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Journal of Fundamentals
of Mental Health
Mashhad University
of Medical Sciences
Psychiatry and Behavioral Sciences
Research Center
Fundamentals of Mental Health, 2022 Jul-Aug http://jfmh.mums.ac.ir 241
Original Article
Obsession improvement in female patients with relationship
obsessive compulsive disorder: A single subject study
*Soheila Ghomian
1
; Mohammad Reza Shaeiri2; Hojjatollah Farahani3
1Ph.D. in clinical psychology, Department of Psychology, Faculty of Humanities, Shahed University, Tehran, Iran.
2Ph.D. in psychology, Department of Psychology, Faculty of Humanities, Shahed University, Tehran, Iran.
3Ph.D. in psychology, Department of Psychology, Faculty of Humanities, Tarbiat Modares University, Tehran, Iran.
Abstract
Introduction: The present study aimed to evaluate the efficacy of the combined protocol of Acceptance and
Commitment Therapy (ACT) for Obsessive-Compulsive Disorder (OCD) and ACT affecting couples' interpersonal
context on improving relationship obsession of female patients with Relationship Obsessive-Compulsive Disorder
(ROCD).
Materials and Methods: The present study was conducted as a single-subject study with a multiple baseline design
to evaluate the efficacy of the combined protocol of ACT for OCD and couples on improving ROCD in Iranian couples.
The sample was married students studying at Tehran universities in 2019 with a ROCD diagnosis. In the combined
treatment of ACT for OCD and couples, two patients; in the ACT for OCD, two patients, and the ACT for couples, two
patients were studied that were randomly replaced in these treatments. Research instruments included New Partner-
Related Obsessive-Compulsive Symptoms Inventory (New PROCSI), and New Relationship Obsessive-Compulsive
Inventory (New ROCI).
Results: The scores of participants' median, average, relative, and absolute levels decreased from baseline to treatment
stage in both new PROCSI and new ROCI. Also, except for participants 5 and 6, the rest of the participants from baseline
to treatment showed stable changes in both questionnaires. The Mean Baseline Reduction (MBLR) and Reliable Change
Index (RCI) of those who received the combined ACT were better than those who received other forms of ACT.
Conclusion: The combined treatment of ACT for OCD and couples is the most effective method to reduce the score
of new PROCSI and new ROCI compared to the other two treatments.
Keywords: Acceptance and Commitment Therapy, Couples, Relationship Obsessive-Compulsive Disorder
Please cite this paper as:
Ghomian S, Shaeiri MR, Farahani H. Obsession improvement in female patients with relationship obsessive compulsive disorder: A
single subject study. Journal of Fundamentals of Mental Health 2022 Jul-Aug; 24(4): 241-251.
Introduction
Doron et al. (1) have proposed a new theme of
OCD called Relationship Obsessive-Compulsive
Disorder (ROCD). ROCD symptoms range from
*Corresponding Author:
Department of Psychology, Faculty of Humanities, Shahed University, Tehran, Iran.
soheila_ghomian@yahoo.com
Received: May. 03, 2021
Accepted: May. 07, 2022
obsessions focused on spouse characteristics (such
as doubt about intelligence and social competence
of spouse) and relationship to spouse (such as
doubt about loving a spouse), as well as a range of
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compulsive behaviors such as frequent checking
(like repeatedly checking how one feels about their
spouse), comparisons (such as comparing the
characteristics of the spouse with others),
neutralization (such as visualizing happy moments
with the spouse) and reassurance. Obsessions and
compulsive behaviors related to ROCD lead to
distress and often affect one's social and
occupational function and other areas of life. For
example, mental occupations about
communication are often ego-dystonic, meaning
that they conflict with one's perception of the
relationship with her/his spouse or that they may
conflict with one's intrinsic values. These mental
conflicts are perceived as unacceptable and
unwanted, and often the individual feels guilty and
embarrassed because of their occurrence and/or
content (1).
