Iranian Journal of Health Psychology Received: 07/13/2020

Vol. 4, No.1, Serial Number 7, p.33-48, Spring 2021 Accepted: 11/15/2020

Paper Type: Research Paper

Comparing The Efficacy of Acceptance and Commitment

Therapy (ACT) and Dialectical Behavior Therapy Skills
Training (DBT-ST) on Cognitive Emotion Regulation in
Patients with Type II Diabetes
Bahareh Montazernia1, Shirin Koushki2*, Mohammad Oraki3, Bahram Mirzaian4

Abstract
Objectives: Diabetes is a chronic, multifaceted and threatening disease which has significant psychological
complications. The purpose of this study was comparing the efficacy of Acceptance and Commitment Therapy (ACT)
and Dialectical Behavioral Therapy Skills Training (DBT-ST) on cognitive emotion regulation in patients with type
II diabetes.
Method: The design of this quasi-experimental research was a pretest-posttest with a control group. The statistical
population of the study included all patients with type II diabetes referred to Baghban (Touba) Medical Clinic in
Sari in 2019, among whom 45 patients were selected through the convenience sampling method and then randomly
assigned into three groups. The first group received ACT, the second group received DBT-ST, and the third group
was considered as a control group. Data were collected using a 36-item Cognitive Emotion Regulation Questionnaire
(Garnefsky et al., 2001) in three stages of pre-test, post-test, and follow-up, and were analyzed by repeated measurement
variance analysis.
Results: The results showed that ACT and DBT-ST were significantly more effective on cognitive emotion regulation
for the experimental groups compared to the control group (effect sizes 0.911 & 0.967, respectively). The effectiveness
of DBT-ST compared to ACT was more significant on cognitive emotion regulation scores (effect sizes 0.967) at
(P>0.01).
Conclusion: Based on the results of this study, it can be concluded that ACT improved psychological indexes and
mental health of patients with type II diabetes due to acceptance of unfavorable emotions and thoughts, commitment,
and DBT-ST for emotion regulation and mindfulness components.

Keywords: Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, Cognitive Emotion Regulation,
Diabetes Type II.

Introduction seeking for the destroying the people’s identity and

Today we encounter with this unpleasant fact that undermining their will and determination, collapsing
the enemies of the revolution, by the use of narcotics the beliefs and values of the society, and weakening
and psychotropic weapons as a software weapon, are the old traditions such as religion and social cohesion
(Ahqar, 2015).
1.Ph.D Candidte of Halth Psychology, Islamic Azad University, Central
Tehran Branch, Tehran, Iran. Diabetes mellitus is a multifactorial metabolic
2.Assosiate Professor, Department of Psychology, Central Tehran disease characterized by high blood glucose
Branch, Islamic Azad University, Tehran, Iran
3.Assosiate Professor, Department of Psychology, Payame Nour and metabolic disorder of carbohydrate, fat, and
University, Tehran, Iran. protein (Poretski, 2017). High blood glucose is as
4. Assistante Professor, Department of Psychology, Sari Branch, Islamic
Azad University, Sari, Iran a result of impaired insulin secretion and hepatic
*Corresponding Author: Shirin Koushki ,Email:shi.kooshki@iauctb. gluconeogenesis (Yamagishi, 2018). The major
ac.ir
34 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

