life values and goals, and committing to more socially engaged objectives—are key factors in combating social isolation in individuals with OCD (Hashemi et al., 2022). Ong argues that ACT therapy, rather than aiming to eliminate harmful factors, helps individuals accept their emotions and thoughts in a controlled way, freeing them from rigid verbal rules that contribute to psychological distress (Ong et al., 2020). Moreover, it enables individuals to relinquish their struggle with problems (Daghagh et al., 2022).

On the other hand, it can be said that Acceptance and Commitment Therapy (ACT) is fundamentally a process-oriented treatment that explicitly focuses on enhancing the acceptance of psychological experiences and commitment through greater engagement in meaningful, adaptive social activities, regardless of the content of psychological or behavioral experiences (Izadi et al., 2013). The goal of ACT is not to improve social thoughts, promote positive emotions, or encourage certain feelings; rather, its primary objective is to reduce avoidance, social isolation, and increase awareness, particularly by fostering a present-moment focus without relying on irrational methods. In this process, individuals with obsessive thoughts learn to distance themselves from unpleasant behaviors, thereby protecting themselves from subsequent distress and emotional turmoil (Hashemi et al., 2022).

Thus, the primary goal of this treatment in such cases is to enhance functionality by reducing social isolation in individuals. Ultimately, it can be concluded that patients with obsessive- compulsive disorder (OCD), due to their psychological condition, experience significant social isolation and tend to avoid social situations, fearing evaluation by others. Acceptance and Commitment Therapy (ACT) for these individuals helps them accept their social isolation and take responsibility for their issues by engaging in committed actions and behaviors. As a result, ACT, using techniques such as addressing the ineffectiveness of experiential avoidance, enables these individuals to experience feelings that are inevitably present in life, as they are, rather than something they should avoid (Li et al., 2023). Therefore, the effectiveness of ACT in reducing social isolation is justifiable.

Based on the results obtained from this study, the following practical suggestions for increasing the effectiveness of this treatment are presented:

• Given the findings of the research that the Acceptance and Commitment Therapy (ACT) approach is effective in improving responsibility and reducing social isolation in OCD patients at the Mizan Rehabilitation and Therapeutic Center for Psychiatric Patients, it is recommended that counselors, therapists, and clinical psychologists use Acceptance and Commitment Therapy alongside other treatment methods in health improvement interventions to enhance various psychological traits, including improving responsibility and reducing social isolation.

• This therapeutic approach can also be recommended as an effective treatment method to increase the responsibility of patients with obsessive-compulsive disorder.

• It is recommended that the Psychology Organization establish Acceptance and Commitment Therapy (ACT) workshops to familiarize doctors and nurses with the concepts of this therapeutic approach, in order to prepare and assist patients who suffer from social isolation.

• Additionally, based on the overall findings of the study, it is suggested that educating families of patients with obsessive-compulsive disorder is effective, as this illness affects all family members and disrupts their ability to stay connected (social isolation and responsibility). Therefore, group counseling using Acceptance and Commitment Therapy (ACT) for families of patients with obsessive-compulsive disorder can play a significant role in improving the mental state and reducing anxiety among family members.

Some of the limitations of this study include: the researcher's inability to control all variables of the study; and the lack of research spirit and proper cooperation from patients with obsessive-compulsive disorder at the rehabilitation and therapy center in Borujerd, in completing and submitting questionnaires and attending the ACT therapy sessions due to their poor mental condition.

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