Multidisciplinary Cancer Investigation Original Article

April 2020, Volume 4, Issue 2

The Effectiveness of Group-Based Compassion-

Focused Therapy on Depression, Anxiety and
Improving the Quality of Life in Women With
Feminine Cancers
Arezou Sourmeh1, Ali Mashhadi1,*, Zohre Sepehri Shamloo1
1
Department of Psychology, Ferdowsi University of Mashhad, Mashhad, Iran
*Corresponding author: Ali Mashhadi, Department of Psychology, Faculty
of Education Sciences and Psychology, Ferdowsi University of Mashhad,
Mashhad, Iran. Postal Code: 9177948974. Tel: +985138805873; Fax:
+985138783012; E-mail: [email protected]

DOI: 10.30699/mci.4.2.21

Introduction: This study aimed to examine the effectiveness of group-based

Submitted:30 January 2020
compassion-focused therapy (CFT) on depression, anxiety, and improving the quality
Revised: 24 February 2020 of life (QoL) in women with feminine cancers.
Accepted: 11 March 2020 Methods: A pretest-posttest control‐grouped, quasi‐experimental study was carried
out on all women with cancer who were referred to the Omid Hospital of Mashhad
e-Published: 1 April 2020
in 2019. Thirty patients with various types of feminine cancers were randomly
assigned to 12 weeks of group-based compassion-focused therapy (CFT) (n=15) or
Keywords:
sham control (n=15). Participants in both conditions completed measures of Beck
Depression Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI-II), and the European
Anxiety Organization for Research and Treatment of Cancer Quality of Life Questionnaire
Quality of life (EORTC QLQ-C30) at pretest and posttest. Analysis of covariance was used for data
Compassion analysis
Results: Our results showed that there was a significant difference between
experimental and sham control groups in depression (F= 4/499, P<0.05, d=1.60 large)
and anxiety (F=19/99, P<0.01, d=1.96 large), but there was no significant difference
in participants’ QoL scale.
Conclusions: Group-based CFT could be considered a promising and potentially
useful intervention to alleviate the depression and anxiety in cancer patients but it did
not affect their QoL. Nevertheless, future randomized trials are needed.

© 2020. Multidisciplinary Cancer Investigation

INTRODUCTION
Cancer is a life-threatening disease the diagnosis and [2]. Quality research on cancer patients’ problems
treatment of which may be stressful. Its common side has shown that their psychological problems are
effects, such as fear, loneliness, a permanent threat estimated to be 8 times higher than healthy people
of death, relationship changes, tolerating painful [3]. Therefore, the impact of emotional, cognitive,
medical processes, and an ambiguous future, may put and social feelings; caused by cancer symptoms,
patients under a great deal of stress [1]. The increase may be compounded with side effects of medical
in cancer prevalence in recent years and its effects treatment, lead to inevitable negative effects on
on physical, mental, and social aspects of life have patients’ psychological adjustment, and cause severe
made cancer the major health problem of the century emotional and affective problems. On the other hand,
Multidiscip Cancer Invest. April 2020, Volume 4, Issue 2

