هم‌سنجی درمان فراشناختی و درمان مبتنی بر فعال‌سازی رفتاری بر ابعاد نشخوار فکری در زنان مبتلا به اختلال افسردگی اساسی

Comparison of metacognitive therapy and treatment based on behavioral activation on rumination dimensions in women with major depressive disorder

Majid Jamehbozorgi,[1] Seyyed Ali Aleyasin^*,[2] Hasan Heidari,[3] Hossein Davoodi[4]

[1] - Ph.D. Student in General Psychology, Department of Psychology, Faculty of Humanities, Khomein Branch, Islamic Azad University, Khomein, Iran.

[2] - Corresponding Author: Assistant Professor, Department of Clinical Psychology, Faculty of Humanities, Ashtian Branch, Islamic Azad University, Ashtian, Iran. Email: Aleyasin_psychology@yahoo.com

[3] - Associate Professor, Department of Counseling and Psychology, Faculty of Humanities, Khomein Branch, Islamic Azad University, Khomein, Iran.

[4] - Assistant Professor, Department of Counseling and Psychology, Faculty of Humanities, Khomein Branch, Islamic Azad University, Khomein, Iran

Abstract

Introduction: Numerous studies point to the high level of rumination in women with major depressive disorder. The aim of the present study was to compare metacognitive therapy and treatment based on behavioral activation on rumination dimensions in women with major depressive disorder.

Methods: The current research was a quasi-experimental study with a pre-test-post-test-follow-up design with a control group. The statistical population of this research included all women with major depressive disorder referring to psychological clinics located in the 8th district of Tehran, 45 of whom were selected in a targeted manner and randomly assigned to two experimental groups and one control group. The instrument of this research was rumination questionnaire. For the first experimental group, metacognitive therapy and for the second experimental group, behavioral activation therapy was held in 8 sessions of 90 minutes, but the control group did not receive any intervention. The data were analyzed using mixed analysis of variance.

Results: The results indicated that metacognitive therapy and behavioral activation therapy reduced rumination and its components at the end of the interventions and the follow-up period (p>0.05). The results showed that behavioral activation therapy is more effective in reducing rumination symptoms than metacognitive therapy (p>0.05).

Conclusion: Because of its effect on depression, behavioral activation therapy alone or with complementary therapy can be effective in reducing rumination and depression symptoms in women with major depressive disorder.

Keywords: behavioral activation therapy, major depressive disorder, metacognitive therapy, rumination

Received: 18/ January/ 2023                             Accepted: 23/ April/ 2023

Introduction:

Depression is one of the most common disorders faced by mental health professionals (1) and epidemiological studies have also reported this disorder as the most common psychiatric disorder (2). Lack of pleasure, sleep disorder, decreased appetite and energy, depressed mood, reduced concentration and mood changes are common in this disorder (3). Approximately 20% of women and 10-17% of men suffer from this disorder during their lifetime (4-5). In this regard, major depressive disorder is between mild and severe depression (6). This type of disease causes deep discomfort and feelings of hopelessness and changes mood and physical performance in people (7).

One of the psychological problems that can negatively affect the mental health of patients with major depressive disorder is obsessive rumination. Rumination is known as a constant preoccupation with a thought or a topic and thinking about it, and it is a class of conscious thoughts that is defined around an axis (8). These repetitive thoughts enter consciousness involuntarily and divert attention and goals (9). In fact, rumination is a set of passive thoughts that are repetitive and focused on the causes and results of symptoms. It also hinders adaptive resolution and increases negative thoughts (10), rumination can be the cognitive foundation of patients. It consists of thoughts that are endlessly reviewed, fueling despair about the future and negative self-evaluations. These thoughts have an effect on the mood and affect the motivation of the patient (11). Rumination is one of the solutions of self-regulatory executive function to reduce cognitive dissonance, and it is actually considered a type of coping style with depressed mood (12).

Today, there are many psychological treatments for patients with depression, some of which have been able to prove their effectiveness. In recent years, new forms of cognitive-behavioral therapy have been created, and one of these approaches is behavioral activation therapy, which focuses mainly on behaviors and activities (13).

