Research Article - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 0, Issue 0
The Effect of Group Therapy Based on Acceptance and Commitment with Psychodrama Components on Social Anxiety of Students with Social Anxiety Disorder
Malihe Kabusi1, Maryam Ebrahimpour Roodposhti2, Maliheh Eshaghzadeh3, Zahra Shafiei4, Zahra Sadeghi5, Hamid Nazari6 and Mohsen Sahebanmaleki7*2MSc in Nursing, Department of Pediatric & Neonatal Intensive Care Nursing, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
4MSc, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
5Department of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
6Department of Nursing, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran
7Assistant Professor of Anesthesiology, MD, FCCM, Department of Anesthesia, Clinical Research Developmental Unit Bohlool Hospital, Gonabad University of Medical Science, Gonabad, Iran
Mohsen Sahebanmaleki, Assistant Professor of Anesthesiology, MD, FCCM, Department of Anesthesia, Clinical Research Developmental Unit Bohlool Hospital, Gonabad University of Medical Science, Gonabad, Iran, Email: mnhosbr@gmail.com
Received: 15-Dec-2021, Manuscript No. CSRP-21-49936; Editor assigned: 17-Dec-2021, Pre QC No. CSRP-21-49936 (PQ); Reviewed: 31-Dec-2021, QC No. CSRP-21-49936; Revised: 05-Jan-2022, Manuscript No. CSRP-21-49936 (R); Published: 12-Jan-2022, DOI: 10.3371/CSRP.MKME.011222
Abstract
Introduction: Social phobia or social anxiety refers to the fear, anxiety and avoidance of social interactions that can be carefully examined. This anxiety becomes a social anxiety disorder when it interferes with daily activities. Acceptance and commitment-based therapy is one of the most helpful methods to reduce anxiety. This method, which is part of the third generation of psychotherapy interventions, strives to improve one's psychological connection with his/her thoughts and feelings, instead of changing cognitions. Therefore, this study was conducted to determine the effect of group therapy based on acceptance and commitment with psychodrama components on social anxiety of undergraduate students.
Methods: This is a randomized trial study with pretest/post-test design that was conducted at Torbat Heydariyeh University of Medical Sciences in 2017. A total 48 students with social anxiety disorder referred to the counseling center of the University were randomly selected and allocated into one intervention group (12 students) and three control groups (12 students each). The intervention group (combined psychotherapy group) participated in 12 sessions of therapy that lasted for 90 minutes each (2 sessions per week). Control groups received psychodrama therapy, acceptance and commitment-based therapy and no therapy. Data were collected through Connor’s Social Anxiety Questionnaire (2000) and then were analyzed by Analysis of Variance (ANOVA) and Analysis of Covariance (ANCOVA).
Results: The scores of social anxiety in four study groups decreased after psychological interventions. The mean score of social anxiety in the group treated with psychodrama was 63.75 ± 11.37 before the intervention and 50.08 ± 5.17 after the intervention. This score in the group treated with acceptance and commitment- based therapy was 60.25 ± 10.71 before the intervention and 43.66 ± 7.05 after the intervention and in the group treated with combined therapy was 61.75 ± 11.49 before the intervention and 34.75 ± 8.19 after the intervention. Also, the mean score of anxiety in the control group did not show a significant difference (p=0.86), but the reduction in social anxiety score of the group treated with combined therapy was significantly higher (p<0.001) than the other two groups.
Conclusion: Due to the effectiveness of this non-pharmacological and low cost method, its use is recommended to reduce social anxiety. Officials and those involved in the health care system have an important role in increasing mental health and the quality of care by using these treatment approaches. Therefore, it is necessary to increase the quality of clinical care by facilitating the use of these treatments.
