The Effectiveness of Acceptance and Commitment Therapy and Existential Cognitive Therapy on Mental Pain and Fatigue Associated with Cancer in Women with Breast Cancer

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The Effectiveness of Acceptance and Commitment Therapy and Existential Cognitive Therapy on Mental Pain and Fatigue Associated with Cancer in Women with Breast Cancer

https://doi.org/10.21203/rs.3.rs-4899237/v1

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Purpose

Cancer significantly impacts the physical and psychological well-being of patients. Breast cancer, in particular, can lead to various psychological distress, including mental pain and fatigue. The purpose of this study was to compare the effectiveness of Acceptance and Commitment Therapy (ACT) and Existential Cognitive Therapy (ECT) in reducing mental pain and fatigue in women with breast cancer.

Methods

A quasi-experimental pre-test-post-test design with a control group was employed in this study. The target population comprised all women diagnosed with breast cancer and referred to pathology departments in Ahvaz, Iran, during 2023. A convenience sample of 60 participants was selected and randomly assigned to three groups of 20: ACT, ECT, and a control group. The ACT and ECT groups received 10 ninety-minute sessions of their respective therapies, while the control group received no psychological intervention. Data were collected using the Pain Questionnaire and the Cancer Fatigue Scale and analyzed using analysis of covariance.

Results

The results indicated that both ACT and ECT were significantly effective in reducing mental pain and fatigue in women with breast cancer (p < 0.01). However, no significant difference was found between the effectiveness of ACT and ECT in reducing mental pain and fatigue.

Conclusions

Both ACT and ECT can be effective interventions for reducing mental pain and fatigue in women with breast cancer.

Acceptance and commitment therapy

Existential therapy

Pain

Fatigue

Cancer

Over the past two decades, the rising incidence and mortality rates have made breast cancer the most common cancer diagnosis and a leading cause of death among women worldwide (1). Breast cancer is also highly prevalent among Iranian women, accounting for 24.6% of all cancer diagnoses (2). This disease is influenced by various factors, including unhealthy lifestyles (3). It is noteworthy that the incidence of cancer in Iran has been increasing in recent years, with reported rates exceeding those estimated by global cancer research centers (4). This upward trend underscores the need for national policies to facilitate early disease detection, thereby increasing patient survival rates and quality of life. The challenges associated with diagnosing and treating breast cancer are typically accompanied by increased psychological distress, fatigue, cognitive impairments, and physical problems, while also imposing a significant economic burden on society (5, 6).

One of the psychological problems experienced by women with breast cancer is mental pain (7). Mental pain arises from the frustration of unmet needs such as love, control, support, security, or understanding, leading to a combination of negative emotions including guilt, shame, humiliation, sadness, grief, despair, and anger (8). Verrocchio et al. (9) suggests that this component is a negative self-perception arising from deficiencies or unmet psychological needs. Studies have also shown that mental pain is a response to interpersonal injury, and depressed individuals do not receive adequate responses from their environment to meet these needs (10). This type of pain is described as a form of psychological suffering manifested as feelings of being broken, wounded, losing control, and having a negative self-concept (11). Therefore, mental pain is a factor associated with chronic and debilitating physical illnesses such as cancer and psoriasis, which are linked to a range of psychiatric disorders including depression and borderline personality disorder (12). Furthermore, research has shown that high sensitivity to mental pain is associated with maladaptive behaviors such as avoidance of experiences and unwillingness to accept painful events (13).

On the other hand, fatigue is the most common and often most distressing symptom associated with cancer and its treatment, reported in 70–100% of patients undergoing treatment (14). According to reports from cancer patients, cancer-related fatigue is the most distressing symptom for them and has a significant negative impact on their quality of life (15). This symptom affects more than 70% of patients undergoing radiation and chemotherapy (16). For many patients, cancer-related fatigue is so severe that, if left untreated, it disrupts and limits their daily activities, profoundly affecting many aspects of their lives, including their ability to engage in valued activities and roles, their quality of life, and their functional status (17).