Cognitive theorists believe that sufferers have a specific cognitive style characterized by pessimism, and the belief that unpleasant events are unpredictable. This cognitive style includes automatic thoughts that emphasize the possibility of failure and social embarrassment. Behavioral activation therapy, which is one of the third wave treatments, is a type of pure behavioral therapy that provides objective and easy-to-implement techniques for the treatment of depression and is cost-effective due to the short duration of the treatment period (14). The goal of behavioral activation is to increase behaviors that are likely to lead to rewards from the patient. Rewards may be intrinsic (such as pleasure or a sense of accomplishment) or extrinsic (such as social attention) (15).

Behavioral activation therapy is a type of pure behavioral therapy that is based on the functional analysis of behavior and is rooted in the behavioral theory of depression. According to the characteristics of behavioral activation treatment method and its effectiveness on depression disorder (16). It can be said that behavioral activation is considered as a valid treatment for the treatment of depression. In the context of the effect of this therapeutic method on rumination, behavioral activation therapy obviously focuses on reducing rumination from the analytical functional point of view (17).

Behavioral activation therapists target the process of rumination instead of its content (18). Due to its objective techniques and easy implementation, this therapeutic approach has been tested in mental health centers, inpatient centers, addiction treatment centers (19), outpatient centers, and counseling centers on a group or individual basis (20). Uphoff et.al. (21) Showed in their research that behavioral activation therapy has an effect on the recovery of patients with depression. Stein et al. (22) stated in their research that behavioral activation therapy is effective in reducing anxiety symptoms and increasing activation in addition to improving depression. The result of the research of Moshier & Otto (23) showed that the symptoms of depression and rumination decreased significantly during the treatment period of behavioral activation. Also, Polenick & Flora (24) concluded in their research that behavioral activation training significantly reduces rumination in people with depression. Kharaei and Azizi (25) showed in their research that behavioral activation therapy has a significant effect on reducing symptoms of depression, anxiety and increasing quality of life. Ataei Moghanlou and Ataei Moghanlou (26) showed in their research that behavioral activation therapy significantly reduced depression and rumination scores in the intervention group compared to the control group.

On the other hand, one of the new therapeutic approaches in this field is metacognitive therapy. Metacognitive therapy, as a pure cognitive therapy approach, has emerged due to dissatisfaction with existing cognitive behavioral approaches that do not take into account the important features of maladaptive thinking and its controlling factors (27). Metacognitive theory is similar to traditional cognitive theory in terms of emphasizing the principle that dysfunctional beliefs affect mental processing, but instead of focusing on the content of cognition, this theory emphasizes the process of cognition (processing styles and dysfunctional control of thinking) (28-30).

The basic principle of this treatment is that the psychological disorder is related to the activation of a maladaptive thinking style known as cognitive-attentional syndrome (31). Cognitive-attentional syndrome has a very important effect on emotional regulation, and metacognitive therapy aims to eliminate this syndrome and adjust metacognitive beliefs related to it (32). This treatment method is a growing trend in new interventions, where the treatment model is based on mechanisms that prevent natural emotional processing (31). The metacognitive model of treatment is one of these interventions. In this model, metacognitions in the form of beliefs, evaluations, and control strategies are among the basic factors of creating and maintaining this disorder, and it is a motivated and active method of evaluating and dealing with the threat created by a person's metabeliefs (33). Basaknejad et al. (34) showed that metacognitive group therapy has an effective role in reducing the symptoms of thought-action confusion, suppression of thoughts and rumination in the population of female students. The results of the research by Ansari et al. (35) and Taheri Daghian et al. (36) show the effectiveness of metacognitive therapy on reducing depression symptoms and improving rumination and the research results of Winter et al. (37) and Hjemdal et.al (38) have shown the effectiveness of metacognitive therapy in reducing people's depression. Also, Baygan et al. (39) and Schaich et.al (40) showed in their research that metacognitive therapy and behavioral activation therapy are effective on patients with depressive disorder and have reduced depression.