Relationship-focused Obsessive-Compulsive
(OC) symptoms, like other symptoms of OCD,
only follow the treatment accompanied by
significant disabling distress. ROCD is usually
diagnosed late because people with this disorder
believe that such experiences, even if distressing,
are a natural part of the relationship that is forming
and reflect the natural problems of life. In addition,
people with ROCD usually seek treatment when
they experience relationship instability.
Therefore, it can be said that a person who suffers
from symptoms of ROCD needs specific
interventions (1). There is plausible evidence of
the efficacy of Cognitive-Behavioral Therapy
(CBT) for OCD (2-6), but not everyone responds
appropriately to this treatment, and many of these
patients either discontinue this treatment or
develop symptoms when the treatment is
completed (3,7).
The results of various studies indicate that to
remain patients with OCD in treatment, it is
necessary to provide a basis for accepting their
beliefs instead of challenging them. Therefore, it is
best to avoid confronting or challenging their
thoughts and focus on the interplay of their
symptoms with their performance. This issue has
been addressed in acceptance-based therapies
(8,9). Therefore, improving patients' acceptability
in treating OCD seems to be a priority (10).
Acceptance and Commitment Therapy (ACT),
one of the acceptance-based therapies, is based on
the assumption that it is challenging to remove
cognitions that the individual has learned over time
(11,12). The goal of ACT for OCD is to help the
patient move toward a meaningful and valuable
life, even with unwanted thoughts, anxiety, and a
desire to perform compulsive behaviors. This goal
can be achieved through acceptance, cognitive
defusion, awareness of the present moment, self as
context, values (moving towards values), and
committed action (13).
ACT is one of the treatments for OCD that is
growing evidence supporting it (14-23). In this
regard, using a multiple baseline design, Twohig
et al. (15) showed that patients with OCD
significantly decreased obsessive-compulsive
symptoms after ACT and three months follow-ups.
Also, as predicted, patients showed a significant
improvement in symptoms of anxiety and
depression, which was seen following the
reduction of experimental avoidance and
believability of thoughts and the need to respond
to obsessions. Also, Twohig et al. (24), in one of
the most extensive randomized controlled trials of
ACT for OCD, treated 79 patients with OCD who
underwent 8-session ACT and Progressive
Relaxation Training (PRT) without the use of
traditional exposure training.
The results of their study, with the help of the
Yale-Brown Obsessive Compulsive Scale (Y-
BOCS), showed that ACT had a more significant
change in the severity of OCD in patients at post-
test and follow-up period compared to PRT.
However, the rate of patients' acceptance (25) of
ACT was significantly higher than that of patients
receiving PRT (on a 5-point scale, ACT: 4.4 and
PRT: 3.7). In Iran, few studies have been
performed on the effect of ACT on OCD.
Nevertheless, all these studies indicate the efficacy
of ACT for OCD (26-28).
On the other hand, the striking point in recent
research is that OCD has been addressed in the
communication context, and there seems to be a
bilateral interaction between OCD and the
communication context: OCD symptoms affect
intimate communication, and aspects of
communication also plays a role in the persistence
of OCD (29). Thus, there is a faulty cycle of OCD
symptoms and maladaptive communication in
couples (30).
Various studies have examined the role of
couples' communications in the persistence of
OCD and have shown limited attention to altering
and modifying these interpersonal dynamics,
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which are associated with prevention of treatment
and increased risk of recurrent OCD (30). In this
regard, few studies have been conducted with the
help of CBT. For example, a study by Boeding et
al. (31) examined the spouse's adaptive behaviors
of patients with OCD and showed that prior to
CBT, spouse compliance was positively correlated
with the patient's OCD symptoms and was
negatively correlated with marital satisfaction.
Also, after 16 sessions of CBT for the patient, there
was a significant relationship between the spouse's
compliance with poor treatment outcomes.
Thus, Boeding et al. (31) emphasized the
necessity of accompanying patients' spouses in the
treatment process. In Iran, in the study by Soroush
et al. (32), the effectiveness of emotion-oriented
and behavioral-integrated couple therapy on
obsessive-compulsive syndrome and marital
boredom of couples with the obsessive-
compulsive disorder has been proven.