Therefore, it is essential to consider the implementation of psychological treatments alongside physical treatments for women with breast cancer. Among third-wave therapies, Acceptance and Commitment Therapy (ACT) has received significant clinical attention in recent years (18). Its goal is not to change disturbing thoughts, feelings, desires, or beliefs, but rather to change the client's relationship with their thoughts and feelings in a way that is not seen as catastrophic (19). Instead of focusing on eliminating harmful factors, ACT helps clients accept their uncontrolled emotions and cognitions, freeing themselves from the control of verbal rules that cause their problems, and allowing them to stop struggling and fighting with themselves (20). This therapy is fundamentally process-oriented and explicitly emphasizes the promotion of the acceptance of psychological experiences and commitment through increasing flexible and adaptable meaningful activities. Thus, this approach emphasizes contextual and environmental changes (21). Dadashi and Momeni (22) also showed in a study that ACT increased scores on variables of life hope and psychological well-being among women with breast cancer undergoing chemotherapy in the post-test phase. Ghorbani et al. (23) reported in a study that ACT were effective in reducing pain anxiety and self-acceptance in breast cancer patients.

Another therapeutic approach used to improve the psychological problems associated with physical illnesses like cancer is Existential Cognitive Therapy (ECT) (24). This intervention is designed to address the specific needs of patients who are facing the threat of losing their own lives or those of loved ones, or who are suffering from other significant losses. This intervention appears to have the necessary components to help reduce depressive symptoms in patients (25). ECT, as an integrated approach, has been highly effective in reducing psychological distress in many patients with chronic pain (26). Kissane et al. (27) first introduced group-based ECT to leverage the benefits of combining aspects of Beck's cognitive therapy and Yalom's existential approach within the framework of group counseling techniques, and reported its effectiveness in reducing depression and increasing hope in cancer patients. Therefore, this therapy can be described as facilitating the search for meaning and purpose in life, enhancing relationships, and helping patients develop adaptive thoughts and attitudes, a sense of meaning, and peace of mind, which can be considered the general endpoint of therapy (28). Farmani-shahrezaet al. (29) found in a study that ECT was effective in reducing depressive symptoms in patients with human immunodeficiency virus (HIV). Farmani Shahreza et al. (30) also reported in a study that ECT had a positive effect on fatigue, depressive symptoms, and perceived stress in patients with multiple sclerosis and improved their overall health.

The high prevalence of breast cancer and its associated psychological sequelae underscore the critical need for effective interventions to enhance the quality of life among affected women. A significant gap exists in the literature regarding a comparative analysis of ACT and ECT in addressing psychological distress and fatigue specifically within the breast cancer population. While previous research has examined the efficacy of these therapies in diverse populations, their comparative impact on women with breast cancer remains underinvestigated. This study aims to determine the relative effectiveness of ACT and ECT in reducing psychological distress and fatigue among women with breast cancer. By comparing these therapeutic approaches, the research will provide evidence-based guidance for clinicians and patients in selecting optimal treatment options. Moreover, the study will explore the underlying mechanisms of change associated with each therapy to deepen understanding of their therapeutic processes.

A quasi-experimental pre-test-post-test control group design was employed for this study. The target population encompassed all women diagnosed with breast cancer and referred to pathology departments within Ahvaz, Iran, during 2023. Eligible women with breast cancer attending the pathology departments of two hospitals were invited to participate, with a pre-test administered to those consenting. The sample comprised 60 women with breast cancer, selected through convenience sampling and randomly allocated to three groups (ACT, ECT, and control) (n = 20 per group). Inclusion criteria specified an age range of 20 to 45 years, provision of informed consent, and the absence of other physical conditions such as epilepsy or sensory-motor impairments. Participants were excluded from the study if they withdrew consent or missed more than two sessions. Data were subjected to descriptive analysis to determine means and standard deviations. To examine group differences, inferential analysis was conducted using analysis of covariance (ANCOVA). SPSS version 24 was utilized for all data analyses.