the development and expansion of human societies of the Third Wave of psychology, is designed to
have highlighted the importance of quality of life alleviate suffering, anxiety, and depression [3]. In
(QoL). Surgical procedures and long-term intensive a study on CFT, Leaviss and Uttley found that the
treatment (e.g. chemotherapy and radiotherapy) and success of CFT depends on the right perception of
the uncertainty that exists during the development the concept of compassion [11]. Compassion can
of cancer can lead to some symptoms such as be considered as an emotion regulation strategy, in
anxiety, fear, and depression [4]. Depression and which irritating and undesirable emotions not only
anxiety can lead to lack of energy and interest in the are not avoided but are also accepted. Therefore,
treatment process and decrease in the QoL of cancer negative emotions may change into positive ones
patients. According to World Health Organization and individuals may find new coping strategies. In
(WHO), QoL refers to individuals’ perceptions of patients with mood disorders, self-compassion was
their position in life in the context of the culture and related to higher levels of QoL and psychological
value systems in which they live, and higher levels well-being [12]. Self-compassion has been defined
of QoL are the results of having more positive and as a three-component construct, including self-
better perceptions [5]. Furthermore, higher scores of kindness versus self-judgment, common humanity
depression and anxiety have been related to disease versus isolation, and mindfulness versus over-
duration [2, 4]. The consequences of metastasis, loss identification. Paul Gilbert, the founder of CFT
of social activities, and disability are reported among [9], defines compassion as a basic kindness with
the most important causes of depression among these a deep awareness of the suffering of oneself and
patients. Since depression is an important risk factor other living things; coupled with the wish and
contributing to decreased survival of cancer patients effort to relieve it [13]. The basic principle of CFT
and an important factor in unsuccessful treatment, implies that external thoughts, factors, images,
it seems that treating depression is essential as a and palliative behaviors should be internalized so
component of the treatment plan of cancer patients, that the human mind can relax in the face of these
especially those with risk factors, and can play an factors, in the same manner, it responds to external
important role in promoting their faster recovery [6]. factors. Compassion-focused exercises emphasize
Cognitive-behavioral therapies, focusing on relaxation, self-compassion, and mindfulness,
mindfulness and compassion, are effective in which play a huge role in individuals’ peace of
controlling depression and anxiety in various clinical mind, and alleviating stress and negative automatic
samples [5, 7]. In a study on the relationship between thoughts [10]. There is ever-increasing empirical
self-compassion and depression, a lack of self- evidence on the effects of CFT on the whole range
compassion revealed to act as a vulnerability factor of psychological problems. In an early attempt to
for depression. Also, results indicated that depressed study CFT effects on patients attending a day center
individuals have lower levels of self-compassion for chronic difficulties, Gilbert and Procter found
in comparison to healthy controls [8]. Research that CFT reduced the shame, self-criticism, self-
has shown that self-compassionate individuals blame, depression, and anxiety [14]. In times of
have fewer mental health issues than non-self- illness, higher levels of self-compassion are related
compassionate ones; for instant, people with low to lower levels of negative emotions, anxiety,
levels of depression and anxiety showed more self- depression (e.g. in asthma and flu), and stress (e.g.
compassion [5]. Self-compassion has been related to in HIV positive), even in the elderly. A comparative
positive psychological abilities such as happiness, study between healthy people and individuals with
positivism, wisdom, curiosity, and inquiry as well cancer or a chronic disease showed that, especially
as emotional intelligence. Compassion-focused in cancer survivors, self-compassion is related to a
therapy (CFT) teaches people not to avoid and better psychological adjustment [15].
suppress their painful feelings; so they can recognize A better understanding of the overall prevalence of
their experience and be compassionate with it. This mental disorders among cancer patients can help the
unified therapy is derived from neuroscience, social, identification of patients in need of psychological
developmental and Buddhist psychology, and many services, clarification, and facilitation of providing
other therapeutic models of mental problems [9, 10]. mental health services, and, eventually, improved
CFT, along with other new therapeutic approaches accessibility of essential psychological care.
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 Sourmeh et al.

Research has shown that psychological intervention sessions. Therapy sessions were begun by expressing
programs, especially when provided in groups, the purpose of the group and stating the problem and
substantially reduced cancer-related psychological the role of positive psychological factors in cancer,
disorders, provided valuable social support, and introducing CFT and new psychological approaches
increased coping skills [16]. Therefore, the present to cancer treatment, and defining compassion and
study examines the effectiveness of group-based self-compassion. Then, the factors contributing
CFT on depression, anxiety, and improving the QoL to each participant’s depression, anxiety and QoL
in women with feminine cancers. were examined, which brought about intimacy and
common sense. Over time, self-compassion topics
METHODS and therapeutic techniques were introduced.
A pretest-posttest control‐grouped, quasi‐
experimental study was carried out on all women Enrolment Assessed for eligibility
(n=50)

with cancer who were referred to the Omid Hospital

of Mashhad in 2019. The Ethics Committee of Patients were selected for
treatment based on interviews
16 excluded

Mashhad University of Medical Sciences and

(did not meet inclusion criteria)
(n=34)

Ferdowsi University of Mashhad (IR.MUMS.