Keywords
Acceptance and commitment-based therapy • Psychodrama • Social anxiety disorder • Students
Introduction
Social phobia or social anxiety refers to the fear, anxiety, and avoidance of social interactions that can be carefully examined [1,2]. This anxiety becomes a social anxiety disorder when it interferes with daily activities [3]. The main characteristics of social anxiety disorder include severe fear and persistent and irrational shyness in situations where one has to do something in front of others [4]. In fact, these people are ashamed of their behavior and are afraid of being seen and judged by others [3]. Hereditary and environmental factors affect the prevalence of this disorder [3]. People with social anxiety disorder experience higher levels of drug dependence and problems, unemployment, poor socioeconomic status, and poor educational quality [5]. People with social anxiety disorder are also more likely to develop co-occurring disorders such as depression, substance abuse and even psychosis [1]. In addition, the presence of this disorder in students causes problems such as low self-esteem, embarrassment, difficulty in communication and discomfort [6]. Symptoms of this disorder will worsen over time if left untreated [4]. Among the treatment methods, non-pharmacological interventions play an important role in increasing creativity and skills [7].
Acceptance and commitment-based therapy is one of the most helpful methods of reducing anxiety. This method, which is part of the third generation of psychotherapy interventions, strives to improve one's psychological connection with his/her thoughts and feelings, instead of changing cognitions [8,9]. In fact, Acceptance and Commitment-based Therapy (ACT) uses the processes of acceptance, behavior change, commitment, and empirical practice to create psychological flexibility without judging or encouraging effective acceptance [9]. Psychological interventions play an important role in improving lifestyle and quality of life [10]. The use of non-pharmacological and low cost psychological methods plays an important role in increasing creativity and life skills [7].
In addition to acceptance and commitment-based therapy, another treatment that is used to improve social anxiety disorder is psychodrama, which due to its display-based nature, is directly related to the problem of people with this disorder [11]. Psychodrama is an experimental treatment method in which, people use a guided therapeutic role to solve individual and social problems and find possible solutions through actions instead of solely using words [12]. This method enhances individual’s creativity through drama techniques and performance-oriented models [13,14]. Psychodrama increases sociability and mental acuity, and also helps to solve life problems [13]. In fact, this method gives people the opportunity to evaluate their behavior and deeply understand their life situations by reconstructing real life situations and concurrent playing [3]. Therefore, the researcher based on his clinical experiences conducted this study to determine the effect of group therapy based on acceptance and commitment with psychodrama components on social anxiety of undergraduate students.
Materials and Methods
The present study is a randomized trial with pre-test/post-test design that was conducted on four groups (one intervention group and three control groups). The statistical population of this study included all undergraduate students at Torbat Heydariyeh University of Medical Sciences in 2017. Through the self-reporting questionnaire of social anxiety designed by Connor, et al. the participants estimated the criteria of social anxiety disorder. Among them, 48 students who received a diagnosis of social anxiety disorder by a clinical psychologist were randomly divided into 4 groups of 12, including one intervention group (combined psychotherapy group) and three control groups (psychodrama therapy group, acceptance and commitment-based therapy group, and no therapy group). The reason for choosing this sample size was that, generally in short-term interpersonal group therapies, the number of group members is recommended to be between 6 and 12, with one or two group leaders, depending on the available resources and educational needs.
The samples were randomly divided into control and intervention groups by permutation blocks (4 blocks). The 4 blocks were considered as code 1 for the intervention group and code 2 for the control group. In each block, two codes 1 and two codes 2 were allocated non-repetitively. The blocks were randomly selected with closed eyes and each block was cancelled after being used and then, the next block was randomly re-selected. With each block, the order of entry of individuals into the intervention or control group was determined. For instance, block 1221 refers to order in which, the first and fourth persons are entered the intervention group and the second and third persons are entered the control group. Exclusion criteria were the use of anti-anxiety drugs and being absent for more than one therapy session. The first stage of the questionnaire was completed in such a way that first, 78 students who referred to the counselling center completed the social anxiety questionnaire during an interview with the center’s psychologist, from whom 48 known cases of social anxiety were randomly assigned to 4 groups (n=12 in each group).