types of diabetes include type I diabetes (insulin- emotion regulation (Yazdi, Saffarnia, & Zare, 2020),
dependent) and type II diabetes (non-insulin- and experiencing negative emotions such as anger,
dependent). The global prevalence of diabetes frustration, fear, disappointment, and depression are
is increasing. While about 422 million people very common among them (Richman, Kubzansky &
worldwide were diagnosed with diabetes in 2014, Maselko, 2005). In recent years, the role of cognitive
645 million are projected to develop diabetes by emotion regulation and the improvement of
2040 (Da Rocha et al., 2016). According to the US emotional regulation strategies in mental disorders
Centers for Disease Control and Prevention (CDC) have been investigated (Fajkowska, 2013).
(2017), 34.2 million people of all ages or 10.5% of Emotional regulation includes any coping strategies
the total US population have diabetes. A national that people use when faced with intense emotions
study conducted in Iran estimated that the prevalence (Gross & John, 2003). Grass (2013) defined the
of diabetes in 2013 was 13.8 (Peykari, 2015), and emotional regulation as “which emotions, where and
it is predicted that if the current trend continues, it when to have, and how to experience and express
will reach about 5.2 million cases in 2025 (Amini them” (Bahrebar, Ahadi, Aghayousefi, 2019). One
& Parvaresh, 2009). It is the most common cause of of the most important aspects of the emotional
amputation, blindness, chronic renal failure, and a regulation process is the regulation of emotional
risk factor for heart disease (Chang, 2010). experiences through the use of cognitive elements.
Diabetes is often associated with mental health The way of evaluating individual cognitive
problems and disorders, which reduce the patient’s apparatus when dealing with negative events is very
ability to cope with the disease. For example, important. In other words, the individual’s mental
longitudinal studies have shown that depression is health stems from a mutual interaction between
15 to 24 percent higher in people with diabetes than the use of certain types of cognitive emotion
in people without diabetes. On the other hand, the regulation strategies and the correct assessment of
prevalence of type II diabetes is between 15 and situations (Thampson, 1991; Ochsner & Gross,
37 percent among people with depression, which 2005). This concept is called cognitive emotion
implies the mutual relationship between these regulation in psychological texts. In fact, cognitive
conditions (Bonora & De Fronzo, 2018). According emotion regulation strategies refer to how people
to Sturt, Dennick, Due-Christensen, and McCarthy think after a negative experience or traumatic event
(2015), symptoms of diabetes-related distress such happens (Garnefski et al., 2002). The cognitive
as worry about the future and the possibility of emotion regulation strategies are dichotomized into
serious complications, guilt or anxiety while dealing maladaptive strategies (self-blame, rumination,
with diabetes, a feeling of discouragement from the catastrophizing, other blame) and adaptive strategies
diabetes diet, 60% of people with type I diabetes or (acceptance, positive refocusing, refocus planning,
type II diabetes are treated with insulin. On the other positive reappraisal, putting into perspective). Many
hand, reducing patients’ ability to control diabetes psychiatric disorders are because of choosing and
aggravates their psychological problems and causes implementing maladaptive emotional regulation
patients to fall into a defective cycle (White, 2001). strategies for emotion regulation (Gross & Jazaieri,
The role of psychological factors affecting diabetes 2014). A meta-analysis showed that maladaptive
has been investigated in many studies (Snock, cognitive regulation strategies are far more relevant
Nicols, Ven, & Lubach, 1999). Patients with diabetes to psychological trauma than adaptive strategies,
are sensitive to negative emotions such as anxiety, and mood-related disorders are more associated with
fear, anger, and the like, and have difficulty in cognitive emotion regulation strategies than other
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 35

disorders (Aldao et al., 2010). In addition, some main assumption of acceptance and commitment
studies show that social-psychosocial problems therapy is that a significant portion of psychological
and disorders, such as fatigue, irritability, anger, distress is a normal part of the human experience
depression, and anxiety are more common in people (Hayes, Strosahland Wilson, 2012). Acceptance
with diabetes, and the prevalence of depression in and commitment therapy helps people experience
people with diabetes type II is three times higher problematic thoughts and emotions differently,
than in diabetes type I (Kruse, 2003), and cognitive rather than having a systematic attempt to change or
elements are important parts of anxiety and various reduce their occurrence (Timothy & Jessica, 2017).
types of depression (Fajkowska, 2013). Because Dialectical Behavioral Therapy, on the other hand,
patients with diabetes type II have a lot of problems, is a cognitive-behavioral approach that Linehan
effective treatments to improve the psychological has identified as a treatment for those who engage
characteristics of these patients is of most importance in destructive behaviors. This approach combines
(George & Joseph, 2014). In the last two decades, interventions related to cognitive-behavioral
psychologists have used a variety of psychological therapy, which are based on the principle of
interventions for a wide variety of psychological change, with oriental teachings and techniques,
problems in people with diabetes. However, not all which are based on the principle of acceptance, and
treatments have been effective. Among new and accordingly, suggests four intervening components:
structured approaches, we can refer to Acceptance 1) Core Mindfulness, 2) Distress Tolerance (as
and Commitment Therapy and Dialectical Behavior the components of acceptance), 3) Emotion
Therapy. Acceptance and Commitment Therapy Regulation, and 4) Interpersonal Effectiveness (as
(ACT) is a psychological intervention based on the components of change). Dialectical behavioral
modern behavioral and evolutionary principles, therapy is a combination of supportive, cognitive,
including the Relational Frame Theory (RFT), which and behavioral therapies (Wagner, Rizvi &Harned,
applies the processes of mindfulness, acceptance, 2007). Miller, Ratos, and Linehan (2006) state
and commitment to developing psychological that the goal of dialectical behavior therapy is to
flexibility (Loma, Hayes, and Walser, 2017). increase self-esteem, achieve individual goals, and
Acceptance and commitment therapy is different resolve feelings of inadequacy. According to Sheets
from cognitive-behavioral therapy. Its underlying (2009), dialectical behavioral therapy teaches skills
principles include 1) acceptance or inclination to for managing stress and difficult emotional states,
experience pain or other disturbing events without and focuses on current problems and concerns here
attempting to control them, and 2) action based and now that lead to troublesome behaviors and
on value or commitment with a desire to act as an emotions.
individual’s meaningful goals before eliminating Among the studies conducted in Iran, we can
unknown experiences. It is linguistic methods and mention the research of Tamannaeifar, Gharraee,
cognitive processes that, in interaction with other Birashk, Habibi and Mojtaba (2014). In their study,
verbal dependencies, lead to healthy functioning they found that both acceptance and commitment
(Valiz et al., 2003). The ultimate goal of this model therapy and Group Cognitive Therapy led to a
is to increase the value of living. Acceptance, reduction in depressive symptoms and rumination;
contact and connection with the present moment, however, there was no difference between the
defusion, the observing self, values clarification, effectiveness of the two groups.
and commitment are six major processes in this Kazemi Rezaei, Kakabarai, and Hosseini (2015)
therapy (Kevin, Sowden & Ashworth, 2014). The in a study to evaluate the effectiveness of emotion
36 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