REC.1396.297) approved the study and informed
consent was obtained from all patients who Allocated to sham control group
(n=17)
Allocated to group-based
compassion-focused therapy (CFT)

participated in the study. We used purposeful

(n=17)

sampling for selecting patients. The sample size Excluded

(n=2)
Excluded
(n=2)
was calculated; using the G×Power (With an
assumption of effect size (0.85 large), alpha=0.05 Completed pretest
(n= 15)
Completed pretest
(n= 15)

and power=0.80, with 2 groups and 1 covariate).

A total of 31 participants were estimated to be Analyzed posttest Analyzed posttest
(n= 15) (n= 15)
included in the study to detect a large effect size
(Cohen’s d=0.85). A total of 50 patients were invited Figure 1: Flowchart of Participants in Study
to participate in the study from which 34 cases met
all the inclusion criteria. Therefore, 34 individuals Measures
were randomly assigned (simple randomization) Beck Depression Inventory (BDI-II): It is a 21-
to the group-based CFT and sham control group. item, self-rated scale that evaluates key symptoms
Two people in each group did not complete the of depression including mood, pessimism, sense
study. Consequently, the data of 30 individuals were of failure, self-dissatisfaction, guilt, punishment,
analyzed. The eligibility criteria were as follows: self-dislike, self-accusation, suicidal ideas, crying,
(1) being a female; (2) having ovarian, uterus, irritability, social withdrawal, indecisiveness, body
cervical and/or breast cancer; (3) aged between 25 image change, work difficulty, insomnia, fatigability,
to 45 years; (4) minimum academic qualification loss of appetite, weight loss, somatic preoccupation,
of high school diploma; (5) no drug and/or alcohol and loss of libido. Individual scale items are scored
abuse; and (6) not receiving any psychological on a 4-point continuum (0=least, 3=most), with a
treatment since the time of cancer diagnosis. Figure total summed score range of 0–63. Higher scores
1 summarizes participant enrolment the study indicate greater depressive severity. The following
process. Then, Beck Depression Inventory (BDI-II), guidelines have been suggested to interpret the BDI‐
Beck Anxiety Inventory (BAI), and the European II: minimal range=0–13, mild depression=14–19,
Organization for Research and Treatment of Cancer moderate depression=20–28, and severe
Quality of Life Questionnaire (EORTC QLQ-C30) depression=29–63. Dabson and Mohammadkhani
were completed by the participants in pretest and assessed reliability; using Cronbach’s Alpha, and
posttest evaluations. The groups lasted 3 months, reported coefficient alphas to be 0.92 for outpatients
with eight sessions lasting 90 to 120 minutes. The and 0.93 for the students. They also gained a test-
group-based CFT received 12 sessions of CFT per retest coefficient of 0.73 within two weeks [17].
week, based on Gilbert’s CFT protocol and the sham Beck Anxiety Inventory (BAI): It was created by
control group participated in 12 groups of discussion Aaron T. Beck and colleagues which is a 21-item
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Multidiscip Cancer Invest. April 2020, Volume 4, Issue 2