According to reviews, it was found that in only
one study, the combination of intervention for
OCD and couple-based intervention was
considered. A study by Abramowitz et al. (30)
introduced an ERP upgrading and couple-based
therapy program for couples whose one of them is
suffering from OCD.
It was a couple-based treatment program that
increased the efficacy of ERP on OCD symptoms.
The results of this study, with the help of a case
study, indicated the efficacy of the designed
program in improving OCD symptoms and
communication context.
In Iran, several studies have shown the efficacy
of ACT in the communication context of couples
(30,33-36). However, according to reviews, so far,
no study has been conducted to evaluate the
efficacy of ACT in improving ROCD as well as in
enhancing the quality of communication context of
couples with OCD, including ROCD.
Thus, according to foreign and Iranian studies,
the vacuum of the study of the efficacy of ACT on
ROCD and, the importance of the interpersonal
context of couples with OCD and the vacuum of
the study of the efficacy of ACT on enhancing the
quality of interpersonal communication in couples
with ROCD, the purpose of the present study was
to evaluate the efficacy of the combined protocol
of ACT for ROCD and ACT affecting couples'
interpersonal context on improving relationship
obsession of female patients with ROCD.
Materials and Methods
The present study was conducted as a single-
subject study with a multiple baseline design to
evaluate the efficacy of the combined protocol of
ACT for OCD and couples on improving ROCD
in Iranian couples (IRCT code of the current article
is IRCT20131128015577N4). The statistical
population of the current study included all
married students studying in Tehran in 2019 who
had a ROCD diagnosis.
After conducting a clinical interview in the
previous study (37) and selecting participants who
achieved high scores (above one standard
deviation) on the ROCI and PROCSI, in order to
measure OCD more accurately, SCID-5-RV and
the new version of the ROCI and PROCSI (38,39)
were performed on them and finally, with the fall
of the two patients that existed from the beginning
of the study, six patients were satisfied to
participate in this study. Coincidentally, two of
them were selected for ACT for OCD, two with
their spouses were selected for ACT for the couple,
and two with their spouses were selected for
combined treatment of ACT for OCD and couples.
All participants were randomly assigned to each
treatment. For each participant, three baseline
sessions were scheduled in the weeks before
treatment. In addition, three evaluation sessions
were considered during and immediately after
treatment and two evaluation sessions in the
follow-up period, each conducted within two
weeks. Participants 1 and 2 were treated with
combined treatment of ACT for OCD and couples,
participants 3 and 4 were treated with ACT for
OCD, and participants 5 and 6 were treated with
ACT for couples. All participants were women;
their age range was 28 to 37 years. The main
symptoms of their ROCD were mainly doubts
about infidelity.
Inclusion criteria in the current study were: being
married, diagnosis of OCD, diagnosis of ROCD
(score above a standard deviation of the new scales
of ROCI and PROCSI), lapse at least six months
of marriage, consent to participate in the study and
signed written consent. In addition, exclusion
criteria in the current study were: they have been
in treatment or hospitalized for the past six months,
history of substance abuse (due to interference
with treatment sessions), suffering other mental
disorders except other obsessive-compulsive
spectrum disorders (according to the Structured
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Clinical Interview based on DSM-5-Research
Version (SCID-5-RV)), and absence of treatment
in three consecutive sessions.
According to the single-subject study with a
multiple baseline design, in terms of data analysis
from visual analysis of graphs and trending and
stability index, Percentage of Non-overlapping
Data (PND), Percentage of Overlapping Data
(POD), and Reliable Change Index (RCI).