regulation skill training based on dialectical to be effective in examining subtests of cognitive

behavioral therapy on cognitive emotion regulation emotion regulation, resulting in subscales of
and quality of life of patients with cardiovascular acceptance, positive focus, re-focus, reappraisal, and
diseases found that after emotion regulation skill others-blame, and has led to greater regulation and
training based on dialectical behavioral therapy, increased ability of subjects in these areas, yet it was
the scores of positive cognitive emotion regulation not effective in subscales of self-blame, rumination,
strategies and quality of life of cardiovascular observing others, and catastrophizing in women
patients in the experimental group increased and their with glass abuse.
negative strategies scores decreased significantly Yaraghchi, Jomehri, Seyrafi, Kraskian Mujembari,
compared to control group. and Mohammadi Farsani (2019) in a study showed
Baygan, KhoshKonesh, HabibiAskar Abad, that acceptance and commitment therapy reduced
and Fallahzadeh (2016) found that group-based body mass index and negative strategies and
dialectical behavior therapy was effective in reducing increased positive cognitive emotion regulation
the symptoms of alexithymia, stress, and symptoms strategies in obese people.
of diabetes in people with diabetes type II. So far, no research has been conducted to compare
Baygan, KhoshKonesh, HabibiAskar Abad, the two methods in people with diabetes, and there is
and Fallahzadeh (2016) found that group-based no scientific evidence available, while both methods
dialectical behavior therapy was effective in reducing have their own advantages and disadvantages.
the symptoms of alexithymia, stress, and symptoms Thus, taking into account the necessity of the
of diabetes in people with diabetes type II. study, this study was conducted to compare the
Ahovan, Balali, AbediShargh, and Doostian (2016) effectiveness of acceptance and commitment
in a study showed that dialectical behavior therapy therapy (ACT) and dialectical behavioral therapy
skills training (DBT-ST) during eight 90-minute (DBT) on cognitive emotion regulation in patients
sessions improved cognitive emotion regulation in with diabetes type II.
female patients with Obsessive–compulsive disorder
(OCD). Method
In Mirani, Moradi, Nouri, and Borhani’s Population and participants
(2017) studies, it was found that acceptance and The present study is a part of applied research
commitment therapy has significantly reduced and was conducted based on a quasi-experimental
maladaptive cognitive emotion regulation strategies design with two experimental groups and one
and increased adaptive cognitive emotion regulation control group. The statistical population of the
strategies among patients under methadone study included all patients with diabetes type II who
maintenance treatment. referred to Baghban Medical Clinic (Touba) in Sari
Darvish Baseri and Dasht Bozorgi (2017) in 2019. A group of 45 (14 males and 31 females)
demonstrated that Group therapy based on acceptance was selected based on research criteria (diabetes
and commitment was effective in cognitive emotion type II diagnosed by an endocrinologist, ages 25 to
regulation and alexithymia of patients with diabetes 45, having at least fifth-grade elementary education,
type II. and being lack of severe mental illness or incurable
The results of the research by Hamidipour and disease, and so on, who were not treated with other
Ghotbian (2017) showed that acceptance and psychological interventions during the study). Then
commitment therapy is effective in cognitive they were randomly assigned into two experimental
emotion regulation. Psychotherapy was shown groups and one control group. Exclusion criteria
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 37