Instruments

Two scales were employed to collect data in this study: the Mental Pain Scale (MPS) and the Cancer Fatigue Scale (CFS). The MPS, developed by Orbach et al. (31), measures the intensity of mental pain. This 44-item scale uses a 5-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (5), with items 25 and 42 reverse-scored. The minimum and maximum scores are 44 and 220, respectively, with higher scores indicating greater mental pain. Orbach et al. (31) reported a Cronbach's alpha of 0.75 for the scale. In Iran, Karimi et al. (32) calculated a Cronbach's alpha of 0.96 for the entire scale. The CFS, developed by Okuyama et al. (33), consists of 15 items rated on a 5-point Likert scale ranging from "not at all" (1) to "very much" (5). The total CFS score ranges from 15 to 75, with higher scores indicating greater fatigue. Aghayousefi et al. (34) conducted a psychometric evaluation of the CFS in Iran, reporting a Cronbach's alpha of 0.90 for internal consistency.

Interventions

In this study, the independent variable was implemented over 10, 90-minute sessions based on ACT protocol and 10, 90-minute sessions of ECT for women with breast cancer. During the intervention period, the control group did not receive any psychological intervention and was placed on a waiting list. A summary of the content of ACT and ECT sessions is presented in Tables 1 and 2.

Table 1

A summary of sessions in acceptance and commitment therapy (ACT) protocol
Sessions	Content
Session 1	Introduction and goals, outlining session rules, introducing the concept of Acceptance and Commitment Therapy, conceptualizing clients' problems, preparing clients, and creating a list of pleasurable activities to be included in the weekly schedule.
Sessions 2 & 3	Acquainting with the principles and concepts of Acceptance and Commitment Therapy, including psychological flexibility, psychological acceptance, mindfulness, cognitive defusion, self-as-context, personal story, values clarification, and committed action.
Sessions 4 & 5	Mindfulness training (emotional awareness and wise mind), training in observing and describing events and skills, and focusing on them without judgment.
Sessions 6 & 7	Focusing on increasing mindfulness, learning how to respond to and appropriately confront mental experiences, setting goals and a social lifestyle, and committing to acting on them, identifying positive and negative aspects of each other without judgment and emotional reaction.
Session 8	Teaching tolerance of negative events through coping skills during crises, distraction, self-soothing using the senses, and mindfulness practice, providing feedback to each other.
Session 9	Teaching emotion regulation (recognizing emotions, understanding their importance, reducing emotional vulnerability and suffering, and increasing positive emotions), changing emotions through actions opposite to the emotion, practicing what has been learned, and receiving feedback from the group and therapist.
Session 10	Increasing interpersonal effectiveness (maintaining and sustaining healthy relationships, interests, etc.), teaching interpersonal skills (self-description and expression, assertiveness, trust, negotiation, self-esteem, etc.), and summarizing and concluding the sessions.

Table 2

A summary of sessions in existential cognitive therapy (ECT) protocol
Sessions	Content
Session 1	Introduction of the subject to the overall goals of therapy sessions/explanation of the general guidelines of sessions including responsibility for the therapeutic process, the need to maintain confidentiality, adherence to session time, and encouraging self-disclosure through expressing thoughts and feelings.
Session 2	Requesting the subject to tell their story about how they contracted the disease and the subsequent emotional and behavioral reactions to the disease/helping to create a safe therapeutic space, self-expression, and being present in the here and now, examining the longitudinal section of the subject's behavior, feelings, and thoughts.
Session 3	Facilitating the expression of the subject's beliefs and opinions about the disease and contracting it and evaluating the cause of it/recognizing cognitive distortions and errors of the subject, for example, attributing the cause of the disease to past sins/extracting existing cognitive errors and reducing and eliminating them.
Session 4	Gradually paying attention to existential anxieties expressed by the subject during self-disclosure/addressing the concept of the unpredictability of the world and the uncertainty of existence/working with manifestations of anxiety about unpredictability and helping to reduce these fears by accepting the anxiety of unpredictability.
Session 5	Working with the theme of death anxiety when expressing reactions to the diagnosis of breast cancer, encouraging the expression of individual meaning in relation to death anxiety, helping to face the reality of death/correcting existing cognitive distortions in the meaning of existential death anxiety, facilitating the grieving process.
Session 6	Helping to create a new meaning in the cause of contracting cancer/familiarizing the individual with the concept of basic loneliness anxiety (based on the feeling that the individual feels alone after contracting this disease).
Session 7	Challenging the concept of losing meaning in life/challenging the ineffective meanings attributed to the disease and the resulting guilt/helping the subject find an effective meaning free of cognitive distortions/helping to accept the choice in giving meaning to life experiences.
Session 8	Helping the individual confront the consequences of not accepting responsibility and ignoring the principle of freedom and choice/challenging the concept of suffering caused by the consequences of contracting/helping the subject accept suffering as a result of the meaning-making process, through cognitive techniques/helping the subject to search more in their proven reality in order to let go of suffering and accept it.
Session 9	Helping the individual to reach these perspectives: life and death are interdependent and death always looks at us and life cannot be postponed either/behind the interpretation of every experience, there is a personal meaning and the individual has unconditional freedom in choosing this meaning.
Session 10	Summarizing all the topics discussed with the help of the subject/reviewing the impact of the interventions performed and the corrected cognitive distortions/talking to the subject about the identity that was confused as a result of the ineffective meaning-making process, maladaptive thoughts, etc./helping to build the subject's new identity suitable for the new situation.