Research instruments
A) New Partner-Related Obsessive-Compulsive
Symptoms Inventory (New PROCSI) (by Iranian
culture): This scale, which is based on Iranian
culture, consists of 22 items. This scale consists of
one factor. After analyzing its content, the factor
consisted of a combination of compulsions and
obsessive thoughts related to spouse
characteristics (such as intelligence, competence,
sociability, morality, emotional stability, and
physical appearance). In confirmatory factor
analysis, this scale showed significant superiority
in the Chi-square index compared to the original
PROCSI. Also, in the previous study (38), the new
PROCSI showed better convergent validity with
the Depression, Anxiety and Stress Scale (DASS),
Relationship Beliefs Inventory (RBI), Obsessive-
Compulsive Inventory-Revised (OCI-R), and
especially Obsessive Beliefs Questionnaire (OBQ)
than the original PROCSI and also better divergent
validity with Dyadic Adjustment Scale (DAS)
than the original PROCSI. The correlation
coefficient of the test-retest of this scale within two
weeks obtained 0.86, which was significant at P<
0.01. Also, Cronbach's alpha was 0.91.
B) New Relationship Obsessive-Compulsive
Inventory (New ROCI) (by Iranian culture): This
scale, which is based on Iranian culture, consists of
19 items and consists of two factors. After
examining the content of the factors, factor 1 refers
to obsessive thoughts about loving a spouse, being
loved by a spouse, and "correctness" of the
relationship, and factor 2 refers to compulsive
behaviors about loving a spouse, being loved by a
spouse and "correctness" of the relationship. In
confirmatory factor analysis, the new ROCI
showed significant superiority over all fitness
indicators over the original ROCI. Also, in the
previous study (39), this scale showed better
convergent validity with the Depression, Anxiety
and Stress Scale (DASS), Relationship Beliefs
Inventory (RBI), Obsessive-Compulsive
Inventory-Revised (OCI-R), and especially
Obsessive Beliefs Questionnaire (OBQ) than the
original ROCI and also better divergent validity
with Dyadic Adjustment Scale (DAS) than the
original ROCI. The correlation coefficients of test-
retest of this scale within two weeks for factors 1,
2, and total score were 0.85, 0.78, and 0.79,
respectively. Those all were significant at P< 0.01.
Also, the Cronbach's alpha for factors 1 and 2 and
the total score were 0.60, 0.74, and 0.83,
respectively.
C) Combined protocol of ACT for OCD and
couples: In combined sessions of ACT for OCD
and couples, the content of sessions of couple
therapy of ACT and OCD therapy of ACT go hand
in hand. Given that the overall course of ACT
sessions in all therapeutic protocols is as follows:
initial evaluation and understanding of ACT logic,
understanding of constructive hopelessness,
acceptance and mindfulness exercises, cognitive
defusion and self as context exercises, and finally,
the exercises to examine life values and behavioral
commitments to life values, thus, the overall
movement in the combination treatment of ACT
for couples and OCD (where each consisting of the
couple (couple therapy) and individual (OCD
therapy) sessions are held separately) was the same
way (40-42). This protocol was evaluated by
experts and showed an excellent Content Validity
Index (CVI) and Content Validity Ratio (CVR).
Results
All participants were women with the mean age
of 31 years. Three were graduate students, and the
other three were doctoral students. Their fields of
study were different and included engineering, art,
management, psychology, and etc. The average
duration of their marriage was four years. Most of
them had suspicions about infidelity, and the
average duration of their obsessive-compulsive
symptoms was two years.
- Visual analysis of participants in the overall
score of the new PROCSI
The results related to inter-situational visual
analysis for participants in the new PROCSI
showed that all participants in the baseline stage
showed stable changes concerning the stability
envelope. However, in the treatment phase,
changes in the fifth and sixth participants have the
highest stability (100%). Also, the relative and
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absolute level change of all participants in the
treatment phase (comparing the two halves of
the treatment) was negative, and accordingly, the
trend of their changes has decreased. Thus, it can
be said that the scores of all participants on the new
PROCSI have changed.