included the absence of more than two sessions of they had full authority to participate in the research
treatment. The first experimental group received and if they wished, the test results would be provided
acceptance and commitment therapy for eight 2-hour to them. Also, after explaining the purpose of the
sessions, two sessions per week for four weeks. For research, obtaining informed consent, the right to
the second experimental group, dialectical behavior leave the study, ensuring harmless treatment based
therapy skills training was performed based on the on the quality of life and treatment based on emotion
components of mindfulness, distress tolerance, and regulation, answering questions and observing
emotional regulation, and interpersonal efficiency fidelity and validity while collecting data, were
during twelve two-hour sessions and six weeks other principles of ethics. Also, the participants were
based on treatment guidelines. At the beginning informed that material and non-material rights will
of the study, there were 15 subjects in each group, be taken into account in reporting the results of the
and later from each experimental group, one person study. The participants were not charged with any
was excluded from the study due to the absence expenses for the research. This study with the ethics
of more than two sessions. Therefore, one person code of IR.IAU.SARI.REC.1399.060 was approved
was randomly removed from the control group to by the ethics committee of Islamic Azad University,
equalize the groups. As a result, the final sample Sari branch.
was 42 participants. All patients responded to the
Cognitive Emotion Regulation Questionnaire Tools
(Garnefski, et al., 2001) in the pre-test phase. 1. Cognitive Emotion Regulation Questionnaire
For the first experimental group, acceptance (CERQ):
and commitment therapy was held in ten 2-hour This questionnaire was developed by Garnefski,
sessions and two sessions per week for five weeks. Kraaij, and Spinhoven (2001) in the Netherlands
In the second experimental group, group dialectical and has two English and Dutch versions. The
behavior therapy skills training was performed in Cognitive Emotion Regulation Questionnaire is a
12 two-hour sessions over six weeks of treatment multidimensional questionnaire used to identify
based on the components of mindfulness, distress cognitive coping strategies after experiencing bad
tolerance, and emotional regulation and interpersonal events or situations. The questionnaire, which can
efficiency. The control group was placed on the be used on people over the age of 12, is a self-
waiting list without receiving any intervention. At report tool with 36 articles. The subscales include
the end of the sessions, individuals from all three nine cognitive strategies, including self-blame,
groups were invited individually for post-test. After acceptance, rumination, positive refocusing,
two months, everyone responded to the Cognitive refocus planning, positive reappraisal, putting
Emotion Regulation Questionnaire for the third time into perspective, catastrophizing, and other blame.
(follow-up phase). The collected data by the use of Questions are answered from never to always on a
questionnaires, medical records, and interviews 5-point Likert scale. The subscale consists of four
were analyzed through descriptive statistics (mean items. The total score of each subscale is obtained
and standard deviation) and inferential statistics by adding the score of the questions. Therefore,
(repeated measurement variance analysis) by SPSS the range score for each subscale is 4 to 20. High
V22 statistical analysis software. scores on each subscale indicate the greater use of
the strategy in coping and dealing with stressful
Ethical statement and unpleasant events (Garnefski et al., 2001).
In this research, the participants were informed that The The Persian version of the Cognitive Emotion
38 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

Regulation Questionnaire in Iran was validated by maladaptive strategies, 0.82 for acceptance, 0.78
Besharat and Bazzazian (2014). In their research, for positive refocusing, 0.80 for focus on planning,
the psychometric characteristics of this form were 0.76 for positive reappraisal, 0.81 for putting into
reported, including internal consistency, retest perspective, and 0.84 for total score of adaptive
reliability, content validity, convergent validity, strategies.
and optimal diagnostic (differential) validity. In an
introductory review of the questionnaire in a sample 2. Demographic questionnaire
of the general population (n = 368, 197 females The questionnaire is a researcher-made tool that
and 171 males), Besharat reported the Cronbach’s collects demographic information such as patient’s
alpha coefficient for subscales from 0.67 to 0.89. age, gender, marital status, education, occupation,
The correlation coefficient of the participants in the type of diabetes, and type of treatment (insulin and
study (43 women and 36 men) was calculated twice non-insulin). Diabetes history included the duration
in two to four weeks’ intervals of the subscales of the of the disease and the type of diabetes treatment.
questionnaire = 0.57 to r = 0.76. In this study, eight The duration of the disease was measured by asking
psychological specialists evaluated the content the patient about the number of years of diabetes.
validity of the Cognitive Emotional Regulation
Questionnaire, and the coefficients of the Kendall 3. Acceptance and commitment therapy (ACT)
agreement for subscales ranged from 0.81 to 0.92. protocol:
The results of Hassani’s study (2010) also showed The protocol was developed by Hayes, Felt, and
that nine subscales of the Persian version of the Linehan (2004) and has been studied in various
Cognitive Regulation Questionnaire had good studies. The results of these studies indicate the
internal emotional excitement (Cronbach’s alpha effectiveness of this treatment for chronic pain
range was 0.76 to 0.92). The article scores were (Scott & McCracken, 2015), cancer (Han &
significantly correlated with the overall score of McCracken, 2014), and MS (Nordin & My Day,
adaptive and maladaptive subscales (r = 0.466 to r = 2012). Acceptance and commitment therapy steps
0.75), and the value of retest correlation coefficients are summarized in Table 1. It is a new behavioral
(0.05 to 0.77) indicates the consistency of the scale. therapy that uses acceptance and mindfulness
The results of the analysis of the main component interventions along with change and commitment
supported the model of the nine main factors of the strategies to help clients build meaningful,
Emotional Cognitive Regulation Questionnaire, purposeful, and satisfying lives. Contrary to more
which explained 74% of the variance. The degree traditional approaches to cognitive-behavioral
of internal relations of subscales was relatively high therapy, acceptance and commitment therapy
(0.32 to 0.67). Finally, considering the criterion does not intend to change the form or frequency
validity, the subscales of the Persian version of the of unwanted emotions and thoughts, but the main
cognitive regulation questionnaire were specifically goal is to promote psychological flexibility, that is
correlated with depressive symptoms. the ability to connect the present moment and adapt
To determine the reliability of the cognitive to the change or persistence of behaviors according
emotion regulation questionnaire for the present to the situation and one’s values. In other words,
study, a cronbach’s alpha was performed and the acceptance and commitment therapy focuses on
reliability of the subscales were 0.84 for self-blame, helping people live satisfactorily, even in the
0.79 for rumination, 0.81 for catastrophizing, presence of unpleasant thoughts, emotions, and
0.83 for others-blame, 0.86 for total score of feelings (Flexman, Blackledge, & Bond, 2011).
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 39

