Original Article Open Access

DOI: 10.19187/abc.201853111-117
Effect of Acceptance and Commitment Group Therapy on
Quality of Life and Resilience of Women With Breast Cancer
a a a b
Fatemeh Sadeghi , Fariba Hassani* , Suzan Emamipour , Hamidreza Mirzaei

a
Department of Psychology, Islamic Azad University, Central Tehran Branch, Tehran, Iran
b
Cancer Research Center, Shohadaye Tajrish Hospital, Department of Radiation Oncology, Shahid Beheshti
University of Medical Sciences, Tehran, Iran

ARTICLE INFO ABSTRACT

Received: Background: Breast cancer diagnosis always causes a great deal of stress and
24 March 2018 results in significant changes in the patient’s routine life, which—apart from
Revised: physical injuries—can lead to loss of social functioning and increased risk of
18 July 2018 mental disorders. Psychological resilience may be a protective factor in dealing
Accepted:
22 July 2018 with stressful clinical situations. The present study aimed at investigating the effect
of acceptance and commitment group therapy on the quality of life and resilience of
women with breast cancer.
Methods: This study had a quasi-experimental, pre-post intervention design
with a control group. Twenty women with breast cancer (stages I or II) were
randomly assigned to an intervention or a control group. The intervention consisted
of eight weekly sessions of acceptance and commitment group therapy. Follow-up
evaluations were carried out two months after the intervention. The Quality of Life
Questionnaire-Core 30 (QLQ-C30), Quality of Life Questionnaire-Breast Cancer
(QLQ-BR23), and the Connor-Davidson Resilience Scale (CD-RISC) were used in
this study.
Results: Sixteen patients completed the study. Compared with the control
group, significant improvements were observed in the total and subscale scores on
QLQ-C30 (partial η2 = 0.40), QLQ-BR23 (partial η2 = 0.73), and CD-RISC scores
key words: (partial η2 = 0.94) and (P < 0.01) in the intervention group.
Acceptance and Conclusion: Acceptance and commitment program appears to be an effective
commitment therapy, therapeutic intervention for improving quality of life and resilience of breast cancer
quality of life(QOL),
patients. Therefore, we suggest that this intervention be provided along with medical
resilience,
breast cancer treatments to improve quality of life and resilience of breast cancer patients.

Introduction treatment of breast cancer could be followed by a lot

Breast cancer is a heterogeneous condition where of psychological problems, which could lead to more
prognosis and survival are affected by multiple severe symptoms, slower recovery, and poorer health
3
factors.1 The incidence rate of breast cancer has outcomes. For example, it has been shown that
increased in Iran recently, making it the most cancer diagnosis and treatments are associated with
2
common cancer among women. The diagnosis and concurrent psychological symptoms such as
4 5
depression, anxiety, and psychosocial sequel of pain
Address for correspondence: including fear, insomnia,7 or agitation.8 Besides,
6

Fariba Hassani, Ph.D these patients experience difficulties in marital

Address: Assistant Professor of Islamic Azad University,
Department of Psychology, Islamic Azad University, Central satisfaction and communication with family and also
Tehran Branch, Tehran, Iran in their relationships with their spouse and children.
Tel: +98 912 305 8632 Therefore, because of perceived social, cognitive,
Email: [email protected]
and emotional problems, breast cancer patients tend

Sadeghi, et al. Arch Breast Cancer 2018; Vol. 5, No. 3: 111-117 111
 Quality of life and resilience and breast cancer