Table 1. Cross-situational visual analysis for participants in the New PROCSI
Base line and treatment stage
Compare the
position
6
5
4
3
2
1
Participants
Trend changes
Direction change
Negative
Negative
Negative
Negative
Negative
Negative
The type of trend
Stable to stable
Stable to stable
Stable to
variable
Stable to
variable
Stable to
variable
Stable to
variable
Stability change
Level change
32 to 30.5
35.5 to 34.5
30.5 to 23
28 to 15.5
35 to 18.5
18 to 32.5
Relative level
change
32 to 32
35 to 36
31 to 26
28 to 19
35 to 24
33 to 22
Absolute level
change
32 to 31
36 to 33
30 to 20
28 to 12
35 to 13
33 to 14
Middle change
32 to 30.66
36 to 33.66
30 to 20
28 to 13.33
35 to 16
32.66 to 15.66
Average change
Data overlap
66.66
66.66
100
100
100
100
PND
33.33
33.33
0
0
0
0
POD
PND: Percentage of Non-overlapping Data, POD: Percentage of Overlapping
As shown in Table 1, the participants' median,
average, relative, and absolute scores decreased
from baseline to treatment stage. Also, except for
participants 5 and 6, the rest of the participants
from baseline to treatment showed stable
changes. In addition, the overall trend of
participants' scores from baseline to treatment
stage was negative, indicating a decrease in their
scores on the new PROCSI from baseline to
treatment stage. Also, as shown in Table 1, the
PND and POD of the participants 1, 2, 3, and 4
were 100 and 0, respectively, indicating the high
efficacy of combined treatment of ACT for OCD
and couples as well as the ACT for OCD for these
participants in terms of changing scores of the
new PROCSI. However, the PND and POD of
participants 5 and 6 obtained 66.66 and 33.33,
respectively, which indicate a relative efficacy of
ACT for couples in the relative decline of the new
PROCSI score of these participants.
A visual analysis diagram of participants at the
new PROCSI is presented along with midlines
and stability envelope of the baseline and
treatment steps in Diagram 1.
Diagram 1. Participants change paths on the new PROCSI
0
10
20
30
40
Participants changes path on the new PROCSI
Participant 1
Participant 2
Participant 3
Participant 4
Participant 5
Participant 6
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As shown in Diagram 1, the first and second
participants receiving the combined treatment of
ACT for OCD and couples and the third and
fourth participants receiving the ACT for OCD
showed the most significant reduction in the new
PROCSI. As such, it can be said concerning the
mentioned content that the combined treatment of
ACT for OCD and couples was the most effective
method in reducing the score of new PROCSI of
participants compared to the other two
treatments.
- Visual analysis of participants in the overall
score of the new ROCI
The results related to inter-situational visual
analysis for participants in the new ROCI showed
that all participants in the baseline stage showed
a stable change concerning the stability envelope.
However, in the treatment phase, changes in the
fifth and sixth participants have the highest
stability (100%). Also, the relative and absolute
level change of all participants in the treatment
phase (comparing the two halves of the
treatment) was negative, and accordingly, the
trend of their changes has decreased. Thus, it can
be said that the score of all participants on the
new RCI has decreased.
Table 2. Cross-situational visual analysis for participants in the New ROCI
Base line and treatment stage
Compare the
position
6
5
4
3
2
1
Participants
Trend changes
Direction change
Negative
Negative
Negative
Negative
Negative
Negative
The type of trend
Stable to stable
Stable to stable
Stable to
variable
Stable to
variable
Stable to
variable
Stable to
variable
Stability change
Level change
16.5 to 16.5
21 to 23
11.5 to 19.5
9.5 to 17
10.5 to 21
9 to 16.5
Relative level
change
17 to 17
22 to 23
13 to 20
11 to 18
11 to 22
10 to 17
Absolute level
change
16 to 17
21 to 23
10 to 19
8 to 17
10 to 21
8 to 17
Middle change
16 to 16.66
21 to 22.66
10 to 19
9 to 17
9 to 21
7.66 to 16.66
Average change
Data overlap
33.33
66.66
100
100
100
100
PND
66.66
33.33
0
0
0
0
POD
PND: Percentage of Non-overlapping Data, POD: Percentage of Overlapping
As shown in Table 2, the scores of participants'
median, average, relative, and absolute levels
decreased from baseline to treatment. Also,
except for participants 5 and 6, the rest of the
participants from baseline to treatment showed
stable changes. In addition, the overall trend of
clients' scores from baseline to treatment was
negative, indicating a decrease in their scores on
the new ROCI from baseline to treatment. Also,
as shown in Table 2, the PND and POD of the
participants 1, 2, 3, and 4 were 100 and 0,
respectively, indicating the high efficacy of
combined treatment of ACT for OCD and
couples as well as the ACT for OCD for these
participants in terms of changing the total score
of the new ROCI. However, the PND and POD of
participant 5 obtained 66.66 and 33.33,
respectively, which indicates a relative efficacy
of ACT for couples in the relative decline of the
new ROCI score of the participant. However, the
PND and POD of participant 6 obtained 33.33
and 66.66, respectively that indicates the
inefficiency of ACT for couples in reducing the
total score of the new ROCI of the participant. A
visual analysis diagram of participants at the total
score of new ROCI is presented along with
midlines and stability envelope of the baseline
and treatment steps in Diagram 2.