Table 1. A brief description of Acceptance and Commitment Therapy (ACT)

Sessions Brief description

Getting acquainted with the patients and establishing a good relationship with them to build trust
Introduction for getting the questionnaires filled out properly, administering the demographic questionnaire
and the pretest
Introducing the teaching expert, the group getting acquainted with each other and establishing
a therapeutic relationship among themselves, introducing the Acceptance and Commitment
The rapy inte rvention and it s main ob jectives and pi llars, setting ground r ules for the entir e
Session 1
sessions, providing information about heart failure and its complications, reviewing ways to
control and prevent disease complications and their costs and benefits, providing psychological
education, break and snacks, assigning the homework
Reviewing experiences of the previous session and receiving feedback from the patients,
discussing the experiences and assessing them, evaluating the patients’ tendency to change,
Session 2
underst anding the p atients’ expectations about th e ACT intervention, fostering creative
distress, break and snacks, summarizing the presented material and assigning the homework
Reviewing experiences of the previous session and receiving feedback from the patients,
id entifying i nefficient str ategies and learning to contro l them and perceive their futility,
explaining the concept of acceptance and its differences with concepts of failure, despair, denial
and resistance, teaching that acceptance is a constant rather than logical process, discussing the
Session 3
problems and challenges of a heart attack, explaining how to avoi d pa inful experien ces and being
mindfu l o f the conse quences of a voidance, discov ering situ ations t hat have been a voided and
con tacting them through accept ance, defining coping and introducing effective and ineffective
coping strategies, break and snacks, summarizing the presented material and an overview of the
next session’s work, assigning the homework
Reviewing experiences of the previous session and receiving feedback from the patients, break
Session 4 and snacks, behavioral commitment and obligation, introducing an d explaining conf used self-
conce pt a nd its diffu sio n, the app lication o f cognitive diffusion therapeutic approach,
intervention in the performance of problematic chains of language and metaphors, discouraging
the patients from wasting their time with thoughts and emotions, summarizing
Reviewing experiences of the previous session and receiving feedback from the patients, sho wing
the dis tincti ons between the self, th erap eutic expe rienc es and behavior, self as context,
weakening the self-concept and self-expression. Through these practices, the participants
Session 5 learn to focus on their activities (such as breathing, walking, et c.) an d be m ind ful of their sta te
at all moments and le arn to per ceive the ir e motions, feelings and cognitions and to process
them without judgment; that is, they learn to pay attention to their thou ghts and emotions bu t
not get attac hed to the ir conte nt, break an d snacks, summarizing the presented material and
an overview of the next session’s work, assigning the homework
Reviewing experiences of the previous session and receiving feedback from the pati ents,
Session 6
iden tifying th e pat ient s’ values in life and focu sing o n these valu es, their elaboration and their
power of choice, assigning the homework
Session 7 Using mindfulness techniques with an emphasis on t he prese nt, break an d sn acks, summ arizing
t he p res ented mat eri al a nd an overview of the next session’s work, assigning the homework
Reviewing experiences of the previous session and receiving feedback from the patients,
Session 8 Mindfulness practice, review of homework from session 7, psycho-education and teaching
specific defusion techniques, and setting homework
40 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

Reviewing experiences of the previous session and receiving feedback from the patients, examining
Session 9 each patient’s values and giving further depth to the concepts previously taught, explaining the
difference between values, goals and routine mistakes in the selection of values, assigning the
homework.
Discussing the potential internal and external barriers to the pursuit of values, the group members
listing and sharing their most important values and the potential barriers to their pursuit, discussing
the goals related to values and the characteristics of goals among the group, the group members
Session 10 identifying three of their most important values and determining the goals they wish to pursue in
keeping with those values, determining the next steps for achieving those goals, break and snacks,
summarizing the presented material and an overview of the next session’s work, assigning the
homework.
Session 11 Understanding the nature of tendencies and commitment (teaching commitment to action),
identifying behavioral models compatible with values and developing commitment to act on them,
briefly discussing the concept of relapse and preparing to cope with it.

Session 12 Reviewing the homework and summarizing the sessions with the patients, the group members sharing
their experiences and discussing their gains and unmet expectations, the researcher expressing his
gratitude to the patients for attending the sessions, administering the post-test.