to have a poor quality of life.9 Quality of life is an to report cancer stages. Therefore, this study was
important consideration when providing care to conducted to examine these hypotheses:
cancer patients.10 It has been demonstrated that A: Acceptance and commitment group therapy
decreased health-related quality of life caused by affects the quality of life of women with breast
chemotherapy side-effects may predispose patients to cancer.
early discontinuation of treatment,11 while studies on B: Acceptance and commitment group therapy
breast cancer survivors have shown that a good affects the resilience of women with breast cancer.
quality of life may benefit breast cancer patients.12
Quality of life is a broad, multidimensional concept Methods
reflecting patients’ perceptions of both positive and A quasi-experimental study with a pre-post
negative aspects of their life with regard to physical intervention design and a 2-month follow-up was
health, psychological state, level of independence, carried out from March 2016 to December 2016.
social relationships, personal beliefs and their Breast cancer patients from the Oncology
13
relationships to salient features of their environment. Department of the Cancer Research Center, Shahid
The concept has attracted the attention of researchers, Beheshti University of Medical Sciences, Tehran,
and there is a growing consensus that it should be one Iran, were recruited for this study. Participation in the
of the main components of medical practice and study was offered to all breast cancer patients who
research.14 came for follow-up in the oncology wards in March
In addition, the contribution of resilience to the and April 2016. The planned sample size was
compliance of patients with breast cancer is N  =  20. In general, it is believed that the size of
highlighted by a number of studies.15 Resilience is an groups is set by the goals and priorities of groups,
individual’s ability to adaptively respond to and it is recommended that the participants in each
hardship, stress, and adversity and has been defined group be limited to 6 to 8 people because of paying
22
as the capacity to “bounce back” from negative attention to the needs of individual members. Then,
events without succumbing to despair.16 A study on 20 patients were randomly assigned to either the
survivors of breast, stomach, and lung cancers intervention or control group. All participants were
showed that resilience was associated with better Iranian women treated for breast cancer, and we used
quality of life and lower levels of depression. the following inclusion criteria: (1) having
Another study examining fatigue in cancer patients histologically confirmed primary breast cancer
undergoing radiation therapy showed that resilience (stages I or II) (2) being aged 18 and above; (3) being
was an important psychological predictor of quality literate and fluent in the Persian language; (4) having
17
of life and coping. no history of mental disorder or psychiatric problem;
Acceptance and commitment therapy (ACT), (5) having no cognitive deficits; (6) being
which the American Psychological Association cooperative with treatments; and (7) having
acknowledges as a modality of treatment for some completed the initial surgical and oncological
18
psychiatric conditions, emphasizes acceptance and treatment at least 2 months before the inclusion.
mindfulness and focuses on strategies to induce Participants were excluded from the study if (1) they
behavior change guided by the patient’s personal had serious physical problems that would preclude
values to improve functioning and coping with them from following the intervention, (2) they
persistent symptoms.19 The treatment approach in missed more than two sessions of therapy, and (3)
ACT is to encourage patients to acknowledge and they participated in concurrent psychological
accept mental experiences to increase their ability to treatment, studies or rehabilitation (i.e. relaxation,
work with problems that cannot be solved. ACT mindfulness, psycho-education, or ACT). Finally, 4
interventions involve addressing six core participants were excluded during the examination
psychopathological processes including acceptance, because they declined to participate or started to use
cognitive defusion, self as a context, values, being psychiatric drugs.
20
present, and committed action. A recent review has The study received the approval of the local ethics
identified studies using ACT in the contexts of lung, committee. Each participant gave written informed
21
breast, blood, and bladder cancers. It is expected consent for participation. The privacy of participants
that ACT has the potential to become a particularly was protected, and also the confidentiality of records
well-suited approach to treating people with breast and personal accounts was maintained. It was also
cancer as it offers a model of healthy adaptation to suggested to the control group that, after completing
difficult circumstances. This is the first study to use the research, they can attend another acceptance and
ACT to improve quality of life and resilience in commitment group therapy held by the researcher.
people with breast cancer. If ACT proves effective in The Iranian versions of the Quality of Life
this trial, it could be recomme-nded to be integrated Questionnaire-Core 30 (QLQ-C30) and Quality of
into treatment plans for breast cancer patients. Life Questionnaire-Breast Cancer (QLQ-BR23)
However, despite providing valuable preliminary were used to measure the quality of life in this study.
data, these studies either had a small sample or failed The QLQ-C30 is the core module that examines