Inclusion criteria were; having knowledge and providing consent to participate in the study, diagnosis of social anxiety disorder based on a questionnaire and interview by a clinical psychologist, and being a student. Exclusion criteria were; not receiving medication to reduce anxiety, suffering from physical illness or other psychiatric disorders at the time of study, and unwilling to continue with the study. The intervention group received combined psychotherapy (acceptance and commitment-based therapy and psychodrama therapy), (Table 1).
| Session | Session structure |
|---|---|
| Session 1 | The group members get to know each other, and the general plan of treatment and training sessions are explained |
| Session 2 | Familiarity with the concepts of mental flexibility, psychological acceptance, psychological awareness, cognitive separation and related exercises |
| Session 3 | Familiarity with the concepts of self-visualization, personal story, clarification of values and committed action, and then related exercises |
| Session 4 | Familiarity with the present and “now”, and focusing on increasing psychological awareness |
| Session 5 | Educate and evaluate how to respond and deal effectively with mental experiences |
| Session 6 | Creating goals and social lifestyle, and being committed to them |
| Session 7 | Dealing with shyness, and introduce walking techniques |
| Session 8 | Introduce and perform mirror techniques and self-introduction |
| Session 9 | Using the role change method and introducing and performing the role playing technique |
| Session 10 | Introduce and perform the empty chair technique |
| Session 11 | Create a realistic situation to test anxiety |
| Session 12 | Review the treatment, and terminate the group |
The therapy was carried out in 12 sessions (each session=90 minutes, 2 sessions per week) based on a researcher-made protocol [15,16], which was regulated and designed with social anxiety disorder by the researcher. The first control group received only acceptance and commitment-based therapy in 10 sessions (Table 2), the second control group received only psychodrama therapy in 10 sessions (Table 3), and the third control group received no treatment. Questionnaires in all groups were completed in two stages before the start of therapy as a pre-test and after the end of therapy as a post-test.
| Session | Session structure |
|---|---|
| Session 1 | Familiarizing the group members with each other and talking about the general plan of treatment and training sessions |
| Session 2 | Familiarity with the concepts of mental flexibility, psychological acceptance, psychological awareness, cognitive separation and related exercises |
| Session 3 | Familiarity with the concepts of self-visualization, personal story, clarification of values and committed action and related exercises |
| Session 4 | Familiarity with the present and “now”, and focusing on increasing psychological awareness |
| Session 5 | Educate and evaluate how to respond and deal effectively with mental experiences |
| Session 6 | Creating goals and social lifestyle, and being committed to them |
| Session 7 | Members' practice on what they have learned from previous sessions and provide feedback |
| Session 8 | Members' practice on what they have learned from previous sessions and provide feedback |
| Session 9 | Members' practice on what they have learned from previous sessions and provide feedback |
| Session 10 | Review the treatment, and terminate the group |
| Session | Session structure |
|---|---|
| Session 1 | Familiarizing the group members with each other, and expressing the general plan of treatment and training sessions |
| Session 2 | Dealing with shyness, and introducing walking techniques |
| Session 3 | Talking about experiences and opinions about social experiences |
| Session 4 | Introduce and perform mirror techniques and self-introduction |
| Session 5 | Using the role change method and introducing and performing the role playing technique |
| Session 6 | Introduce and perform the empty chair technique |
| Session 7 | Select a display position from the clients' memories and perform it by themselves |
| Session 8 | Create a realistic situation to test anxiety |
| Session 9 | Create a realistic situation to test anxiety |
| Session 10 | Review the treatment, and terminate the group |
The therapy session in the intervention group was as follows:
The present study has been approved by the ethics committee of Torbat Heydariyeh University of Medical Sciences (code: IR.THUMS. REC.1397.008). Before starting the study, the study objectives were explained to the students with social anxiety disorder and they were invited to enter the study. All participants were assured that their information would remain confidential, and all ethical principles were observed. Participants were allowed to leave the study whenever they wished. Also, the training given to intervention groups was also offered to the control group at the end of the study. The data in this study was collected by the social anxiety questionnaire developed by Connor, et al. This questionnaire is a selfreporting tool that has 17 items. It is designed to assess a wide range of symptoms of social anxiety disorder in three areas of experience of fear in social situations (6 items), avoidance in social interaction (7 items) and physiological distress in social situations (4 items). In this tool, the subjects are asked to rate their symptoms during the last week in the following order: no symptom (score=0), low (score=1), [2] somewhat, (score=3), high (score=4), and very high. The total score of this tool is between 0 and 68. This questionnaire has high validity and reliability. Its reliability by retest method in groups with a diagnosis of social anxiety disorder was 0.78 to 0.89. Also, its internal consistency coefficient, using Cronbach's alpha method, in a normal group has been reported at 0.94 and also in the areas of fear, avoidance and physiological discomfort, it has been reported at 0.89, 0.91 and 0.80, respectively [17]. SPSS software version 20 was used to analyze the data. To describe quantitative variables, the standard deviation ± mean and to describe qualitative variables, the frequency (percentage) was used. Data analysis was performed using Analysis of Variance (ANOVA) and Analysis of Covariance (ANCOVA) at 95% confidence level.