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Diagram 2. Participant changes path on the new ROCI
As shown in Diagram 2, the first and second
participants receiving the combined treatment of
ACT for OCD and couples and the third and
fourth participants receiving the ACT for OCD
showed the most significant reduction in the new
ROCI. As such, it can be said that the mentioned
that the combined treatment of ACT for OCD and
couples has been the most effective in reducing
the total score of new ROCI of participants
compared to the other two treatments.
Discussion
The current study showed that the individuals
who participated in the combined treatment of
ACT for OCD and couples showed the highest rate
of remission and most significant effect size in
terms of improvement of symptoms of ROCD
compared to other clients.
ACT for OCD, in particular, addresses the
functional context underlying OCD and its
associated anxiety. Highly valued thoughts,
reassurance, and avoidance of internal experiences
occur in this functional context. Therefore, it can
be said that ACT focuses more on the function of
the obsessions rather than reducing their frequency
(17).
Although ACT does not focus on reducing
symptoms, due to the focus on functional context
and increased psychological flexibility to
obsessions, symptom reduction occurs as a
consequence of this condition, and in the current
study, we also saw this happen. The critical point
is that due to the decrease in the control of
annoying thoughts and the increase in
psychological acceptance of these thoughts, which
is one of the most important goals of the ACT, one
can expect that symptoms of ROCD can also be
seen in clients, especially those who experience
ACT for OCD, conditions that also occurred in the
present study. Obsessions can result from a failure
in the initial control of thoughts, which in turn
leads to an extreme effort to suppress the thoughts,
and its result is to intensify and reinforce these
thoughts. Ultimately, the effort to control the
thoughts increases and the cycle of extreme effort
continues (43,44). Phenomenological reports of
OCD also emphasize that the primary complaint of
many individuals with OCD is the inability to
control obsessions mentally, and its witness is the
frequency, intensity, and duration of the annoying
thoughts (45). Consistent with the current study,
the efficacy of this treatment in improving OCD
has been demonstrated in the uncontrolled case
study (46) and controlled studies (15,24). For
example, the study by Twohig et al. (15) using
multiple baseline designs showed that patients
with OCD significantly decreased obsessive-
compulsive symptoms after ACT and three
months follow-ups. Also, in line with the current
study, Twohig et al. (24), in one of the most
extensive randomized controlled trials of ACT for
OCD, showed that ACT had a more significant
change in the severity of OCD at post-test and
follow-up compared to progressive relaxation.
On the other hand, one of the most important
reasons for the greater efficacy of the combination
0
5
10
15
20
25
Participant changes path on the new ROCI
Participant 1
Participant 2
Participant 3
Participant 4
Participant 5
Participant 6
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therapy of ACT for OCD and couples in the
current study, compared to ACT for OCD and
ACT for couples on improving OCD, is the
simultaneous use of ACT for OCD and ACT for
couples in order to improve the communication
texture of couples whom one of them had OCD. In
fact, in line with the current study, results of the
research show that OCD harms relationship
function (47), and these effects, in turn, exacerbate
the symptoms of OCD. For example, the pressures
that people with OCD exert on their spouses to act
on their obsessions are one of the factors of
relationship tensions and conflicts and impair the
quality of relationships (48). Accordingly, the
spouse's compliance with symptoms of OCD (by
reassuring the person, checking or preventing
contaminated objects) results in the formation of
an interpersonal dynamic that contrasts with
exposure-based treatment (29).