112 Sadeghi, et al. Arch Breast Cancer 2018; Vol. 5, No. 3: 111-117
 Quality of life and resilience and breast cancer

the total quality of life in the course of cancer disease. practicing how to solve barriers and problem; setting
The questionnaire contains 30 questions comprising goals based on values; defusion exercise using the
a global health scale, 5 functional scales (physical, metaphor of bus passengers; classification of thoughts
emotional, cognitive, social, and role-playing), 3 exercise.
symptom scales (fatigue, nausea and vomiting, and Session 5: Practicing to consider the thought just as a
pain), and a number of individual items (dyspnea, thought; practicing defusion from verbal threats;
loss of appetite, insomnia, constipation, diarrhea, mindfulness exercise. The assignment was designed
and financial difficulties).23 In the functional scales, with the aim of initiating work on the commitment
higher scores represent a better level of functioning, and allowing barriers to be identified.
while, in the case of symptom scales/items, higher Session 6: Identifying traces in the value path and
scores mark a higher level of symptomatology or acceptance awareness training; identifying the goals
problems.24 The QLQ-BR23 is a 23-item breast along the path with values; examining useful
cancer–specific questionnaire about the common solutions to barriers and learning daringness;
side effects of therapy, body image, sexuality, and the examining the barriers to a valuable life.
outlook for the future, which cannot be used alone Session 7: Learning the impact of thoughts;
25
but has to be administered along with QLQ-C30. acknowledging that the disease (primary suffering)
The QLQ-BR23 is scored in a similar fashion to the is unavoidable, but the meaning we give to the
QLQ-C30. Both of the questionnaires have been disease (secondary suffering) is a choice and also
translated into Persian and validated by Montazeri et learning that pursuing commitment is not enough;
al. Cronbach’s alpha coefficient for multi-item commitment to actions and values even in the face of
scales (to test the reliability of QLQ-C30) ranged obstacles and exploring the barriers to satisfaction.
from 0.48 to 0.95 at baseline and from 0.52 to 0.98 at Session 8: Teaching primary suffering and
follow-up administration of the questionnaire.25 The secondary suffering by drawing a circular diagram;
alpha coefficient of the Persian version of the QLQ- group satisfaction survey and teaching what one can
BR23 was 0.65 to 0.95 in the initial interview and achieve in his or her path of values.29
26
0.72 to 0.92 at the time of follow-up (two months). (3) Carrying out the posttest. (4) Carrying out the
The Connor-Davidson Resilience Scale (CD- follow-up test after two months and data collection.
RISC) is comprised of 25 items rated on a 5-point scale Since the study design is quasi-experimental with
(0 to 4). The scale has a total score between 0 and 100, multivariate repeated measures, multivariate
with higher scores corresponding to greater resilience. analysis of variance (MANOVA) with repeated
Reliability (0.87), validity (0.89), and factor analytic measurements was used to evaluate the assumptions.
structure of the scale were evaluated, and reference After data collection, data normality was tested using
scores for study samples were calculated.27 In general, the Kolmogorov-Smirnov test, and, based on their
the findings indicate that the Iranian version of CD- normal distribution, parametric tests were used.
RISC provides a reliable and valid measure of SPSS software version 16 was used for data
resilience and can be used in clinical trials. Cronbach’s analyses. The significance level was set at 0.05.
alpha coefficient is reported 0.89 and the validity of the
scale is ranged from 0.41 to 0.64.28 Results
The process of the study was divided into four According to Mauchly’s Test of Sphericity, the
stages: (1) Recruiting subjects, carrying out pretests, assumption of sphericity was violated for scores on
2
and informing the participants of what the course QLQ-C30, χ (2)  =  0.41, P  <  0.05. Therefore, the
would give them and what was required to attend the Greenhouse-Geisser correction was used in the present
course. Also, the participants were offered the study. The scores on QLQ-BR23 met the sphericity
2
opportunity to discuss what the expected from the assumption, χ (2)  =  2.19, P  >  0.05; therefore, the
program. (2) Intervention: the intervention groups Sphericity test was used in the present study.
received eight 2-hour sessions (one session per
week) of ACT, while the control group was placed on Table 1. Mean Quality of Life and Resilience Scores
a waiting list. The description of therapeutic Statistical components Groups ACT Control
intervention is mentioned below:
Measure
Session 1: Providing an opportunity for QLQ-C30 Pretest 39.28 47.00
participants to become acquainted with the purposes Posttest 63.98 45.08
of the intervention; using creative frustration. Follow-up 54.71 44.12
Session 2: Teaching the harmful role of
QLQ-BR23 Pretest 39.85 38.60
suppressing feelings and thoughts; practicing Posttest 71.13 38.22
mindfulness skills. Follow-up 61.15 39.76
Session 3: Defining the concept of acceptance and
identifying values; the practice of scanning the body Resilience Pretest 14.25 16.44
Posttest 72.50 29.25
according to mindfulness. Follow-up 67.12 27.12
Session 4: Setting values based on goals; .