Participants in the present study were women diagnosed with breast cancer aged between 20 and 45 years. The mean age of participants in the ACT group was 36.45 ± 5.38, in the ECT group 36.85 ± 5.17, and in the control group 37.48 ± 6.62. Table 3 presents the means and standard deviations (SD) of mental pain and fatigue scores for the experimental and control groups at the pre-test and post-test stages. As shown in Table 3, the mean scores of mental pain and cancer fatigue in both the ACT and ECT groups decreased significantly from the pre-test to the post-test. These results indicate that both ECT and ACT were effective in reducing mental pain and cancer fatigue in women with breast cancer.

Table 3

Means and standard deviations of mental pain and cancer fatigue scores for the experimental and control groups at pre-test and post-test
Variables	Phases	ACT group		ECT group		Control group
Variables	Phases	Mean	SD	Mean	SD	Mean	SD
Mental pain	Pre-test	124.66	14.71	152.64	14.42	124.73	14.83
Mental pain	Post-test	114.33	12.78	115.40	14.06	125.53	15.04
Cancer fatigue	Pre-test	54.53	8.05	54.60	8.38	54.45	9.29
Cancer fatigue	Post-test	45.46	8.06	46.26	9.29	54.80	8.78

As shown in Table 4 and the results of the Kolmogorov-Smirnov test, the assumption of normality of the data was confirmed. Moreover, Levene's test results indicated homogeneity of variances for both mental pain (F = 1.13, p = 0.207) and cancer fatigue (F = 1.01, p = 0.184). Additionally, the assumption of homogeneity of covariance matrices, as assessed by Box's M test, was met for both ACT and ECT groups (F = 1.01, Box's M = 14.04, p = 0.401). Therefore, it can be concluded that the covariance matrices were homogeneous, satisfying the assumptions for covariance analysis.

Table 4

Results of the Kolmogorov-Smirnov test and Levene's test.
Variables	Kolmogorov-Smirnov						Levene's test
Variables	Statistics	p	Statistics	p	Statistics	p	F	p
Mental pain	0.14	0.200	0.15	0.186	0.11	0.200	1.13	0.207
Cancer fatigue	0.19	0.173	0.15	0.188	0.12	0.200	1.01	0.184

Covariance analysis was conducted on the post-test mean scores of mental pain and cancer fatigue for the experimental and control groups. As shown in Table 5, after controlling for the pre-test scores, there was a significant difference between the experimental and control groups in terms of mental pain (F = 93.03, p < 0.01) for the ACT group and a significant difference in mental pain (F = 26.58, p < 0.01) for the ECT group. Similarly, there was a significant difference between the experimental and control groups in terms of cancer fatigue after controlling for the pre-test scores (F = 46.25, p < 0.01) for the ACT group, and a significant difference in cancer fatigue (F = 24.34, p < 0.01) for the ECT group.