This interpersonal dynamic is associated with an
increase in the severity and duration of symptoms
of OCD and impairment of one's overall
performance and is a risk factor for long-term
problems in people with OCD (29,30). Thus, it can
be expected that with the focus of the combined
treatment in this study on the treatment of OCD
and couples (due to the deleterious effect of
obsession on the communication context), this
treatment is more effective than OCD or couple
therapy alone.
On the other hand, according to the results of this
study, the role of ACT components such as
acceptance, cognitive defusion, mindfulness,
valueness, and commitment to it can be considered
according to the clients' path of change. People
with OCD feel an extreme need to control their
thoughts, and many with ROCD prefer avoiding
communication conflicts. Beliefs about the over-
importance of thoughts in individuals with OCD
include this feature: paying attention to the thought
is important because it happens, and there is a
potential for Thought Action Fusion (TAF) (49).
In OCD, beliefs about controlling thoughts are
closely related to the over-importance of thoughts
(49,50). Paradoxically attempting to control these
thoughts will increase the frequency of these
thoughts (44,51).
Thus, ACT, with the help of components of
acceptance and cognitive defusion, can play a
significant role in reducing the control of thoughts
and the TAF associated with OCD. In the present
study, we saw the most changes in clients after the
sessions of acceptance and cognitive defusion. The
results of some studies consistent with the current
study have shown a relationship between the
component of cognitive defusion and therapeutic
outcomes. For example, Zettel and Hayes (52) and
Zettel and Rains (53), both comparing ACT with
Cognitive Therapy (CT), concluded that cognitive
defusion mediated the effects of ACT on patients
with depression.
Another component that led to significant
changes in the mid-to-late-stage process of ACT
different forms was increased awareness of the
present moment. Consistent with the current study,
the results of various studies have shown that
mindfulness-based interventions have positive
consequences for a wide range of psychological
problems (54-57). Also, the results of various
studies indicate the effectiveness of mindfulness
on OCD.
Also, the component of valueness and action
based on it was another therapeutic component
influencing improvement of OCD. Consistent with
the current study, the impacts of valueness and
action based on it have been shown in various
studies based on ACT. For example, Lundgren et
al. (57) showed that achieving the values of life in
epileptic individuals mediates changes in quality
of life and psychological well-being from the pre-
treatment to the follow-up period. Vowles and
McCracken (58) also found that increasing
practice based on values was associated with
decreased depression and distress in patients with
chronic pain. One of the limitations of the current
study is the limited number of individuals with
ROCD and having specific demographic
characteristics to participate in clinical
interventions such as being a student, etc.
Also, not being equal the number of combined
sessions of ACT for OCD and couples with the
number of sessions of ACT for OCD and ACT for
couples, not using placebo to increase internal
validity, performing multiple evaluations
(baseline, treatment sessions, and follow-up
evaluations) by the researcher and performing all
three treatments of combined treatment of ACT for
OCD and couples as well as the ACT for couple
and ACT for OCD by the researcher because of the
limited access to other therapists, and the time
limitation of conducting this research are other
limitations of the current study.
RELATIONSHIP OBSESSIVE COMPULSIVE DISORDER GHOMIAN, SHAEIRI, AND FARAHANI
Fundamentals of Mental Health, 2022 Jul-Aug http://jfmh.mums.ac.ir 249
Conclusion
It can be said that the combined protocol of ACT
for OCD and couples has been the most effective
in decreasing relationship obsessions of clients
compared to the ACT for OCD and ACT for
couples alone.
Acknowledgments
We must thank all the participants and specialists
who collaborated with us to conduct this research.
We would also like to thank Shahed University for
financial support in conducting this research. The
authors declare any conflict of interest.
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