multiple-choice self-report inventory that measures QoL of cancer patients in multicultural research
the severity of anxiety in adults and adolescents. situations. Moghimi Dehkordi and colleagues
The BAI describes the emotional, physiological, found that the third edition of the Persian version of
and cognitive symptoms of anxiety. Each of EORTC QLQ-C30 is a valid and reliable instrument
the items on the BAI is a simple description of a for evaluating the QoL of cancer patients and it can
symptom of anxiety in one of its four expressed be used in clinical and epidemiological studies of
aspects: (1) subjective (e.g., “unable to relax”), (2) cancer. The internal consistency of this scale has
neurophysiologic (e.g., “numbness or tingling”), been reported to be desirable and most of its scales
(3) autonomic (e.g., “feeling hot”) or (4) panic- have desirable reliabilities. The Cronbach’s alphas
related (e.g., “fear of losing control”). Each item is of the fatigue, pain, nausea/vomiting, and the rest
scored on a 4-point Likert scale; ranging from 0 to of the scales are 65%, 69%, 66% and higher than
3. The total score is calculated by finding the sum 70%, respectively, which confirms its validity and
of the 21 items. The scores are defined as follows: reliability [19].
0-21=low anxiety, 22-35=moderate anxiety, 36 and
Statistical Analysis
above=potentially concerning levels of anxiety. The
BAI is psychometrically sound. Internal consistency We used an Analysis of Covariance (ANCOVA) to
(Cronbach’s alpha) ranges from 0.92 to 0.94 for examine pre- and post-training changes in the BDI-
adults and test-retest reliability is 0.75. Our findings II, BAI, and EORTC QLQ-C30 between groups. All
showed that the Persian version of BAI has a very analyses were conducted using SPSS (IBM SPSS
good validity (r=0.83, P<0.001) and an excellent Statistics version 21.0).
internal consistency (Cronbach’s alpha=0.92) [18].
RESULTS
The European Organization for Research and
Treatment of Cancer Quality of Life Questionnaire Table 1 shows the sociodemographic characteristics.
(EORTC QLQ-C30): It is a 30-item self-report Demographic information showed that, in the
questionnaire that specifically evaluates the group-based CFT, 53%, 40%, and 6% had high
QoL of cancer patients. This questionnaire has school diploma, bachelor’s degree, and master’s
been developed by Aaronson and contains five degree, respectively; whereas, in the sham control
functioning scales (physical, social, role, cognitive, group, 46% and 53% had high school diploma and
and emotional functioning), eight symptom scales bachelor’s degree, respectively. Furthermore, in
(fatigue, nausea/vomiting, pain, dyspnea, sleep terms of the cancer type, in the group-based CFT,
disturbances, appetite loss, constipation, and 40%, 26%, and 20% had ovarian, cervical, and breast
diarrhea), financial impact, and the overall QoL. cancers, respectively; while in the control group,
All of the scales and single-item measures range in 20%, 6%, and 75% had ovarian, cervical, and breast
score from 0 to 100, with higher scores representing cancers, respectively. Moreover, in the group-based
a better overall QoL and greater symptom burden. CFT, 26% and 73% were aged 25-35 and 36-45
Validation studies have reported this questionnaire years old, respectively; while in the control group,
to be a valid and reliable scale for evaluating the 33% and 66% were aged 25-25 and 36-45 years old,

Table 1: Sociodemographic Characteristics of Participants

Group-Based Compassion-Focused Therapy (n=15) Sham Control group (n=15)
Age, Mean±SD 37.20±1.59 37.40±1.15
Academic Qualification, No.(%)
Diploma 8 (53.30) 7 (46.70)
Bachelors 6 (40.00) 8 (53.30)
Master’s 1 (6.70) –––
Cancer Type, No.(%)
Ovarian 6 (40.00) 3 (20.00)
Cervical 4 (26.70) 1 (6.70)
Womb 2 (13.30) 6 (75.00)
Breast 3 (20.00) 5 (40.00)

