The Effect of Behavioral-Emotional Spiritual Therapy on Obsessive-Compulsive Symptoms, Obsessive Beliefs and Fusion of Thought and Action

Obsessive Compulsive Disorder (OCD) is a common and exhausting disease. The present study aimed to investigate the effect of integrated behavioral-emotional spiritual therapy on obsessive-compulsive disorder, obsessive beliefs, and fusion of thought and action in patients with obsessive-compulsive disorder. The study used a controlled trial with pre-test, post-test, and two-month follow-up design. In this study, 40 people suffering from OCD participated and were divided into two groups experimental and control. The experimental group received emotional-spiritual behavioral therapy in 15 ninety-minute sessions, and the control group did not receive any intervention. The data collection tools included a semi-structured interview based on DSM5 (SCID-I), the Obsessive-Compulsive Questionnaire, the Obsessive Beliefs Questionnaire, and the Questionnaire on the Fusion of Thought and Action. The participants answered to the scales at the beginning and end of the treatment and two months after the treatment. The data were analyzed using the analysis of the covariance test. The findings of the research showed that emotional-spiritual behavioral therapy significantly reduced obsessive-compulsive disorder, and obsessive beliefs including extreme responsibility, perfectionism, control of thoughts, and fusion of thought and action. According to the findings of the research, emotional-spiritual behavioral therapy was effective in reducing obsessive-compulsive disorder, obsessive beliefs, and fusion and action.
Obsessive Compulsive Disorder is characterized by obsessive thoughts or compulsive behaviors or both. Obsessions include recurrent and persistent thoughts, desires, or perceptions that are experienced in an intrusive and obnoxious manner. Compulsions are experienced in two ways of overt behaviors and hidden behaviors. Overt compulsions are like frequent hand washing, extreme order, and checking, hidden compulsions are repetitive mental activities such as counting and slowly repeating words (Najafi et al., 2022). Obsessive beliefs and fusion of thought and action are factors that perpetuate obsessive-compulsive disorder. Obsessive beliefs and fusion of thought and action are factors that perpetuate OCD. 
Cognitive-behavioral therapy and exposure and response prevention therapy are among the most important treatments for OCD. However, each of these treatments has shortcomings. Nowadays, therapists are looking to combine the effective components of different treatments and increase their efficiency to solve shortcomings. Paying attention to different and numerous variables in the explanation of OCD leads to a deeper and more comprehensive look at the dimensions of OCD and as a result, more efficient treatment formulation (Fisher et al., 2020). The past research has shown a positive relationship between religiosity and mental health (Borghei et al., 2020). Today, a wide range of therapists believe that to increase the effectiveness of psychotherapy for religious people, positive religious and spiritual attitudes and feelings should be combined with psychotherapy (Fox et al., 2020). Therefore, the question of this research was: What is the effectiveness of behavioral-emotional-spiritual therapy in reducing OCD symptoms, obsessive beliefs, and fusion of thought and action in obsessive-compulsive patients?
 
The design of the present study was a randomized controlled trial with pre-test-post-test and follow-up. The statistical population included all people suffering from OCD in the city of Qom. The sample consisted of 40 people who were selected and randomly and equally placed in two experimental and control groups based on the variables of age, marital status, education, and history of OCD.
The participants in the experimental group received the spiritual-emotional behavioral protocol in the form of 15 group therapy sessions, and the control group remained in the waiting line and received obsessive-compulsive therapy due to ethical issues after the research. The behavioral emotional-spiritual protocol for the treatment of OCD includes 15 sessions: establishing a therapeutic relationship and explaining the logic of the treatment, secondary positive spiritual evaluation of negative thoughts, accepting doubts, self-soothing, reducing the fusion of thought and action, exposure and response prevention, Acceptance of doubt and behavior management, mindfulness skills mixed with spirituality, removing barriers to exposure and response prevention therapy, increasing quality of life and modifying lifestyle.
All participants completed the research questionnaires. Analysis of variance, multivariate analysis of covariance (MANCOVA), and univariate analysis of covariance were used to analyze the data with SPSS-24 software. 
 