Table 5

Results of analysis of covariance on post-test mean scores of mental pain and cancer fatigue
Variables	Groups	SS	df	MS	F	p	η²
Mental pain	ACT group	930.53	1	930.53	93.03	0.001	0.78
Mental pain	ECT group	904.20	1	904.20	26.58	0.001	0.50
Cancer fatigue	ACT group	661.72	1	661.72	46.25	0.001	0.63
Cancer fatigue	ECT group	562.49	1	562.49	24.34	0.001	0.47

To compare the effectiveness of ACT and ECT on mental pain and cancer fatigue in women with breast cancer, post-hoc comparisons were conducted using the Bonferroni test. The results are presented in Table 6. The Bonferroni test showed that both ACT and ECT were significantly more effective than the control group in reducing mental pain in women with breast cancer. The mean difference in mental pain between the control group and the ACT group was − 11.14, and between the control group and the ECT group was − 10.96. However, there was no significant difference between ACT and ECT in terms of their effectiveness in reducing mental pain. Similarly, both ACT and ECT were significantly more effective than the control group in reducing cancer fatigue. The mean difference in cancer fatigue between the control group and the ACT group was − 9.39, and between the control group and the ECT group was − 8.66. Again, there was no significant difference between ACT and ECT in terms of their effectiveness in reducing cancer fatigue.

Table 6

Results of Bonferroni post-hoc comparisons
Variable	Groups	Mean difference	p
Mental pain	ACT - ECT	-0.18	0.999
	ACT - Control	-11.14	0.001
	ECT - Control	-10.96	0.001
Cancer fatigue	ACT - ECT	-0.74	0.999
	ACT - Control	-9.39	0.001
	ECT - Control	-8.66	0.001

This study aimed to evaluate the comparative efficacy of ACT and ECT in alleviating mental pain and fatigue among women diagnosed with breast cancer. The findings indicated that both ACT and ECT resulted in significant reductions in mean scores of mental pain among women with breast cancer during both the intervention and follow-up phases. Notably, the comparison of group effects revealed no significant difference between ACT and ECT in reducing mental pain, suggesting that both therapies were equally effective in alleviating psychological distress among women with breast cancer.

Both mental pain and suffering allude to a sense of personal disunity. When this distress becomes intolerable, it can halt an individual's psychological growth. Mental pain encompasses a broad spectrum of mental experiences resulting from events, trauma, and loss, leading to negative emotions and destructive changes within the individual (10). It represents a form of psychological suffering, a feeling of brokenness, inadequacy, and a sense of being flawed, wounded, and out of control. It is a distressing state of heightened self-awareness regarding one's perceived inadequacies when personal failures and shortcomings fall below one's idealized standards. In ACT, patients are encouraged to accept their unpleasant and distressing thoughts and feelings. Additionally, they are taught to consider the context in which their behavior occurs and the function it serves (23). Despite the numerous challenges faced by breast cancer patients, higher rates of depression and mood disorders are commonly observed. Mental pain, often exacerbated by negative thoughts, becomes more prevalent in these individuals. ACT can be particularly beneficial in helping these patients accept their current circumstances and the challenges they face, such as the difficulties and duration of treatment, ultimately improving their quality of life.

Furthermore, it was found that ECT also induced a significant decrease in mental pain among breast cancer patients. This finding can be explained by the fact that while the primary emotion associated with mental pain is self-despair, other crucial characteristics include a lack of awareness of one's personal role and a sense of personal incompleteness, all of which are central features of mental pain. Existential Cognitive Therapy aims to alleviate emotional distress by helping individuals identify, challenge, and modify the distorted and maladaptive cognitions underlying their distress (29). According to this cognitive perspective, the human mind actively constructs its reality. To change one's circumstances, the individual's mental construction of reality, based on their interpretation of events, must be adjusted (25). Consequently, when individuals experience cognitive distortions such as negative views of life or excessive anxiety about death, they suffer from mental pain and distress. Existential Cognitive Therapy helps individuals develop a more accurate and adaptive perspective and expectations, thereby improving their quality of life.

