The Effectiveness of Acceptance and Commitment-Based Therapy on the Death Anxiety of Patients with Advanced Cancer

Received: 16-Dec-2021 Accepted Date: Dec 30, 2021 ; Published: 06-Jan-2022

Introduction

Cancer is one of the most terrifying diseases that human beings suffer from, and people constantly feel at risk of cancer [1]. More than 15.5 million people are currently suffering from cancer, which is projected to increase to 20.3 million by 2026 [2]. People with cancer are at risk of increased mortality and disease recurrence, which in turn leads to reduced quality of life [3]. For example, cancer can even lead to a deep crisis in one’s life that endangers his or her future [4]. It can also lead to chronic symptoms such as depression and anxiety, which are caused by the thought of death [5]. One of the great fears of human beings is the fear of death, which is seen in 80% of people with advanced cancers [6].

Fear of Death (FOD) occurs when people feel terrified, frightened, or overly anxious while thinking about the process of death or disconnecting from the world and what happens after death [7], which is a common phenomenon in all societies [8]. Death anxiety can be one of the most important psychological diagnoses in people with advanced cancer [9]. People react differently to death anxiety. For example; some people are emotionally detached, some may began to do insignificant works, and others may suppress or deny their thoughts [10]. As the disease progresses, people suffer from pain, loneliness, and decreased control, all of which have been reported as dimensions of death anxiety [11]. According to the above statements, it can be said that people with death anxiety require emotional and social support that helps to maintain their quality of life [12]. The meaning of life for these people is correlated with the death anxiety [13]. Advanced cancer can lead to psychological distress and awareness of illness can lead to more symptoms. In patients, who experience these symptoms psychologically, the ability to cope with impending death and the resulting fear may be difficult, so they require psychotherapeutic interventions [14].

So far, various psychotherapeutic approaches such as cognitive- behavioral therapy and semantic therapy have been effective in reducing patients' death anxiety [15,16]. Among these, therapy that is based on the acceptance of death may create positive coping in cancer patients [17]. In the last two decades, the significant growth of studies in the field of third wave therapies, especially acceptance and commitment-based therapy, has emphasized on the effectiveness of this therapeutic approach in the treatment of several diseases [18]. Acceptance and commitment-based therapy is one of the third wave behavioural therapies, and is considered as an interdisciplinary treatment for medicine and psychology [19]. The main purpose of this treatment is to create psychological flexibility, which means to create the ability to make practical choices between different options that are more appropriate, rather than just taking action to avoid disturbing thoughts, feelings, memories, or desires, or actually imposing them on the individual [20].

Various studies have examined the role of acceptance and commitmentbased therapy in improving pervasive anxiety, and their results show that creation and cultivation of commitment and acceptance in patients, especially those suffering from social anxiety, reduces their stress and problems [21]. It also reduces death anxiety in people with AIDS [22]. Similarly, various studies have shown the effectiveness of this treatment in improving depression, social phobia and empathy [22,23]. In another study, the effectiveness of acceptance and commitment-based therapy in improving stress and promoting health among women with physical disabilities, including spinal cord injury and multiple sclerosis, was evaluated and the results showed that this treatment is effective in reducing stress [24]. Supportive and empowerment-based interventions play an important role in the positive coping of patients and caregivers [25,26].

Therefore, according to the needs of patients with advanced cancer and also the psychological effects of death anxiety, in this study we decided to investigate the effect of acceptance and commitment-based therapy on the death anxiety of patients with advanced cancer.

Methods

This is a control clinical trial study with pre-test and post-test design to control the factors undermining internal validity. The population in this study comprised of 120 cancer patients referred to the palliative therapy center of Torbat-e Heydariyeh University of Medical Sciences in 2019 to undergo chemotherapy. The sampling was done by convenience method.

Inclusion criteria: Inclusion criteria included the confirmed diagnosis of cancer by physician and age of over 18 years. Exclusion criteria were; inability to communicate and unwillingness to participate in the study.