According to what was said, examining the effectiveness of metacognitive therapy on patients with major depressive disorder can be an important step in the direction of inventing new treatments in the field of clinical psychology. It is obvious that the findings obtained from such studies can provide researchers, clinical psychologists and others interested in this field with new strategies in the two fields of prevention and treatment. Considering the few studies that have been conducted on the effectiveness of these treatment methods on the mental disorders of patients with major depressive disorder in the Iranian population, and considering the clinical importance that this perspective can be effective in the treatment of this disease, the present research aims to investigate the effectiveness of the treatment. Metacognitive and behavioral activation has been done in improving the symptoms of rumination in women with major depressive disorder. Considering the control group along with the experimental group, it examines the effectiveness of these treatment methods in more detail and aims to evaluate the effects of each treatment method on the group of patients with the disorder. Compare major depression. In other words, considering the ever-increasing number of people suffering from this disorder and, on the one hand, the significant material and spiritual costs that both families and governments bear, and considering the research gap in the field of psychological interventions to compare these two approaches to rumination, the present research seeks to answer this fundamental question whether the effectiveness and continuity of the effect of metacognitive therapy and treatment based on behavioral activation on the dimensions of rumination in female patients with major depressive disorder are different.

Research Methodos:

The current research was a quasi-experimental method and a pre-test-post-test-follow-up design of 60 days was used with a control group. The statistical population of the current study was made up of all women with major depressive disorder who referred to psychological clinics located in District 8 of Tehran in 2021. The sample size in this research was determined according to the number of groups and the number of investigated variables. The selected groups to implement the experimental intervention and play the role of witnesses were already three different groups. Based on this, 45 people from the aforementioned community were selected based on Cohen's table (1988) and after the preliminary interview and based on the criteria for entering and exiting the research in a non-random and purposeful way and randomly assigned to experimental and control groups (activation therapy experimental group behavioral, 15 people), (metacognitive therapy experimental group, 15 people) and (control group, 15 people) were placed. The criteria for people to enter the research include informed consent, female gender, receiving a diagnosis of major depressive disorder (depression) by a psychiatrist, not participating in other psychotherapy courses at the same time, not taking antidepressants at least one month before the evaluation, literacy at least one cycle, group Age 20 to 50 years, physical and mental readiness to answer the questions and exclusion criteria included absence of more than two sessions.

The method of conducting the research was that after making the necessary coordination with Islamic Azad University of Khomein and the management of Aramesh and Rovanbeh clinics, Zendegi Aram and Khaneh Omid, the patients' files were given to the researcher and an initial telephone interview was conducted with each of the patient woman suffering from major depressive disorder and based on the entry and exit criteria, 45 patients were selected and randomly assigned to three groups, including two test groups and one control group before the experiment. After being replaced in the groups, the subjects answered the research questionnaire as a pre-test before the implementation of the intervention. The first experimental group received metacognitive therapy and the second experimental group received behavioral activation therapy in 8 sessions of 90 minutes in a face-to-face group manner with two sessions each week on Monday and Thursday by the researcher. But the subjects of the control group did not receive any intervention. After the end of the treatment sessions, all three groups answered the research questionnaire again in the post-test phase and 60 days later in the follow-up phase. Ethical considerations were as follows: 1) The main goal of the research is to improve human health along with respecting their dignity and rights. 2) In this research, the principle of confidentiality and keeping the secrets of the subjects and taking appropriate measures to prevent its publication have been observed. 3) The researcher is obliged to respect the privacy of the subjects during the research. 4) Any possible harm or damage caused by participating in the research must be compensated according to the approved laws. 5) There was no financial burden or damage during the research. 6) At the end of the research, every person who entered the study as a subject has the right to be informed about the results of the study and to benefit from the interventions or methods that have been shown to be useful in that study. 7) The researcher is obliged to publish the results of the research honestly, accurately and completely, whether the results are negative or positive. 8) If during the implementation of the research, a subject with capacity loses his capacity or a subject without capacity becomes capable, according to the resulting change, informed consent to continue the research should be obtained from the legal guardian or the person himself. 9) Non-acceptance of the subject's participation in the research or his non-continuation and cooperation is accepted, and this has no effect on the services provided to the individual in the same institution. 10) The information was in the form of code. 11) After finishing the work in the witness group, educational pamphlets or other items were presented and made available to them if they wished. The structure of the behavioral activation therapy sessions was based on the protocol designed by Dimidjian et al. (41) and adapted from Martel et al. (16) and the content of the metacognitive therapy sessions was also implemented according to the manual of metacognitive therapy for depression by Wells (42). A brief description of behavioral activation therapy sessions is presented in Table 1 and metacognition therapy is presented in Table 2.

