The Effectiveness of Acceptance and Commitment Based Therapy on Death Anxiety in Women with Breast Cancer in Shiraz

Among all cancers, breast cancer is the second most common disease in women (2). Cancer can be a stressful event that endangers various aspects of a patient's health, including physical, mental, and family health (3). At present, the results of screening indicate that it causes an increase in worry about cancer, mental distress in women, and a lot of anxiety in women (4). According to Degi, cancer patients often suffer severe mental and emotional reactions, such as the feeling of imminent death (7). Death anxiety has been reported as an important psychological factor in cancer patients (8). Hence, it is crucial to explore various psychotherapeutic approaches for managing and enhancing the mental well-being of breast cancer patients. Among the psychotherapies that can be employed for individuals diagnosed with breast cancer, one of the effective methods is Acceptance and Commitment Therapy (ACT) (13). Acceptance and Commitment Therapy is a third-wave behavioral therapy introduced by Hayes (14). This treatment approach emphasizes having a comprehensive awareness of one's condition. The person is encouraged to be open and accepting of their pain and to allow thoughts related to the disease to arise naturally without trying to control them. When these experiences, such as thoughts and feelings, are observed with openness and acceptance, even the most painful ones become less threatening and more bearable (15). Therefore, the present study was conducted to investigate acceptance and commitment-based therapy for the death anxiety of women with breast cancer.

This study employs a quasi-experimental research design with a pre-test, post-test, and follow-up, along with a control group. The statistical analysis of the research includes 243 women aged 30 to 50 with breast cancer who, during the first four months of 2022, were referred to the breast cancer clinic located in the Motahari Clinic in Shiraz. The statistical sample size in this study was 50 people based on Cohen's table (1986). According to Sarmad et al. (16), It was selected by the purposeful sampling method based on the entry and exit criteria and randomly, in two groups of 25 people, test and control, using a 15-question questionnaire of the death anxiety questionnaire designed by Templer (1970); were selected and divided.The study utilized the acceptance and commitment therapy protocol of Hayes and Strossahl (19) to conduct intervention sessions for the experimental group. This approach was chosen to evaluate the effectiveness of the therapy based on acceptance and commitment. This study involved an 8-week treatment program for the experimental group, consisting of 90-minute group sessions held once a week. The control group did not receive any intervention. In each session, a specific topic, goal, and activity were discussed. The obtained information was analyzed at two descriptive and inferential levels. At the descriptive level, mean, standard deviation, maximum, and minimum scores were calculated and at the level of inferential statistics, repeated measurement variance analysis and post hoc tests were used, which were analyzed through SPSS version 24 computer software. In this article, a significant level (P<0.05) has been considered in data analysis.

The current study included 50 women aged 30 to 50 diagnosed with breast cancer, who were tested in two groups of 25 and assigned as witnesses. The average (standard deviation) age of the experimental group members was 41.36 (6.83) and the control group was 42.48 (60.50). The descriptive index table of the primary research variable displays the mean and standard deviation in the pre-test, post-test, and follow-up stages for both the test and control groups. Since there is not a significant difference between the pre-test scores of death anxiety in the control and experimental groups, the average scores of the post-test and follow-up stages of death anxiety in the experimental group are much lower than those of the control group. The study utilized analysis of variance with repeated measures to examine the impact of the acceptance and commitment-based treatment method on death anxiety. The study also looked at the significance of the difference between groups, as well as the effect of pre-testing and monitoring the change over time. Initially, Mochli's test was performed to verify the assumption of sphericity in the data. The test results indicate that the assumption of sphericity is met (X2 (2)= 0.07, p=0.967). The findings of the data analysis have been presented using a repeated measure analysis of variance test. The outcomes indicate that the interaction between death anxiety and the group is significant. In simpler terms, the average trend of the experimental and control groups differs from each other concerning the levels of the dependent variable of death anxiety (F=120.20, p<0.01). To compare the differences in death anxiety levels among the groups, we used an independent t-test. Additionally, to investigate alterations in the dependent variable levels over time, we conducted a one-way repeated measurement analysis of variance test. The independent t-test showed no significant difference in death anxiety pre-test scores between the control and experimental groups. However, post and follow-up scores were lower in the experimental group, indicating the intervention was effective. The results of the data analysis, using the repeated measurement analysis of variance test, indicate that there is a significant difference between the averages of at least one pair of dependent variable levels in the experimental group (F=105.84, p<0.01) and the control group (F=32.99, p<0.01). The Benferroni's post hoc test was used to compare means. Results revealed that death anxiety scores in the experimental group were lower in the post-test and follow-up compared to the pre-test. In the control group, death anxiety scores were lower in follow-up than both post-test and pre-test.

The study found that treating women with breast cancer through acceptance and commitment therapy reduced their fear of death. The results support a previous study on multiple sclerosis patients. They found that such treatment reduced death anxiety and hopelessness and had a long-lasting effect. (22) Khalili's research shows that acceptance and commitment to treatment reduce pain catastrophizing and death anxiety in cancer patients, as previously found. However, it doesn't significantly reduce pain intensity. Thus, it can improve the quality of life for cancer patients (23). Individuals with a positive attitude towards death have less death anxiety and avoidance, according to research by Kaladozan, Kajbaf, Areidi, Abedi, and Makarian. The study also found a significant increase in mental health, which is a key indicator of quality of life (24). In their research, Arch and Mitchell found that acceptance and commitment-based treatments are effective in helping breast cancer patients cope with anxiety related to re-entering their lives after treatment (25). The treatment based on acceptance and commitment techniques effectively decreases death anxiety in patients by controlling negative emotions and increasing self-awareness. This creates a better connection to the acceptance of medical treatments. It is important to note the following limitations of this research: 1) The sample size of women with breast cancer in Shiraz City was limited, 2) Other potential mental health issues for those with breast cancer were not examined, and 3) The focus was solely on patient issues, without considering the mental health of family members. To improve future research, investigate other groups and diseases, and different regions. Check for physical or psychological disorders that may coexist with dependent variables. Study patients' families in future research.