Accordingly, 60 patients who had the necessary criteria were invited to enter the study. The sample size in this study was calculated to be 15 subjects in each intervention and control groups, so 30 individuals were selected from the eligible patients, and then were allocated into the intervention and control groups by simple random method.

The present study has been approved by the Ethics Committee of Torbat-e Heydariyeh University of Medical Sciences (Code: IR.THUMS. REC.1397.0019). Before the study, its general objectives were explained to the cancer patients and they were assured that their information would remain confidential. All ethical principles have been observed in this study. The participants were allowed to leave the study at any time, and the control group received the intervention at the end of the study.

The Templer’s Death Anxiety Scale (TDAS) was used in this study for data collection. This tool was designed by Professor Donald Templer in 1970, and has been used as a valid tool to measure death anxiety for about 40 years. The validity and reliability of this tool have been proven in different countries and articles, and it has also been translated and validated in Iran.

This scale consists of 15 items with the correct and incorrect responses. In 9 out of 15 items, the choice of correct response is given a score of 1, and in 6 items, the choice of incorrect response is given a score of 1. The total score of this scale ranges from 0 to 15, with higher score indicating higher death anxiety.

The Templer’s Death Anxiety Scale is a valid and standard scale that has been used repeatedly to measure death anxiety in various studies around the world [1,27]. This fact was adequate to confirm the validity of this tool for this study. The reliability of this tool was confirmed in the study of Masoud Zadeh et al. with a correlation coefficient of 0.95 [28].

The intervention group underwent acceptance and commitment-based therapy on a weekly basis for eight sessions (each season was 60 minutes). Therapeutic sessions were held at the palliative therapy center of Torbat-e Heydariyeh University of Medical Sciences. The description of therapy sessions is given in Table 1. Samples in the intervention and control groups completed the TDAS tool at pre-test and post-test.

Chi-square test, Fisher's exact test, independent t-test and analysis of covariance (ANCOVA) were used for statistical analysis and study hypothesis with the help of SPSS software version 21. Also, a significant level of 0.05 was considered in all tests.

Results

The mean age of patients in the intervention group was 55.13 ± 20.27 years and in the control group was 53.83 ± 17.36 years, and statistically, independent t-test did not show a significant difference between the two groups in this regard. Chi-square test did not show a significant difference between the two groups in terms of gender (P=0.7). Fisher’s exact test did not show a significant difference between the two groups in terms of income level (P=0.86) and education (P=0.74) (Table 1).

The score of death anxiety before intervention in the intervention group was 8.3 ± 1.53 and in the control group was 7.3 ± 1.46. Independent t-test did not show a significant difference between the two groups in terms of the death anxiety score before the intervention (P=0.41). However, after the intervention, the death anxiety score in the intervention group was 6.3 ± 2.77 and in the control group was 8.3 ± 1.18, and independent t-test showed a significant difference between the two groups in this regard (P<0.01). Also, paired t-test showed a significant difference between the mean scores of death anxiety before and after the intervention in the intervention group (P<0.01), but it did not show a significant difference in the control group (P=0.31) (Table 1).

The ANCOVA test, by controlling the score of death anxiety before the intervention, showed a statistically significant difference in the mean scores of death anxiety in both groups after the intervention (P=0.03), (Table 2). The results of this study showed that intervention was able to reduce the level of death anxiety in patients.