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 Quality of life and resilience and breast cancer

Table 2. Results of Repeated Measures ANOVA to Evaluate the Effect of Acceptance and Commitment Group
Therapy on Quality of Life
Measure Statistical Sum of df Mean F Sig. Partial Eta
indicators squares Square Squared
QLQ-C30 Tests 1046.88 1.47 712.24 9.32 0.003 0.40
Groups 1013.38 1 1013.38 8.66 0.01 0.38
Group*test 1727.08 1.47 1157.69 15.39 0.01 0.38

Tests 1920.46 2 960.23 38.65 0.0001 0.86

QLQ-BR23 Groups 3407.25 1 3407.25 93.13 0.0001 0.86
Group*test 2006.70 2 1003.35 40.39 0.0001 0.74

Examination of hypotheses and global health scales of the QLQ-C30 and the
A: Acceptance and commitment group therapy is symptom scales of the QLQ-BR23; consequently,
effective in improving the quality of life of women Huynh-Feldt correction was used in their analysis.
with breast cancer The obtained F values (155.71, 25.72, 7.34, 125.39,
Quality of life (QLQ-C30): F = 9.32, partial η2 = 0.40 and 152.51) were significant for all scales (partial
(P = 0.003). There was no difference in quality of life η2:  0.34-0.91, P  <  0.01). Therefore, there were
scores among the 3 time points in the control group significant differences in the scores on scales of quality
(Table 1). The mean quality of life scores for the of life among the 3 time points and also between the
intervention group were: pretest  =  39.28, intervention and control groups (P < 0.01). The mean
posttest  =  63.98, and 2-month follow-up  =  54.71.
The results indicate that quality of life score QLQ-C30 functional scale scores for the intervention
increased significantly during the trial. The group were: pretest  =  29.16, posttest  =  81.38, and 2-
difference between posttest and follow-up scores month follow-up = 71.11; the mean scores on symptom
was not significant (P  ≤  0.01) so it could be scales were pretest  =  75.34, posttest  =  19.56, and 2-
concluded that intervention was effective, and the month follow-up  =  26.60; and the mean scores on
result was retained over time. global health scale were pretest  =  37.57,
Quality of life (QLQ-BR23): F  =  38.65, partial posttest = 67.70, and 2-month follow-up = 51.90. The
2
η  = 0.73 (P ≤0.01). The mean quality of life scores for mean scores on QLQ-BR23 functional scales for the
the intervention group were: pretest  =  39.85, intervention group were: pretest  =  32.34,
posttest = 71.13, and 2-month follow-up = 61.15. The posttest  =  60.33, and 2-month follow-up  =  66.14; the
results indicate that quality of life score increased mean scores on symptom scales were: pretest = 65.27,
significantly during the trial, although the difference posttest = 17.22, and 2-month follow-up = 29.16; and
between posttest and follow-up scores was not the mean scores on quality of life scale were:
significant (P  ≤  0.01). It could be concluded that pretest = 39.85, posttest = 71.13, and 2-month follow-
intervention was effective, and the result was retained up = 56.15. There was a significant difference between
over time. No difference was observed in QLQ-BR23 pretest and posttest quality of life scores; however, the
scores among the 3 time points (Table 1). The difference between posttest and 2-month follow up
assumption of sphericity was violated for the functional values was not significant.

Table 3. Results of Repeated Measures ANOVA to Evaluate the Effect of Acceptance and Commitment
Group Therapy on Quality of Life Scales
Subscale Statistical Sum of df Mean F Sig. Partial Eta
indicators squares Square Squared
Functional scales Tests 7879.74 2 3939.78 152.51 0.0001 0.91
(QLQ-C30) Groups 6422.07 1 6422.07 119.44 0.0001 0.89
Group*test 4902.00 2 2451.00 94.88 0.0001 0.87

Symptom scales Tests 8070.22 1.39 5797.22 125.36 0.0001 0.90

(QLQ-C30) Groups 8516.04 1 8516.04 86.36 0.0001 0.86
Group*test 6728.76 1.39 4833.58 104.52 0.0001 0.88

Global health scales Tests 2637.15 2 1318.57 7.34 0.03 0.34

(QLQ-30) Groups 2134.48 1 2134.48 13.90 0.002 0.34
Group*test 1154.70 2 577.35 3.21 0.05 0.20