Furthermore, the findings revealed that both ACT and ECT led to significant reductions in mean scores of cancer-related fatigue among women with breast cancer during both the intervention and follow-up phases. Notably, the comparison of group effects indicated no significant difference between ACT and ECT in reducing cancer fatigue, suggesting that both therapies were equally effective in alleviating fatigue among women with breast cancer.

Breast cancer patients often endure prolonged and arduous treatments, necessitating the use of multiple medications and disrupting their normal routines. Consequently, they experience chronic psychological fatigue, often referred to as cancer-related fatigue. ACT is a therapeutic approach that utilizes acceptance, commitment, mindfulness, and behavior change processes to foster psychological flexibility. It aims to shift one's perspective on current events rather than seeking to alter reality. In essence, ACT focuses on reducing the psychological experience of distress and increasing awareness of the present moment (21). Through approximately 10 sessions, ACT helps individuals reduce self-critical and exhausting thoughts, thereby alleviating psychological fatigue.

ECT, through specific techniques employed over ten sessions, helps individuals become aware of and express emotions stemming from existential anxieties such as death anxiety, uncertainty, meaninglessness, loneliness, and the perceived uncontrollability of the world, which are often exacerbated by the threat of death or significant losses associated with illness (28). By fostering honest acceptance and authentic responses to these emotions, ECT, using cognitive therapy techniques, also identifies and corrects certain schemas, automatic thoughts, and cognitive distortions that contribute to the avoidance of existential anxiety. The ECT intervention protocol was designed to gradually create a safe therapeutic space for emotional expression, facilitating self-disclosure and confrontation of repressed, distorted, and denied emotions. Building on this increased awareness of one's emotional experiences, the therapy then moves towards identifying, correcting, or eliminating the dysfunctional, irrational, and erroneous cognitions underlying the avoidance of existential experiences (30). By altering an individual's perspective and beliefs about existence, the world, and the meaning of life, ECT helps reduce cancer-related fatigue, which is often exacerbated by the negative psychological burden of the disease, thereby enhancing the quality of life. Whether through ECT's modification of beliefs about death, loneliness, and human mortality or through ACT's emphasis on accepting one's circumstances during illness, both therapies have been shown to effectively reduce cancer-related fatigue and improve overall quality of life. These findings support the results of the present study.

Similar to other studies, the present research had certain limitations. The study was conducted on women with breast cancer exclusively and was limited to the city of Ahvaz. Additionally, other variables such as family history of cancer, socioeconomic status, and disease duration were not examined.

Findings from this study demonstrated that both ACT and ECT significantly reduced mental pain and fatigue among women with breast cancer. Notably, no significant differences emerged between the two interventions in their efficacy, suggesting that both ACT and ECT may be considered effective treatment options for alleviating psychological distress and fatigue in this population. Future research could explore the long-term effects of these interventions on the quality of life and overall well-being in women with breast cancer. Additionally, investigating the potential moderating effects of factors such as disease stage, treatment regimen, and personality traits on treatment outcomes could provide valuable insights. Comparative studies examining the cost-effectiveness of ACT and ECT would also contribute to evidence-based practice.

Ethical Approval

This study has been conducted in accordance with the ethical standards set forth by the Declaration of Helsinki and has received approval from the Institutional Review Board (IRB) of Islamic Azad University- Ahvaz Branch (Approval ID: IR.IAU.AHVAZ.REC.1403.004). Prior to the initiation of the research, we ensured that all participants provided informed consent. Participants were informed about the study’s purpose, procedures, potential risks, and benefits, and were assured of their right to withdraw at any time without penalty.

Competing interests

The authors declare no conflict of interest in this current study.

Funding

This study did not receive any funding.

Availability of data and material

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Authors' contribution

F.J: Study concept and design, acquisition of data, analysis and interpretation of data, and statistical analysis. S.S: Administrative, technical, and material support, study supervision. S.S and F.J: Critical revision of the manuscript for important intellectual content.

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No competing interests reported.

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The Effectiveness of Acceptance and Commitment Therapy and Existential Cognitive Therapy on Mental Pain and Fatigue Associated with Cancer in Women with Breast Cancer

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References

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Status:

Version 1