Discussion

The aim of this study was to evaluate the effectiveness of acceptance and commitment-based therapy in reducing the death anxiety of cancer patients. Subjects in the intervention group reported a significant reduction in their death anxiety compared to those in the control group after receiving the intervention. Findings of this study are in line with the study of Pourfarahani et al. which examined the effectiveness of acceptance and commitment-based therapy in reducing the social anxiety of adolescent girls and showed a significant reduction in their social anxiety (P<0.05) [21]. The study of Mirzaeian et al. which examined the effectiveness of acceptance and commitment-based therapy in reducing death anxiety and increasing mental health in women with AIDS, also showed the positive effect of this treatment [22]. Zarei et al. conducted a similar study on pregnant women and obtained the same results [23]. The results of another study by Hoffman et al. indicated the positive effect of acceptance and commitment-based therapy on health anxiety and psychological flexibility of individuals [29]. Acceptance and commitment-based therapy does not directly reduce the anxiety of patients with chronic diseases such as AIDS, but since the psychological suffering of affected patients’ stems from their dysfunctional thoughts and feelings, this treatment reduces their connections with these thoughts and dysfunctional feelings, and consequently reduces their psychological distress, anxiety and depression and increases their mental health [30].

Acceptance and commitment-based therapy eliminates psychological inflexibility in two ways. On the one hand, acceptance and commitmentbased therapy, by strengthening the processes of mindfulness, including acceptance, commitment and communication with the present time (active contact with internal and external stimuli, without trying to change their shape or frequency), helps patients to respond to internal and external stimuli without avoiding internal and external experiences. On the other hand, in acceptance and commitment-based therapy, therapists are committed to respect patient’s values and patients are encouraged to explore and identify what is important to them in different aspects of life [22]. In fact, values are general and abstract concepts that show a person the important directions in life. In acceptance and commitment-based therapy, the therapist challenges clients to identify what is important to them in life, including marriage and intimacy, family relationships, friendships and social interaction, careers and Jobs, personal and educational growth and development, recreation and leisure, religion and spirituality, citizenship behaviour, and physical-mental well-being [24]. One of these values and dimensions is spirituality and religion. Various studies have emphasized on the negative relationship between religious affiliation, spirituality and death anxiety. This means that the more religious and spiritual beliefs a person has, the less anxiety he or she experiences [22]. The use of spiritual dimensions plays an important role in patient adjustment and reduction of suffering [31,32]. Therefore, nurses can use interdisciplinary therapies in their nursing practice and also, by taking into account the mental and psychological needs of patients, implement effective nursing care for patients. One of the limitations of present study was the lack of followup period (due to time constraints) to evaluate the effectiveness of this treatment in long term. Another limitation that can be mentioned is the use of death anxiety self-assessment tool, which is a self-reporting tool that may cause the subjects to show a more favourable image of them. According to the results of this study, it is suggested that a study with this therapeutic approach be performed in other diseases over a longer period of time.

Conclusion

Due to the effectiveness of acceptance and commitment-based therapy, this treatment method can be used as a complementary, effective and low-cost treatment method in nursing care. Therefore, it is suggested that managers and health care providers play an important role in promoting health and reducing patients' anxiety by considering such methods and train the treatment staffs such as nurses and caregivers about the use of these complementary methods.