Functional scales Tests 2645.69 2 1322.84 25.72 0.0001 0.64

(QLQ-BR23) Groups 1628.48 1 1628.47 18.41 0.0001 0.56
Group*test 2593.24 2 1296.62 25.21 0.0001 0.64

Symptom scales Tests 1005.65 1.07 9325.65 155.71 0.0001 0.91

(QLQ-BR23) Groups 1133.41 1 1333.41 3.62 0.001 0.49
Group*test 1715.87 1.07 1592.09 26.58 0.0001 0.65

114 Sadeghi, et al. Arch Breast Cancer 2018; Vol. 5, No. 3: 111-117
 Quality of life and resilience and breast cancer

Table 4. Repeated Measures ANOVA to Evaluate the Effect of Acceptance and Commitment Group Therapy
on Resilience of Women With Breast Cancer
Measure Sum of df Mean F Sig. Partial Eta
Source of Changes squares Square Squared
Tests 12192.40 1.34 9080.49 240.86 0.0001 0.94
Groups 8759.88 1 8759.88 141.50 0.0001 0.91
Group*test 5141.63 1.34 3829.32 101.57 0.0001 0.91

We concluded that the intervention was effective, directly focusing on effective life in valuable
and the result was preserved over time. The scores for areas.21 ACT serves this purpose by exposing the
the control group were not significantly different patient to negative thoughts, emotions, and feelings in
among the 3 time points (Table1). a controlled manner.39
Our results also showed that acceptance and
B: Acceptance and commitment group therapy is commitment group therapy promotes resilience
effective on the resilience of women with breast among breast cancer patients, which is Consistent
40-45
cancer with previous studies. It could be that ACT helps
According to Mauchly’s Test of Sphericity people to play a more significant role in the challenges
2
[χ (2)  =  16.89, P  <  0.01] variances of differences they face, regain hope, and step forward on the road to
46
between all the combinations of the conditions related a meaningful and genuine life. Also, it can increase
to the resilience of the studied groups were not equal; self-efficacy and the sense of empowerment, both of
therefore, the Huynh-Feldt correction was used. which contribute to increased resilience. A feeling of
According to the obtained F  =  240.86 and partial competence and capability is necessary for resiliency,
2
η   =  0.94, P  <  0.01 (Table 4), there are significant and it is only in this case that an individual can step out
differences among pretest, posttest, and follow-up of his passive position and start dealing with the
resilience scores (Table 4). The mean resilience scores challenges and managing his or her life. 2 6
for the intervention group were: pretest  =  14.25, A limitation of the present study was that it had
posttest  =  72.50, and 2-month follow up  =  67.12. A only one intervention group, so the effect of ACT was
reduction in posttest and follow-up scores can be seen not compared with other interventions. On the other
in the control group (Table 1). hand, this is the first study in Iran that investigates the
effect of acceptance and commitment group therapy
Discussion on quality of life and resilience among women with
The current study investigated the effectiveness of breast cancer. There is a hope that the results of this
acceptance and commitment group therapy in research will encourage the practitioners to give
improving the quality of life and resilience of women more importance to psychological aspects of the
with breast cancer. The results indicated that ACT disease, which can result in better and faster
intervention was able to significantly enhance the treatment of the disease and improvement of
scores on all scales of QLQ-C30, QLQ-BR23, and patients’ quality of life and resilience. Future studies
CD-RISC, and the effect almost remained stable over should look into the effectiveness of this therapy in
the follow-up period. other types of cancers, with both genders.
30
According to Yalom and Vinograd, most of the
breast cancer patients are affected by pessimistic Conflict of Interest
thoughts, hopelessness, despair, loneliness, and fear The authors have nothing to disclose.
of death because of suppressing their feelings about
their illness. Consequently, their participation in Acknowledgment
group psychotherapy sessions and dealing with their Authors would like to express their gratitude to
feelings can lead to a different perspective on the the professional staff and all the participants in this
30
human’s life meaning. Also, all aspects of their lives study. This study was supported and funded by
are significantly influenced by the traumatic Cancer Research Center, Shahid Beheshti University
experience of “losing the breasts,” which are the of Medical Sciences in Tehran. The study was
31
attributes of femininity. Research has shown that conducted independently of funding sources.
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