4. Dialectical behavior therapy skills training session, discussing and practicing, and reviewing
(DBT-ST) protocol: outside class. Dialectical Behavioral Therapy book
The treatment plan applied in the present study was (McKay, Wood, & Brent Lee, 2007; Linhan, 1993)
provided in 12 two-hour sessions. Each session was used to develop the program and package
included introducing the goals and topics of the therapy. The steps of dialectical behavioral therapy

Table 2. A brief description of dialectical behavior therapy (DBT) intervention sessions based on Marsha Linehan
instructions
Sessions Brief description

Session 1 Familiarity with the concept of mindfulness and three mental states (reasonable
(mindfulness1) mind, emotional mind, and wise mind)
Teaching two types of skills to attain mindfulness; “What” skills (including
Session 2
viewing, description, and participation) and “How” skills (including non-
(mindfulness2)
judgmental stance, inclusive self-consciousness)
Session 3 Learning distraction strategies with ACCEPTS skills (activities, contributing,
(distress tolerance 1) comparisons, emotions, pushing away, thoughts, and sensation)
Session 4 Learning self-soothing with five senses
(distress tolerance 2)
Session 5 Teaching a pattern of identifying emotions and tagging them, which leads to
(emotion regulation 1) increased emotional control
Session 6 Teaching positive emotional experiences by creating short-term positive
(emotion regulation 2) emotional experiences
Session 7 Opportunities for interpersonal effectiveness (the proportionality between your
(interpersonal effectiveness 1) demands and the demands of others; the proportion of demands and musts)
Session 8 The goals of interpersonal effectiveness (obtaining goals in a situation and
(interpersonal effectiveness 1 confronting with resistance and conflict)
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 41

training are summarized in Table 2. Table 4 demonstrates mean and standard deviation
Results of pre-test and post-test scores of cognitive emotion
Demographic data of the patients based on age and regulation subscales in the experimental and control
diabetes variables are presented in Table 3. groups.

Table 3: Frequency distribution of the experimental and control group in terms of age and duration of diabetes
(Experiment (ACT (Experiment (DBT control
variable group frequency percent frequency Percent frequency percent
30-40 5 35.7 4 28.6 6 42.9
age 41-45 9 64.3 10 71.4 8 57.1
diabetes 1-5 5 35.7 4 28.6 3 21.4
duration 6-10 8 57.1 7 50 10 71.4
Above 10 1 7.1 3 21.4 1 7.1
Total 14 100 14 100 14 100

Table 4: Mean and standard deviation of pre- and post-test scores of cognitive emotion regulation subscales in the
experimental and control groups
Pre-test Post-test Follow up
Dependent group Mean SD Mean SD Mean SD
variable
Experiment 11.29 0.914 10.07 1.328 9.86 1.512
Self-blame (ACT)
Experiment 11.36 1.216 9 0.901 9 1.177
(DBT)
Control
11.21 0.893 10.93 1.072 10.79 1.122

rumination Experiment 13.14 1.292 11.07 1.685 10.93 1.730

(ACT)
Experiment 13.07 1.385 10.29 1.590 10.07 1.639
(DBT)
Control 13.07 1.439 12.57 1.158 12.21 1.311
catastrophizing Experiment 12.64 1.277 11.21 1.311 10.79 1.188
(ACT)
Experiment 12.93 1.141 11.07 1.269 11.07 1.207
(DBT)
Control 12 1.486 11.64 1.336 11.43 1.399
Experiment 11.57 1.869 10.14 2.349 9.93 2.200
Other-blame (ACT)
Experiment 12.21 1.805 9.36 1.737 9.29 1.773
(DBT)
Control 11 1.840 11.07 1.817 10.93 1.730
Experiment 48.64 3.153 42.79 4.980 41.79 5.026
Total score of (ACT)
maladaptive Experiment
strategies 49.64 3.249 39.86 4.294 39.43 4.450
(DBT)
Control 47.29 3.625 46.21 3.827 45.43 3.956
42 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

Experiment
6.64 1.550 9.57 2.593 9.43 2.593
acceptance (ACT)
Experiment
6.57 1.505 11.79 2.966 11.93 3.496
(DBT)
Control 6.50 1.787 6.86 2.070 6.71 1.939
Experiment
9.21 1.718 10.21 1.626 9.93 1.269
Positive refocusing (ACT)
Experiment
9.36 1.447 10.50 1.454 10.50 1.454
(DBT)
Control 9.14 1.834 9.36 1.946 9.43 2.102
Experiment
11 1.617 11.64 1.336 11.50 1.401
Focuse on planning (ACT)
Experiment
10.57 1.910 11.57 1.330 11.29 1.26
(DBT)
Control 10.36 1.26 10.29 1.326 10.21 1.311
Experiment
10.86 2.107 11 2.075 10.57 1.785
positive reappraisal (ACT)
Experiment
10.81 2.092 11.21 1.968 11.07 1.859
(DBT)
Control 10.29 1.729 10.43 1.55 10.50 1.557
Experiment
7.57 1.342 8.14 1.748 7.93 1.900
Putting into (ACT)
Perspective Experiment
7.50 1.345 8.36 1.781 8.43 1.828
(DBT)
Control 7.44 1.160 8.07 1.385 8.07 1.385
Experiment
44.50 3.917 50.57 4.108 49.36 3.875
Total score of (ACT)
adaptive strategies Experiment
44.79 3.867 53.21 4.509 52.93 4.393
(DBT)
Control 42.86 4.833 43.71 4.762 43.57 5.049