References

1. Pour, N. Hekmati and H. Hojjati. "The Relationship between Praying and Life Expectancy in Cancerous Patients." J Med Life 8 (2015): 60-64.
2. Basharpoor, Sajjad, Sholeh Amani and Mohammad Narimani. "The Effectiveness of Narrative Exposure Therapy on Improving Posttraumatic Symptoms and Interpersonal Reactivity in Patients with Cancer." Arch Rehab 20 (2019): 230-41.
3. Hirschey, Rachel, Ashley Leak Bryant, Catherine Macek and Claudio Battaglini, et al. "Predicting Physical Activity among Cancer Survivors: Meta-Analytic Path Modeling of Longitudinal Studies." Health Psychol 39 (2020): 269.
4. Jemal, Ahmedin, Freddie Bray, Melissa M. Center and Jacques Ferlay, et al. "Global Cancer Statistics." CA Cancer J Clin 61 (2011): 69-90.
5. Griffiths, Roland R., Matthew W. Johnson, Michael A. Carducci and Annie Umbricht, et al. "Psilocybin Produces Substantial and Sustained Decreases in Depression and Anxiety in Patients with Life-Threatening Cancer: A Randomized Double-Blind Trial." J Psychopharmacol 30 (2016): 1181-1197.
6. Grossman, Christopher H., Joanne Brooker, Natasha Michael and David Kissane. "Death Anxiety Interventions in Patients with Advanced Cancer: A Systematic Review." Palliat Med 32 (2018): 172-184.
7. Karampour, Saraa, Malek Fereidooni-Moghadam, Kourosh Zarea, and Bahman Cheraghian. "The Prevalence of Death Anxiety among Patients with Breast Cancer." BMJ Support Palliat Care 8 (2018): 61-63.
8. Vahdat, Sahar. "The Complex Effects of Adipokines in the Patients with Kidney Disease." J Res Med Sci 23 (2018).
9. Hajabadi, Negar Ranjbar, Roya Ebrahimi, Sakine Farhadi and Hojjati Hamid, et al. "The Relationship between Frequency of Prayer and Death Anxiety in Cancer Patients." Ind J Forensic Med Toxicol 14 (2020): 2163-2167.
10. Safari Mousavi, Sayed Sina, Firoozeh Ghazanfari, and Fazlolah Mirderikvandi. "Effectiveness of Acceptance and Commitment Therapy on Death Anxiety in Women with Multiple Sclerosis in Khorramabad." J Clin Nurs Midwifery 7 (2019): 234-241.
11. Borjali, Mahmoud, Moslem Abbasi, Arezo Asadian and Nader Ayadi. “Effectiveness of Group Logo Therapy on the Anxiety of Death and Life Expectancy of Patients with Stomach Cancer.” J Jundishapur Scientific Med 15 (2017): 635-464.
12. Uslu-Sahan, Fatma, Fusun Terzioglu and Gulten Koc. "Hopelessness, Death Anxiety, and Social Support of Hospitalized Patients with Gynecologic Cancer and their Caregivers." Cancer Nurs 42 (2019): 373-380.
13. Özdemir, Seher, Süleyman Kahraman and Hakan Ertufan. "Comparison of Death Anxiety, Self-Esteem, and Personality Traits of the People Who Live in Turkey and Denmark." OMEGA-J Death and Dying 84 (2021): 360-377.
14. An, Ekaterina, Christopher Lo, Sarah Hales and Camilla Zimmermann, et al. "Demoralization and Death Anxiety in Advanced Cancer." Psychooncology 27 (2018): 2566-2572.
15. Fathi, D. "Effectiveness of GroupCognitive-Behavioral Therapy on Death Anxiety among the Breavement Elderly‌‌ Man." J Geriat Nurs 1 (2015): 60-69.
16. Ghorbanalipour, M. and A. Esma’ili. "Determining the Efficacy of Logo Therapy in Death Anxiety among the Older Adults." Culture Counseling 3 (2012): 53-68.
17. Philipp, Rebecca, Anja Mehnert, Chris Lo and Volkmar Müller, et al. "Characterizing Death Acceptance among Patients with Cancer." Psychooncology 28 (2019): 854-862.
18. Powers, Mark B., Maarten B. Zum Vörde Sive Vörding, and Paul MG Emmelkamp. "Acceptance and Commitment Therapy: A Meta-Analytic Review." Psychother Psychosom 78 (2009): 73-80.