Findings
In this study, 48 people with social anxiety disorder participated in equal numbers in 4 groups of psychodrama therapy, acceptance and commitment-based therapy, combined therapy and no therapy. Mean age of individuals in the psychodrama therapy group was 20.5 years ± 5.34 years, in the acceptance and commitment-based therapy group was 20.66 years ± 4.91 years, in the combined group was 5.40 years ± 20.58 years and in the group that received no therapy was 20.5 years ± 5.16 years. The groups were similar in terms of gender (P=0.18) and educational level (P=0.39). Demographic information of individuals by study groups is reported in (Table 4).
| Variable | Therapy Frequency (%) |
Psychodrama therapy Frequency (%) |
Acceptance and treatment-based therapy Frequency (%) |
Test of both therapies Frequency (%) |
Chi-square test | |
|---|---|---|---|---|---|---|
| Gender | Female | 7 (58.3) | 6 (50) | 10 (83.3) | 5 (41.7) | 0.18 |
| Male | 5 (41.7) | 6 (50) | 2 (16.7) | 7 (58.3) | ||
| Education level | First year | 1 (8.3) | 4 (3.33) | 1 (8.3) | 2 (16.7) | 0.39 |
| Second/third year | 9 (75) | 8 (66.7) | 8 (66.7) | 7 (58.3) | ||
| Last year | 2 (16.7) | - | 3 (25) | 3 (25 ) | ||
|
Note: *Significant level of 95% |
||||||
The results showed that the score of social anxiety and its components in all three groups decreased significantly, so that the mean score of social anxiety in the group treated with psychodrama before the intervention was 63.75 ± 11.37% and after the intervention was 50.08 ± 77.05. This score in the group that received acceptance and commitment-based therapy before the intervention was 60.21 ± 10.71 and after the intervention was 43.66 ± 7.05, and in the group that received combined therapy was 61.75 ± 11.49 before the intervention and 34.75 ± 8.19 after the study period. The mean anxiety score in the control group did not show a significant difference p=0.86, (Table 4), but the difference in scores and in other words, the intensity of reduction in social anxiety of the intervention group (combined therapy group) was significantly higher than the other two groups P<0.001, (Table 5).
| Variable | No therapy group Frequency (%) |
Psychodrama therapy group Frequency (%) |
Acceptance and commitment-based therapy group Frequency (%) |
Combined therapy group Frequency (%) |
|
|---|---|---|---|---|---|
| Social anxiety | Pre-test P-value in ANOVA test |
60.58 ± 9.50 0.86 |
63.75 ± 11.37 | 6.75 ± 10.71 | 61.75 ± 11.49 |
| Pre-test P-value in ANCOVA test |
61.75 ± 8.40 - |
50.08 ± 5.71 <0/0001* |
43.66 ± 7.05 <0/0001* |
34.75 ± 8.19 <0/0001* |
|
| Shyness | Pre-test P-value in ANOVA test |
120.16 ± 14.05 0.93 |
118.25 ± 17.52 | 120.33 ± 12.43 | 116.83 ± 15.49 |
| Pre-test P-value in ANCOVA test |
120.25 ± 13.92 - |
87.16 ± 10.09 <0/0001* |
89.16 ± 6.99 <0/0001* |
69.75 ± 11.74 0/02* |
|
| Fear | Pre-test P-value in ANOVA test |
38.92 ± 8.52 0.71 |
37.83 ± 7.89 | 35.75 ± 7.78 | 35.75 ± 8 |
| Pre-test P-value in ANCOVA test |
39.83 ± 7.52 - |
29.66 ± 4.08 <0/0001* |
25.50 ± 5.72 <0/0001* |
20.92 ± 3.68 0/02* |
|
| Note: *Significant level of 95% | |||||
Discussion
The aim of this study was to evaluate the effectiveness of group therapy based on acceptance and commitment along with psychodrama components on the social anxiety of students with social anxiety disorder. Findings of this study showed that, the psychological interventions applied in all three groups were effective in reducing the social anxiety of the students. In other words, psychological interventions were able to significantly reduce students’ social anxiety, but in the combined therapy group, the students' social anxiety significantly decreased.
