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The Effect of Acceptance and Commitment Therapy on Hypochondria and Cognitive Emotion Regulation among Divorced Women

Received: 17 June 2021 Accepted: 8 August 202


Introduction
Women's mental health has a major share in forming a healthy family that will guarantee society's health (1). Divorce is a phenomenon leading to family breakdown and one of the main deficits in family life. Divorce rates have increased dramatically in countries worldwide, representing one of the major societal shifts of the late twentieth century (2). Globally, the divorce rate has more than doubled in the nearly four decades, from 2.6 divorces for every 1,000 married people to 5.5. In the Middle Eastern and North African nations, rates range from 1.80 and 1.98 for Iran and Syria to 4.27 and 4.68 for Egypt and Kuwait (3). Divorce affects the family members' compatibility in all cognitive, emotional, and social aspects. In this situation, women are mainly affected by interpersonal and social problems (1,4). Studies suggest that people's social class predict their psychological well-being (5).
Hypochondriasis is a continuum concept that represents minor concerns about one's health and being affected by the disease on the one hand and the health anxiety disorder on the other hand. Hypochondriasis imposes a high cost in healthcare (6), occupational capability, and quality of life (7). Hypochondriasis or health anxiety is accompanied by excessive concern about diseases and especially severe diseases, inability to ignore minor physical symptoms, lack of selective attention to these symptoms in the case of being exposed to heard or written information about a disease, frequently referring to doctors and treatment centers, and excessive fear of death. The prevalence of hypochondriasis in the general population is around 0.05%-1.3% and between 3% and 9% in primary care settings (8,9). There is a positive correlation between hypochondriasis and psychiatric symptoms, especially depression and anxiety (10,11).
Emotion regulation refers to the ability to control and change the intensity and orientation of emotions. It is also related to balancing negative emotions, eliminating unfavorable effects on psychological adaptability, and preserving the positive emotions that bear hedonic values (12).
Awareness of emotions lets people perceive them and employ the emotions to decrease disorders. Emotions can be used as a strong force for "conducting cognition" and "promoting social relationships," strongly affecting reasoning ability. Emotion regulation helps the person to seek their goals regarding their socio-cultural demands. Advanced emotion regulation skills allow the growth of adaptive behaviors and proper and flexible responses (13).
Third-wave (cognitive-behavioral) psychotherapy emphasizes issues including mind, relationships, values, acceptance, emotions, goals, and metacognition. Acceptance and commitment therapy (ACT) are considered as a part of third-wave cognitive-behavioral therapy (CBT), and it includes treatments such as mindfulness-based cognitive therapy (MBCT) and integrative behavioral couple therapy (IBCT) (14). This treatment mainly aims to provide psychological flexibility that eliminates the need to get rid of unfavorable emotions; instead, the person can move towards a thought-based positive behavior despite unfavorable emotions. ACT is a behavior-oriented treatment that provides a comprehensive experimental analysis of human cognition (15). In clinical behavior analysis, the ACT is fundamentally focused on spirituality, values, and self (16).
ACT application for the treatment of hypochondriasis is based on a functional methodology and the emphasis on the function of internal experiences, i.e., how thoughts about diseases and physical emotions are experienced and controlled by acceptance, tendency, and reduction strategies (17). Mohammadi et al. (18) reported that this treatment improves cognitive emotion regulation. Bluett et al. (19) found that ACT is effective in treating anxiety spectrum disorder and obsessive-compulsive disorder. Yadavaia et al. (20) concluded that ACT is effective in the treatment of psychological distress, anxiety, depression, and stress. Hoffmann et al. (21) reported that ACT intervention could decrease the symptoms of hypochondriasis and stress by affecting psychological flexibility and The Effect of Acceptance and Commitment … 220 mindfulness. Brinkborg et al. (22) found that ACT decreases stress and increases general health. Wojnarowska et al. (23) concluded that ACT could increase the emotion regulation ability. White et al. (24) investigated the effect of ACT on emotional dysfunction in patients with psychosis, and they reported that this treatment could decrease emotional dysfunction.
Accordingly, the present research aims to study the effect of ACT on hypochondriasis and cognitive emotion regulation in divorced women, referring to consultation centers of Tehran city.