19. Burian, Hannah, Kerem Böge, Ronald Burian and Annette Burns, et al. "Acceptance and Commitment-Based Therapy for Patients with Psychiatric and Physical Health Conditions in Routine General Hospital Care–Development, Implementation and Outcomes." J Psychosom Res 143 (2021): 110374.
20. Golestanifar, Soroush and Zahra DashtBozorgi. "The Effectiveness of Acceptance and Commitment Based Therapy on Depression, Psychological Health and Life Expectancy of the Elderly with Nonclinical Depression." Aging Psychol 6 (2020): 191-203.
21. Pourfarahani, Monireh, Hossein Ahmad Barabadi and Ahmad Heydarnia. "The Effectiveness of Acceptance and Commitment Group Therapy in the Social Anxiety of Adolescent Orphan Girls." Quart J Soc Work 8 (2020): 5-13.
22. Mirzaeidoostan, Zeynab, Yadola Zargar, and Arash Zandi Payam. "The Effectiveness of Acceptance and Commitment Therapy on Death Anxiety and Mental Health in Women with HIV in Abadan City, Iran." Iran J Psychia Clin Psychol 25 (2019): 2-13.
23. Vaghee, Saeed, Masoud Kashani Lotfabadi, Azam Salarhaji, Nastaran Vaghei, and Bibi Maryam Hashemi. "Comparing the Effects of Contact-Based Education and Acceptance and Commitment-Based Training on Empathy toward Mental Illnesses among Nursing Students." Iran J Psychiatry 13 (2018): 119-127.
24. Aalaei, M. "The Effectiveness of Acceptance and Commitment Therapy on Test Anxiety and Academic Achievement in Secondary School Students." PhD diss., University of Kurdistan, (2017).
25. Yazarloo, Mahla, Hamid Hojjati and Zahra Abdolreza Gharebagh. "The Effect of Spiritual Self-Care Education on Stress of Mothers of Premature Infants Admitted to NICU of Hospitals Affiliated to Golestan University of Medical Sciences (2019)." Pak J Med Health Sci 14 (2020): 1615-1619.
26. Sajadi, Hanieh, Golbahar Akhoundzadeh and Hamid Hojjati. "The Effect of Empowerment Program on Participation of Mothers with Premature Infants Hospitalized in Neonatal Intensive Care Unit of Sayyed Shirazi Hospital in Gorgan, in 2018." Ind J Forensic Med Toxicol 14 (2020): 1269-1276.
27. Delnavaz, P., M. Sadeghi, H. Hojjati and N. Hekmatipour. "The Effect of Prayer Voice and Therapeutic Reminders on the Anxiety of Death of Hospitalized Patients in the CCuDepartment." Int J Psychosocial Rehab 24 (2020): 1475-7192.
28. Tomás-Sábado, Joaquín and Juana Gómez-Benito. "Psychometric Properties of the Spanish Form of Templer's Death Anxiety Scale." Psychol Rep 91 (2002): 1116-1120.
29. Hoffmann, Ditte, Lea Halsboe, Trine Eilenberg and Jens S. Jensen, et al. "A Pilot Study of Processes of Change in Group-Based Acceptance and Commitment Therapy for Health Anxiety." J Context Behav Sci 3 (2014): 189-195.
30. Mirzaeidoostan, Zeynab, Yadola Zargar and Arash Zandi Payam. "The Effectiveness of Acceptance and Commitment Therapy on Death Anxiety and Mental Health in Women with HIV in Abadan City, Iran." Iran J of Psychia Clin Psychol 25 (2019): 2-13.
31. Yolme, Aman Bibi Soltani, Hamid Hojjati and Golbahar Akhoundzadeh. "The Effect of Islamic Semanticism on Self-Reporting and Lifestyles of Mothers of Adolescents with Thalassemia." Int J Adolesc Med Health (2020): 1-3.
32. Sadeghloo, Adeleh, Somayyeh Meshkani, Hamid Hojjati and Devender Bhalla. "Therapeutic Health Benefits of Religion among Elderly-A Population based Representative Survey from Iran." Ind J Forensic Med Toxicol 14 (2020): 1-5.

Citation: Sahebanmaleki, Mohsen, Anahita Zandi, Zahra Sadeghi and Hamid Nazari, et al. “ The Effectiveness of Acceptance and Commitment-Based Therapy on the Death Anxiety of Patients with Advanced Cancer.” Clin Schizophr Relat Psychoses 15S(2021). Doi:10.3371/CSRP.SMAZ.010622.

Copyright: © 2022 Sahebanmaleki 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.