Table 1. Behavioral activation therapeutic interventions of Dimidjian et al. (41) and Martel et al. (16)

Table 2. Wales metacognitive therapy sessions (42)

In this research, in order to collect data, in addition to collecting demographic information, the following psychological questionnaire was also used:

Rumination Responses Scale (RRS): This questionnaire was compiled by Nolen-Hoeksema & Morrow (43) and contains 22 items and consists of two subscales of rumination responses and distracting responses and each contains 11 statements. It can be This questionnaire is scored according to the Likert scale from (1) never to (4) most of the time. The range of each score for each subject is between 22 and 88 variables. This questionnaire evaluated four different types of reaction to negative mood. Based on empirical evidence, the scale of rumination responses has high internal reliability. The results of many studies show that the scale of rumination responses can predict the severity of depression in follow-up periods in clinical and non-clinical samples by controlling variables such as the initial level of depression or stress factors (44). This scale was first translated into Farsi by Bagherinejad et al. (44). They reported the reliability coefficient of the questionnaire using Cronbach's alpha method as 0.90 and for its dimensions as 0.92 and 0.89. Cronbach's alpha was 0.86 in the only research of Rashwanlou et al. (45).

For data analysis at the level of descriptive statistics, mean and standard deviation indicators were used, and at the level of inferential statistics, mixed variance analysis was used, which was analyzed by spss-26 software.

Findings:

The findings of the research on demographic information showed that 14 people (31%) of the participants in the research were 20 to 30 years old, 21 people (46%) were between 30 to 40 years old, and 10 people (23%) were 40 to 50 years old. They were. In addition, the mean and standard deviation of the average age of the participants are 37.28 and 5.29 years, respectively. 25 people (55.6 percent) of the people participating in the research had a diploma, 4 people (8.9 percent) had associate degree, 10 people (22.2%) had a bachelor's degree, 5 people (11.1%) had a master's degree, and 1 person (2.2%) had a Ph.D degree.

As seen in Table 3, the components of rumination are shown for the three groups of control, metacognitive therapy, and behavioral activation in three measurement stages (pre-test, post-test and follow-up). As can be seen, in the control group, the average component of rumination responses, deviant responses and moral criteria and the total score of rumination in the post-test and follow-up compared to the pre-test stage do not show much change. But in the groups of metacognitive therapy and behavioral activation, we see a significant reduction of rumination components in the post-test and follow-up phase compared to the pre-test phase. Also, the scores of the sub-components of rumination responses, diverting responses and moral criteria have decreased in the post-test and follow-up phase compared to the pre-test phase.

The significance of these changes was checked using the mixed variance analysis test. Before the test, the mixed variance analysis test was performed using the Kolmogorov-Smirnov test to check the normality of the distribution of rumination scores and its components in the three stages of measurement (p<0.05) and the Levine test to check the homogeneity of rumination variances in the three measurement stages. Pre-test (F=0.186), (P=0.20), post-test (F=1.105, P=0.123) and follow-up (F=1.33, P=0.263) in the variable of rumination responses in 3 stages of pre-test measurement. (F = 1.782, P = 0.214), post-test (F = 1.543, P = 0.252) and follow-up (F = 1.346, P = 0.46) in the variable of distracting responses in the three stages of pre-test measurement (F = 1.23) =, P=0.3), post-test (F=0.817, P=0.45) and follow-up (F=1.72, P=0.19) in the variable of ethical criteria in the three stages of measuring deviant responses in the three stages of pre-test measurement (64 F=/0.53), post-test (F=1.127, P=0.115) and follow-up (F=0.316, P=0.175) and to check the homogeneity of the variance-covariance matrix using Mbox test in the variable Rumination (MBOX = 29.73, F = 1.04, P = 0.32), rumination responses variable (MBOX = 17.47, F = 1.35, P = 0.33), distracting responses variable (MBOX = 31.54, F = 1.814, P = 0.1), ethical criteria variable (MBOX = 14.95, F = 1.561, P = 0.35) was used; that the results of these tests were not significant, Mauchly’s test was also used to check the assumption of sphericity and the results showed that the assumption of sphericity was not met for any of the components of rumination except rumination responses, so the Greenhouse-Geisser method was used to interpret the results.