Explaining the above findings, Villatte, et al. pointed out that acceptance and commitment-based therapy can improve mental health and social adjustment and consequently, increase social functioning [18]. Results of Kabatzarin, et al. study also showed that acceptance and commitmentbased therapy leads to a reduction in anxiety and psychological distress [19]. Yabandeh, et al. compared the effect of two methods of acceptance and commitment-based therapy and cognitive-behavioral therapy on social anxiety, and found that acceptance and commitment-based therapy significantly reduced social anxiety compared to cognitive-behavioral therapy, but this difference was not significant. The researchers said that the positive effects of both methods could be due to the commonalities of the two treatments, such as dealing with anxious thoughts instead of suppressing or controlling the thoughts [20]. Rickardsson, et al. believed that use of psychodrama technique plays an important role in reducing chronic psychological pain in patients, because this treatment method by emphasizing on the subconscious has an important role in emotional discharge of patients and their relaxation [16]. Li, et al. argued that acceptance and commitment-based therapy has appositive effect on health-related outcomes fin patients with advanced cancer. Therefore, this treatment has an important role in reducing anxiety and stress in patients [15].
Pour Rezaian pointed out the positive effect of psychodrama on the treatment of social anxiety disorder, and believed that the reason for the effects of psychodrama is its display ability. Psychodrama can help clients to reduce their anxiety by recreating stressful situations through practice and creative dramatic techniques [11].
Easter, et al. also concluded in their study that psychodrama reduces the level of social anxiety in children by cognitively reconstructing emotions towards anxious situations [3]. Rahimi stated that psychodrama methods play an important role in promoting the skills and creativity of children with autism [21]. The use of empowerment programs and the use of nonpharmacological interventions play an important role in improving the quality of life and care [22,23]. Munawar, et al. referred to the effectiveness of acceptance and commitment-based therapy for people and children with ADHD [24].
Considering the effectiveness of this treatment method on different health variables and also taking into account the results of present study, it can be said that, this treatment method has an important role in reducing students' social anxiety and fear [25].
One of the limitations of this study was that, it was not possible to follow up the students for several months after the end of the training sessions. Also in this study, some participants were possible to suffer from another mental disorder that could affect their social behavior. Therefore, it is better to rule out these possibilities in future studies. Another limitation was the spatial constraint on sampling, which could have affected the possibility of generalizing the results to other members of society. Despite these limitations, the researchers in the present study were able for the first time to design a new treatment protocol based on two conventional methods of psychotherapy, which in turn led to innovation in the treatment of social anxiety disorder.
Conclusion
In general, given the prevalence of social anxiety disorder at the social level, especially among students, and the problems it can cause for the development of individuals and society, it is necessary to pay attention to this disorder and find a more effective way to treat it. On the other hand, it has been shown that the separate use of psychodrama components and therapy based on acceptance and commitment can have a significant effect on the symptoms of social anxiety disorder. But using these two methods at conjunction with each other increases their positive effects even more. Therefore, it is recommended that people involved in mental health, such as psychotherapists, use this protocol to improve their clients' social anxiety disorder, quality of life and social relationships.
Acknowledgments
This article is the result of a research project approved and supported by Torbat Heydariyeh University of Medical Sciences. We would like to thank all our colleagues at Torbat Heydariyeh University of Medical Sciences and also the participants for their patience and cooperation.
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Citation: Kabusi, Malihe, Maliheh Eshaghzadeh, Elahe Ashouri and Zahra Sadeghi, et al. "The Effect of Group Therapy Based on Acceptance and Commitment with Psychodrama Components on Social Anxiety of Students with Social Anxiety Disorder." Clin Schizophr Relat Psychoses 16S (2022). Doi: 10.3371/CSRP.MKME.011222.
Copyright: © 2022 Kabusi M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.