As can be seen in Table 4, the mean scores before The results of Table 5 show that the value of F
the cognitive emotion regulation test in the calculated for the effect of stages (pre-test, post-test,
two experimental groups (DBT and ACT) and and follow-up) at the level of 0.01 is significant in
control group were almost equal, but, in the post- the between-group factor. As a result, it demonstrates
cognitive emotion regulation test, the mean scores the effectiveness of acceptance and commitment
of the experimental groups (DBT and ACT) were therapy and dialectical behavioral therapy skill
significantly higher than the mean scores of control training on cognitive emotion regulation in patients
group. Also, the follow-up value can be seen in two with diabetes type II. Also, there is a significant
experimental groups (DBT and ACT) and control difference between the mean of pre-test, post-test,
group. Using the Kolmogorov-Smirnov test, the and follow-up of cognitive emotion regulation
normality, and by examining the Levine test and the scores. However, there was no significant difference
Crochet Mochley test, the variance homogeneity between the subscales of focus on planning, positive
was confirmed, respectively. reappraisal, and putting others into perspective.
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 43

The Toki test was used to examine the differences between the means of treatment processes.

Table 5: Results of analysis of variance of repeated measurements with between and within group factors in subscales
Factors Variables Subgroup Mean Effect
Sources df F Sig.
squares size

Self-Blame 1 13599.056 4591.889 0.000 0.992

Rumination 1 17619.841 3742.338 0.000 0.990

Catastrophizing 1 17080.071 3941.000 0.000 0.990

Other-blame 1 14187.056 1491.457 0.000 0.975

Total Score of maladaptive 1 250224.008 6006.344 0.000 0.994

strategies

Therapy Acceptance 1 8984.889 623.877 0.000 0.941

Within-Group Stages of
Factors Subscales Positive refocusing 1 11948.643 1611.783 0.000 0.976

Focus on planning 1 15092.389 2789.903 0.000 0.976

Positive reappraisal 1 14571.627 1438.111 0.000 0.974

Putting into perspective 1 7968.286 1215.049 0.000 0.969

Total score of adaptive 1 28633.722 6030.511 0.000 0.994

strategies

Self-blame 1 14.889 5.027 0.000 0.805

Rumination 1 23.270 4.942 0.000 0.902

Catastrophizing 1 0.286 4.066 0.000 0.924

Other-blame 1 5.484 3.577 0.000 0.875

Total score of maladaptive 1 117.460 4.820 0.000 0.834

strategies

Between-Group Acceptance 1 122.056 8.475 0.000 0.911

Group
Factor
Positive refocus 1 6.952 5.938 0.000 0.877

Refocus on planning 1 14.151 2.616 0.086 0.118

Positive reappraisal 1 4.437 0.438 0.649 0.022

Putting into perspective 1 0.643 0.098 0.907 0.095

Total score of adaptive 1 527.627 11.298 0.000 0.967

strategies
44 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

Table 6: Summary of the results of the Toki follow-up test for three groups

variable Steps Mean differences Standard deviation Sig.

DBT- ACT 0.987 0.125 0.000
Self-blame Control - ACT 0.635 0.125 0.000
DBT - Control 0.785 0.125 0.000
rumination DBT- ACT 1.542 0.107 0.000
Control - ACT 1.436 0.107 0.000
DBT - Control 1.698 0.107 0.000
catastrophizing DBT- ACT 0.874 0.154 0.000
Control - ACT 0.968 0.154 0.000
DBT - Control 1.142 0.154 0.000
Other-blame DBT- ACT 1.117 0.236 0.000
Control - ACT 1.134 0.236 0.000
DBT - Control 1.598 0.236 0.000
Total scores of DBT- ACT 2.867 0.574 0.000
maladaptive Control - ACT 4.457 0.574 0.000
strategies DBT - Control 5.764 0.574 0.000
acceptance DBT- ACT 0.956 0.244 0.000
Control - ACT 1.754 0.244 0.000
DBT - Control 1.968 0.244 0.000
Positive refocusing DBT- ACT 0.345 0.65 0.000
Control - ACT 0.468 0.165 0.000
DBT - Control 0.677 0.165 0.000
Total scores of DBT- ACT 3.387 0.224 0.000
adaptive strategies Control - ACT 4.754 0.224 0.000
DBT - Control 5.968 0.224 0.000

different (P= 0.02), and this, with regard to the the quality of life of adolescent boys in the risk of
difference between the mean of coping and control drug abuse (P= 0.10). After removing the effect of
groups, showed a positive effect of coping-therapy pre-test scores, the mean of life quality (follow-up)
on quality of life. Also, there is no significant variables was not significantly different between
difference between the efficacy of emotional the two experimental groups (emotion regulation
regulation training and coping therapy training on and coping therapy) and control (P <0.05), which