Table 3. Mean and standard deviation of rumination variable and its components in the pre-test, post-test and follow-up stages.

Based on this, the results of mixed variance analysis are presented in Table 4. As seen in Table 4, the effect of time is significant in the variable of rumination responses (P<0.05), so there is a significant difference between the three stages of pre-test, post-test and follow-up in this variable. Also, according to the results of the table, it shows that there is a significant difference between the group and time in the variables of rumination responses, diverting responses and rumination, and it is clear that there is a difference in the dependent variable between the pre-test and post-test stages and follow-up between the two treatment groups and the control group. In the effect of the group, according to the values and significance level of F, there is a significant difference between the two groups of metacognitive therapy and behavioral activation and the control group in the variables of rumination responses, diverting responses and rumination. Pairwise comparison of these groups was conducted separately for each stage using the Bonferroni face test and its results are presented in Table 5. According to table 5, it can be seen that there is a significant difference between the metacognition therapy and control groups in the variable of rumination responses (P<0.05) and between the metacognition therapy and control groups in the variables of rumination responses, diverting responses and rumination, and behavioral activation therapy and control group in variables of rumination responses, diverting responses, and moral and rumination criteria (P<0.05). Also, the results showed that there is a significant difference between the behavioral activation method and metacognitive therapy at the significance level of 0.05. According to Table 5, the mean difference of the metacognitive treatment method and behavioral activation for the variable of rumination and its components in the post-test and follow-up phase is positively significant. As a result, the behavioral activation method has been more effective in reducing rumination than metacognitive therapy (P<0.05).

Table 4. Results of mixed analysis of variance related to intragroup and intergroup effects

Table 5. Benferoni's post hoc test results for pairwise comparison of rumination component averages

Discussion and conclusion:

The present study sought to answer the question whether there is a difference between the effectiveness and continuity of the effect of metacognitive therapy and treatment based on behavioral activation on the dimensions of rumination in women with major depressive disorder. The results of mixed variance analysis showed that both treatment groups were effective on rumination compared to the control group, and behavioral activation therapy was more effective in reducing rumination in women with major depressive disorders than metacognitive therapy.