Methods
The method was experimental with a pre-test, post-test design, and a control group. The study population included the divorced women who have been affected by divorce-related psychological problems and referred to Tehran consultation centers from May 31 to September 3, 2018. The sample included 30 divorced women selected by purposive sampling and randomly divided into experimental and control groups. Fifteen divorced women were included in each group using G*Power software version 3.1 with an effect size of 1.09, a test power of 0.95, and α=0.05 based on the means index. Randomization was performed by the researcher using a table of random numbers. Odd numbers were considered for the experimental group members, and even numbers were considered for the control group members. The inclusion criteria were: getting a score lower than mean in the health anxiety inventory and cognitive emotion regulation questionnaire, having psychiatric disorders based on the health anxiety inventory, having at least a middle school literacy level, having one year of living together. The exclusion criteria were: having serious mental disorders or physical disability, reluctance to continue the treatment process, and the absence of more than two treatment sessions. In order to observe the ethical principles, the control group also received intervention sessions after the end of the experimental group sessions and performed the post-test in the experimental and control groups. The participants were informed of the research goals and the procedures. Also, the researchers received written consent for participation in the research from the participants.

Research instruments
The Health Anxiety Inventory (HAI): Short form of this inventory (25) was used in the present research. It is designed based on the hypochondriasis cognitive model, and it includes 18 items. Each item is answered based on four choices that present the person's description of health and illness components in a declarative sentence. The participants should choose one of the sentences describing them in the best way. Each item is assigned a score of 0-3. Higher scores indicate hypochondriasis in the participants. Testretest reliability and Cronbach's alpha were respectively reported as 0.90 and 0.70-0.82 for this inventory (25). Nargesi (26) reported the Cronbach's alpha of this 18-item inventory was 0.87. In this study, Cronbach's alpha coefficient reported as 0.90.

The
Cognitive Emotion Regulation Questionnaire (CERQ): CERQ was prepared by Garnefski and Kraaij in 2006 (27). CERQ is scored based on a five-point Likert scale ranging from from 1 "never" to 5 "always". The cognitive emotion regulation scale includes the subscales of acceptance, self-blame, rumination, blaming others, catastrophizing, and positive refocus, positive reappraisal. Garnefski and Kraaij (27) reported that the internal consistency of this questionnaire is equal to 0.71 based on Cronbach's alpha coefficient. Also, the reliability and validity of the questionnaire have been reported at an acceptable level (28). In this study, Cronbach's alpha coefficient reported as 0.79.

Intervention program
The experimental group received ten 90-min sessions of ACT intervention. A summary of ACT sessions is summarized in Table 1.

First
Communicating with the participants, providing them with a familiarity with the research subject, answering the questionnaire, and contracting the participants for the treatment sessions.

Second
Detecting and studying the treatment methods and evaluating their effectiveness, discussing the temporary effectiveness of the treatments by giving examples, getting feedback, and determining the assignments.

Third
Helping the participants detect inefficient controlling strategies, accepting the upsetting incidents without conflict, giving examples, getting feedback, and determining the assignments.

Fourth
Discussing avoidance of unfavorable experiences and getting awareness of its consequences, teaching the steps of acceptance, changing language concepts by giving examples, relaxation training, getting feedback, and determining the assignments.

Fifth
Introducing a three-dimensional behavioral model to express the mutual relationship of behaviors/emotions, psychological functions, and observable behaviors, discussing the attempt to change behaviors based on the proposed model, getting feedback, and determining the assignments.

Sixth
Describing the concepts of the role and the context, regarding oneself as a context and self-contact by giving examples, awareness of different sensory receptions, and isolation from the senses that are part of the mental content, getting feedback and determining the assignments.

Seventh
Describing the concept of values, creating motivation for change, and enabling the participants to move towards a better life, practicing concentration, getting feedback, and determining the assignments.

Eighth
Educating commitment to action, identifying the behavioral plans based on the values and inspiring commitment to them, summarizing the sessions.

Ninth
Reviewing the assignments of the previous session and continuing the education of skills.

Tenth
Reviewing the assignments of the previous sessions and the summary of the contents taught in previous sessions, investigation of the treatment progression and the achievement of the treatment goals, the participants' perspective of the future, the end of the treatment program.

Statistical analyses
The normality of the data distribution was checked by the Shapiro-Wilk test. Homogeneity of variances was approved by Levene's test. Pearson's correlation coefficient was used to check the correlation of covariates (pre-test). According to the results of Pearson's test, there was a normal correlation between hypochondriasis and emotion regulation. The effectiveness of ACT (independent variable) in hypochondriasis and cognitive emotion regulation (dependent variables) in divorced women was studied by multivariate analysis of covariance (MANCOVA). In the present study, because the pre-test stage was considered a covariance, multivariate analysis of covariance was used to analyze the data. SPSS version 24 was further used for analyzing the data. The significance level of the study was considered to be α=0.05.