The assumptions of the analysis of the covariance test were checked. Multivariate covariance analysis was performed and the results in the post-test were in the Pillai's Trace (F(5,26)=0.661, p <0.001), Wilks' Lambda (F(5,26) =0.339, p <0.001), Hotelling's Trace (F(5,26) =1.950, p <0.001), the Roy's Largest Root (F(5,26) =1.950, p <0.001) showed that the difference between the two experimental and control groups in the total variables of obsessive compulsiveness, a fusion of thought and action and obsessive beliefs was 66% significant (p<0.001). Also, the results in the follow-up test in the Pillai's Trace (F(5,26) =0.612, p <0.001), Wilks' Lambda (F(5,26) =0.388, p <0.001), and the Hotelling's Trace(F(5,26) =1.576, p <0.001), the Roy's Largest Root (F(5,26) =1/576, p<0.001) showed that the difference between the two experimental and control groups in total variables is significant by 61% (p<0.001). To determine the variables in which the post-test had a significant difference from the pre-test, a univariate analysis of the covariance test was performed. The results are presented in Table 1.
 
 
Table 1
The Results of Univariate Analysis of Covariance (ANCOA) In the Post-Test and Follow-Up with Pre-Test




Source of changes


The dependent variable


Time


Degrees of freedom


mean square


F


P


Eta squared




group


obsessive compulsive


Posttest


1


1280.796


22.69


0.001


0.400




Follow-up test


1


282.620


40.484


0.001


0.544




obsession


Posttest


1


320.280


19.187


0.001


0.361




Follow-up test


1


73.436


30.855


0.001


0.476




compulsion


Posttest


1


319.313


22.693


0.001


0.400




Follow-up test


1


62.781


24.025


0.001


0.414




Thought action fusion


Posttest


1


781.421


16.214


0.001


0.323




Follow-up test


1


608.212


6.639


0.014


0.163




likelihood thought-action fusion


Posttest


1


152.582


16.580


0.001


0.328




Follow-up test


1


101.048


4.950


0.013


0.131




Moral thought action fusion


Posttest


1


266.897


9.553


0.004


0.219




Follow-up test


1


219.149


3.916


0.014


0.123




Extreme sense of responsibility


Posttest


1


3083.484


16.750


0.001


0.330




Follow-up test


1


1844.798


12.935


0.001


0.276




Perfectionism


Posttest


1


4218.571


14.475


0.001


0.299




Follow-up test


1


2263.043


9.965


0.003


0.227




Thought control


Posttest


1


1828.083


25.772


0.001


0.431




Follow-up test


1


1661.643


22.671


0.001


0.400




*P<0.05     ** P<0.01  

The results of Table 1 shows that the participants in the behavioral-emotional spiritual group had significantly more reductions in OCD, fusion of thought and action, and obsessive beliefs in the post-test and follow-up test than the participants in the control group.
 
The research showed that behavioral-emotional spiritual therapy significantly reduced OCD and the fusion of thought and action and obsessive beliefs, and the achievements of the treatment were maintained two months after the treatment. In explaining this finding, it can be said that in religious people suffering from obsession, psychological and spiritual issues are intertwined in such a way that they cannot be separated. The behavioral-emotional spiritual therapy pays special attention to the spiritual aspects of OCD. This treatment pays attention to a person's religious values and differentiates between religious values and obsessive beliefs. It increases the client's insight into obsessional doubts and teaches him that avoidant, safe-keeping, and reassurance-seeking behaviors may be revealed in the religious context and are different from healthy religious practices and cause the persistence of obsessions. On the other hand, by reviewing the purpose of life and conceptualizing OCD as an opportunity to get closer to God, this treatment creates a sense of meaning in the person and strengthens his motivation to do exposure and response prevention exercises.
In this treatment, OCD is conceptualized as a psychological injury like a physical injury. The difference between obsessive thoughts, which are involuntary and accompanied by suffering and voluntary thoughts accompanied by pleasure, which is a kind of moral vice, was explained. Spiritual anxiety, which is due to a little faith in God, is separated from psychological anxiety, which is due to problems with hormones and neurotransmitters. Patience over doubts and trying to do exercises is conceptualized as an opportunity to get closer to God. It is explained to the person that striving in the way of God increases the capacity of existence and when a person performs his academic, job, family, and social activities despite the obsessive discomfort, he gets more reward and spiritual growth than healthy people. Creating these positive spiritual attitudes reduces obsessive beliefs.
 
Ethical Consideration
Compliance with Ethical Guidelines: All ethical issues were compiled based on ethical committee of Semnan University.
Authors’ Contributions: All authors contributed to the study. The first author administered behavioral emotional-spiritual therapy to the participants and written the first draft of the manuscript. The second author edited the manuscript.Conflict of Interest: The authors declare no conflict of interest for this study.
Funding: The study had no financial support.Acknowledgment: The authors would like to thank all participants for their time and contribution to the study.