Table 7: Summary of results of variance analysis with repeated within group measurement
Variable Mean
Comparison Df F Sig. Effect size
sources squares
Group 2 289.178 11.419 0.000 0.911
ACT and Control groups
Error 38 24.826
DBT-ST and Control Group 2 437.143 16.388 0.000 0.967
groups Error 39 22.608
Group 2 492.200 24.871 0.000 0.998
DBT-ST and ACT
Error 40 16.526
 Comparing Efficacy ACT and DDT-ST on Cognitiie Emotion Regulation ;;oushki, et al 45

suggests no effect for the emotion regulation program significant difference between the subscales of focus
and coping-therapy training on the quality of life on planning, positive reappraisal, and putting others
variable up to the follow-up stage. into perspective. The results of this study are consistent
The results of Table 7 show that both (DBT) and with the research of Eri et al. (2018), Yaraghpi et
(ACT) methods were significantly effective and the al. (2018), Jalodari et al. (2019), and Tamnaei Far,
effect size of DBT-ST treatment was slightly higher Gharayi, Birshak, and Habibi (2014).
than the effect size of acceptance and commitment Acceptance and commitment therapy and dialectical
therapy (effect size= 0.968) compared to the control behavioral therapy skill training increase disease
group (effect size= 0.911). Regarding Cohen’s view acceptance, tolerance, and adaptive cognitive emotion
that the Eta coefficient equal to 0.01 indicates the regulation. The basic skills that patients with diabetes
small effect size, 0.66 indicates the moderate effect type II learned in these two types of treatment allowed
size, and 0.14 indicates the large effect size, so both them to add these skills to their behavioral resources and
DBT-ST and ACT methods are effective on cognitive use more constructive strategies in difficult situations.
emotion regulation. Emotional cognition has been In the process of acceptance and commitment therapy,
effective, but the effect of DBT-ST is greater than psychological flexibility is recognized as the basis
ACT in the cognitive emotion regulation scores, with of psychological health (Hayes et al., 2014). The
higher effect size of DBT-ST compared to ACT. Also individual with psychological flexibility does not
there is different between Effect size of DBT-ST and avoid unwanted events and does not attempt to control
ACT based on F and sig. The effect size of DBT-ST and change them, rather spends his energy on values
compared to ACT was found to be 0.967. Therefore, it and meaning of life instead of avoiding unwanted
means that DBT-ST was more effective than ACT on events (Hayes et al., 2013).
cognitive emotion regulation. The acceptance and commitment therapy process
helps patients accept responsibility for behavioral
Discussion and conclusion changes and change whenever necessary, and in fact,
The aim of the present study was to compare the this treatment seeks to balance appropriate strategies
effectiveness of acceptance and commitment therapy for the situation. ACT through factors such as non-
and dialectical behavioral therapy skills training on judgmental acceptance, being in the moment, coping
cognitive emotion regulation in patients with diabetes with internal experiences without avoidance, and
type II. For this purpose, in this study, acceptance suppressing or trying to change them improves how
and commitment therapy in the form of eight group people think after a negative experience or traumatic
therapy sessions, and dialectical behavioral therapy event (i.e., cognitive emotion regulation) (PetrosVinert,
skills training in the form of twelve sessions were 2011), and help patients with diabetes type II accept
provided to 14 patients with diabetes type II. Members their feelings, emotions, and thoughts despite being
of the control group did not receive any treatment. uncomfortable and reduce their hypersensitivity to
The results of data analysis proved the effectiveness the disease, thereby increasing their mental health and
of acceptance and commitment therapy and dialectical quality of life. On the other hand, the transparency of
behavioral therapy skill training on cognitive emotion values and the internalization of the committed action
regulation in patients with diabetes type II. These that takes place during acceptance and commitment
two types of treatment significantly reduced scores therapy give individuals sufficient motivation to
of maladaptive cognitive emotional regulation and continue and complete the treatment (Harris, 2019).
increased adaptive cognitive emotion regulation scores This model of treatment uses the processes of
in patients with diabetes type II; however, there was no acceptance, mindfulness, commitment, and behavior
46 Iranian Journal of Health Psychology; Vol. 4, No.1, Spring 2021

change processes to create psychological flexibility. health of patients with diabetes type II.
Increasing cognitive flexibility helps people accept
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