Results
The participants were 30 women of 20-50 years old. 40.2% of the samples had a high school degree, 24.4% of the samples had a middle school degree, and 35.4% of the participants had an academic degree. The results showed no significant difference between the experimental and control groups regarding demographic characteristics, so the two groups were homogeneous. Table 2 presents the mean and standard deviation (SD) of the pre-test and posttest scores of hypochondriasis and emotion regulation for the experimental and control groups. Table 2. Mean and standard deviation of the variables in experimental and control groups in pre-test and post-test The mean and standard deviation (SD) of hypochondriasis post-test scores in the experimental and control groups were 35.13±1.92 and 37.33±3.07, respectively. The mean and SD of positive emotion regulation post-test scores in the experimental and control groups were respectively reported as 54.80±1.92 and 50.80±1.77. Meanwhile, the mean and SD of negative emotion regulation post-test scores in the experimental and control groups were respectively reported as 61.60±3.51 and 66.33±2.02. According to the results, the post-test scores of positive emotion regulation (planning and broad perspective) and negative emotion regulation (self-blame, blaming others, rumination, catastrophizing, and acceptance) were respectively increased and decreased in the experimental groups. Table 3 presents the results of the analysis of covariance hypochondriasis and emotion regulation in the experimental and control groups. According to Table 3, ACT was significantly effective in reducing hypochondriasis in divorced women (P=0.04). The observed difference implied the decreased symptoms of hypochondriasis in divorced women following the ACT intervention compared to the control group. ACT was also significantly effective in positive and negative emotion regulation in divorced women (P=0.01). Therefore, following the ACT intervention, the symptoms of positive emotion regulation (planning and broad perspective) were significantly increased. The symptoms of negative emotion regulation (self-blame, blaming others, rumination, catastrophizing, and acceptance) significantly decreased in divorced women compared to the control group.

Discussion
This study aimed to investigate the effectiveness of ACT on hypochondriasis and cognitive emotion regulation in divorced women in Tehran city. The present research revealed that ACT intervention could effectively decrease hypochondriasis. This finding is consistent with the research results of Mirzaeidoostan et al. (30), Hoffmann et al. (31), and Eilenberg et al. (32). Divorce brings about social, economic, mental, physical, psychological, and emotional problems for the divorced person (5,33,34). In other words, the stress and pressures imposed by divorce can increase anxiety, social and mental inadaptability, and depression, decrease psychological well-being and disturb the person's social and occupational relationships (34). ACT 223 intervention provides the person with an inclusive awareness of the present time, openness, tendency, and acceptance of life (21,35). ACT creates awareness of the present time, activity, and avoidance of the thoughts reflecting the problems (18,19). In other words, the inclusive awareness enables the persons to let their thoughts and emotions move to the unconscious mind without any control; so that, accepting the mentioned thoughts, the person can change the threats into opportunities, bear the unfavorable incidents, and seek a solution for problems (21). This ability can decrease anxiety under difficult conditions, create a problem-oriented approach instead of an emotion-oriented one, and preserve occupational and social adaptability.
The present research revealed that ACT intervention could effectively increase cognitive emotion regulation in divorced women. This finding is consistent with the research results of  (37), and Tarkhan (38). ACT could significantly decrease self-blame, rumination, catastrophizing, and blaming others, and increase acceptance, positive refocus, attention to planning, positive reappraisal, and perspectivetaking (39). So, by training how to accept the thoughts and conditions, ACT can effectively improve emotion regulation and increase emotion regulation ability (40). Cognitive emotion regulation refers to the physiological and behavioral psychological processes adopted by the person to change the negative emotions and tend to positive emotions by reappraisal of special cognitive strategies in his/her own and others' emotions; these processes are adopted aimed at avoiding the probable harms and achieving goals (4). In other words, cognitive emotion regulation refers to the internal and external responding processes as opposed to inhibition and evaluating and balancing the emotional interactions and especially their transient characteristics to achieve a goal. ACT defenders believe that the thoughts and emotions should be identified in the conceptual context of the events. So, unlike the cognitive-behavioral approaches, which try to modify the inefficient cognitions and beliefs to improve emotions and behaviors, ACT teaches persons to accept their thoughts and regulate their emotions, live in the present moment, and become more flexible.
The present study was performed on divorced women in Tehran city in 2018. Therefore, caution must be exercised in generalizing the results to other communities. Due to the limitations of this study, especially the geographical, the sample size, and the lack of control on individual difference variables such as social support, a similar study is recommended to be conducted on larger sample size.

Conclusion
Divorce is always described as one of the most stressful incidents of life that can increase the sensitivity to diseases and mood disorders. This research reported that ACT is an effective intervention for divorced women experiencing social, interactive, and adaptive problems. Therefore, ACT effectively reduces the effect of unfavorable emotions and replaces them with more rational and adaptive thoughts. Meanwhile, ACT has been effective in reducing the symptoms of hypochondriasis. The research findings can be useful for family psychologists, consultants, and family experts. Also, the results can be used for developing new interventional and educational protocols for treating divorced women.