24
 Sourmeh et al.

respectively. There were no significant differences that group-based CFT alleviated symptoms of
between groups in all demographic characteristics. depression in cancer patients. These findings are in
To test the hypotheses, analysis of covariance line with previous findings [7, 11, 13, 14]. Results of
(ANCOVA) was applied. We first examined the systematic review and meta-analysis [7] indicated
assumptions of normality and homogeneity of the that self-compassion related therapies produced
variance-covariance matrix. To test for normality greater improvements in depressive symptoms.
and homogeneity of variances, the Kolmogorov– The results also showed that greater levels of self-
Smirnov test, and the Box’s M test were used, compassion have been linked to reduced mental
respectively. Results of the Kolmogorov–Smirnov health symptoms such as depression. The results
test confirmed the data normality in the pretest of other meta-analysis carried out by Leaviss and
and posttest (P>0.05). Furthermore, the results of Uttley [11], showed that compassion therapy is an
the Box’s M test were not statistically significant effective intervention for a range of mood disorders.
(P>0.05); confirming the above-mentioned A meta-analysis performed by Kirby et al., [13],
hypothesis. has indicated that CFT reduces depression in
Table 2 shows the means and standard deviations for various groups both with and without mental health
key variables. Results show that there is a significant conditions. Also, the results of research performed
difference between the group-based CFT and sham by Sadeghi, Yazdi-ravandi, and Pirnia [14] showed
control groups in depression (F=4.499, P<0.05, that compassion therapy had a significant effect on
d=1.60 large) with large effect size. Participants in the reduction of depression symptoms in patients
the CFT scored significantly lower than those in the with breast cancer. Our results also showed that
sham control group after being observed at post- group-based CFT alleviated symptoms of anxiety
intervention. In other words, compassion-focused in cancer patients. These findings are consistent
group therapy affects symptoms of depression. with previous findings [3, 7, 11, 13-15]. Three
Concerning our secondary outcome, significant meta-analyses [7, 11, 13] that have examined the
differences were observed for anxiety. The result effectiveness of CFT have shown that it improves
shows that there is a significant difference between the levels of self-compassion, as well as reduce
anxiety scores of the CFTand sham control groups anxiety, depression, and psychological distress in
in the posttest (F=19/99, P<0.01, d=1.96 large) with various groups. The overall consensus across these
a large effect size. These differences show that the studies is that increases in self-compassion are
mean of these scores in the CFT group is significantly related to improvements in psychopathology. Also,
lower than the sham control group. As Table 2 the results of two studies in Iran [3, 14] showed
shows, no significant effects were found for QoL that CFT successfully reduces the levels of anxiety
variable (P>0.05). However, group comparisons in women with breast cancer as compared with a
revealed significant pre- to post-improvements for control condition.
QoL in the CFT group. In patients with chronic diseases, an insecure
attachment was correlated with negative emotions
DISCUSSION such as anxiety, stress, worry, depression, reduction
The current study aimed to examine the effectiveness of coping strategies effect, and low QoL [15].
of group-based CFT in alleviating symptoms CFT is based on the attachment theory, therefore
of depression, anxiety, and the improvement of this approach alleviates negative emotions via
QoL in women with feminine cancers. We found affecting the attachment system and moving it

Table 1: Means, Standard Deviations, and ANCOVA Statistics for Study Variables a
Group-Based Compassion-Focused Sham Control Group
Therapy (n=15) (n=15)
F Statistic P Value Cohen’s d
Pretest Posttest Pretest Posttest
Mean±SD Mean±SD Mean±SD Mean±SD
Depression 32.87±4.14 30.27±4.05 31.47±2.07 31.47±2.07 4.49 0.040 1.60
Anxiety 32.33±3.85 31.00±3.86 35.07±2.17 35.07±2.17 19.99 0.002 1.96
Quality of life 34.93±2.56 33.00±2.35 35.13±1.21 35.13±1.21 2.51 0.090 1.96
a
d=0.20 is small, d=0.50 is medium, and d=0.80 is large

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Multidiscip Cancer Invest. April 2020, Volume 4, Issue 2

towards a secure one. Mindfulness and compassion future studies are needed to examine the impact of
both alleviate the effect of stress on depression the treatment phase as an important variable. We
through enhancing the feeling of security and recommend that cancer treatment centers integrate
confidence [20], self-compassion acts as a shield psychotherapeutic methods in their therapeutic
against negative events. People with high levels strategies and programs.
of self-compassion judge themselves less strictly, In general, the findings of this study showed that
accept negative events more easily and their self- group-based CFT could be considered a promising
evaluations and reactions are more precise and based and potentially useful intervention to alleviate
on their actual functions because their judgment the depression and anxiety in cancer patients, but
neither tends toward an exaggerated self-criticism it did not affect their QoL. Nevertheless, future
nor go towards self-defense inflation. Moreover, randomized trials are needed.
being present in the group and recognizing the
commonness of experiences makes individuals feel ACKNOWLEDGMENTS
connected to others, which, in turn, reduces their fear The authors would like to express their thanks to all
of loneliness and ambiguity in the face of cancer’s the patients participated in the study.
pain and suffering. The mindfulness component
of compassion keeps one’s emotions balanced and CONFLICT OF INTEREST
leads to less rumination and negative feelings [5]. The authors declared no conflict of interest.
Our investigation also revealed that group-based
CFT did not increase the QoL of cancer patients ETHICS APPROVAL
significantly. This finding is inconsistent with The Ethics Committee of Mashhad University
previous research that has shown that CFT could of Medical Sciences and Ferdowsi University
enhance the QoL. Research in the cancer context of Mashhad approved this study (IR.MUMS.
links greater self-compassion with a better QoL REC.1396.297).
[5, 15]. Saidan, Sohrabi, and Zemestani indicated
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