In explaining the effectiveness of metacognitive therapy on rumination and its components in women with major depressive disorder, no study was found that was directly aligned with the results of this research, but the results obtained indirectly, to some extent, were consistent with the studies of Basaknejad et al. (34), Ansari et al. (35), Taheri Daghian et al. (36), Winter et al. (37), Hjemdal et.al. (38), Baygan et al. (39) and Schaich et.al. that have confirmed the effectiveness of metacognitive therapy in patients with depression and major depression. In explaining the effectiveness of this treatment on rumination and its components in women with major depressive disorder, it can be said that depression is associated with things such as rumination and positive and negative metacognitions. Therefore, if the treatment focuses on components such as reducing rumination and changing metacognitions, it can reduce the symptoms of rumination in people with depression (50). The success of metacognitive treatment of depression lies in targeting the main characteristic of depression, which is rumination (51). Negative ruminative thoughts (rumination and worry) are recognized as one of several factors at the same time in the vulnerability and maintenance of the effective disorder are considered as coping strategies. The content of positive metacognitive beliefs includes topics related to rumination as a coping strategy. Negative metacognitive beliefs, rumination includes issues related to rumination. Although many people believe that rumination helps them solve their problems, responding to problems through rumination is associated with more problems and tension. Therefore, it can be assumed that the treatment used in this research has been able to affect the rumination related to the subjects' rumination. In explaining the effectiveness of metacognitive techniques, Nolen-Hoeksema pointed out the nature of this treatment and considered it effective in the effectiveness of the treatment process (52). Since in depression a person's thinking patterns are focused on himself and threatening issues, the aforementioned treatment emphasizes changing these thinking patterns. On the other hand, metacognitive therapy has dealt with the change of processes and activities such as rumination, threat monitoring, focusing on danger, suppressing thoughts and behaviors such as behavioral, cognitive and emotional avoidance that depressed people do to deal with the perceived dissonance and regulate the resulting negative emotions, but in the long run they get the opposite result (53). In fact, metacognitive therapy provides the basis for obtaining better treatment results through creating insight in patients. In other words, the goal of the metacognitive treatment model of depression is to show the metacognitions and processes that perpetuate depressive episodes. Also, in explaining the results of the treatment, it can be pointed out that the metacognitive treatment of depression has an evaluation program and accurate scales, and in this way, the therapist is informed about the results of the treatment and gives appropriate feedback to the patients. Some behavioral change principles can challenge metacognitive beliefs. Therefore, one of the reasons for the stability of treatment results in the follow-up phase can be due to the increase in metacognitive control of people with depressive symptoms on their metacognitive beliefs. Increasing metacognitive control allows depressed people to establish a new relationship with their thoughts, to change metacognitions that increase the maladaptive pattern of repetitive negative thinking or increase rumination (54).

In general, according to the changes that happened in all three subjects, it can be concluded that facilitating the basic thinking styles, such as rumination and metacognitive beliefs, was able to reduce negative thoughts and, as a result, reduced rumination in patients with major depression. The effectiveness of behavioral activation therapy on reducing rumination is consistent with the results of studies (21, 24, and 26) that have confirmed the effectiveness of activation therapy on depression.

In connection with explaining the effectiveness of behavioral activation therapy on rumination in women with major depression, it can be said that the behavioral theory of depression suggests that this therapy is effective because it leads to an increase in positive reinforcement. The goal of behavioral activation is to increase behaviors that are likely to lead to rewards from the patient. Rewards may be intrinsic (such as pleasure or a sense of accomplishment) or extrinsic (such as selective attention). These increased rewards help to improve the mood of the patient (15). Over time, such a process leads to an increase in environmental reinforcement, followed by an improvement in mood (1). Martel et al. (54) also suggested that the reason for the effectiveness of this treatment could be that during the treatment, people learn to change their lifestyle and follow a new rule in their lives. That is, get active instead of getting inactive when they feel sad. Regarding the effectiveness of this treatment on rumination with self-blame and rumination, it can be said that one of the goals of behavioral activation is to reduce depressing rumination by focusing the patient on environmental activities (55). According to the behavioral activation theory, rumination is a private behavior that prevents full engagement in life activities and therefore can act as a form of avoidance. According to this theory, rumination leads to two specific forms that are the target of treatment for depression: First, rumination separates the person from his environment and instead of engaging in the activities of that moment, focuses him on inner thoughts. Second, rumination prevents fruitful problem solving (16). Behavioral activation therapy using specific techniques such as highlighting the consequences of rumination, problem solving, paying close attention to sensory experience, refocusing on the task at hand, causes the person to turn their attention away from rumination and problematic thoughts. These techniques provide a way to target the rumination process without interfering with the content of thoughts. It has been suggested that behavioral change, followed by behavioral activation therapy, may represent a particularly effective method of changing cognitions.

Another finding of the present study showed that behavioral activation therapy was more effective in reducing rumination in women with major depressive disorder compared to metacognitive therapy. That is, behavioral activation treatment has been able to reduce rumination in women with major depressive disorder. In explaining the effectiveness of behavioral activation therapy on rumination, it can be said that the therapeutic approach of behavioral activation tries to identify the factors that play a role in depression. From the point of view of this type of treatment, in order to reduce the amount of rumination that leads to depression, it is necessary to make changes in some aspects of life and to reduce the state of withdrawal, which is an important factor in maintaining or increasing the amount of rumination. The therapist used a method called guided activities to reduce rumination. In this method, a series of approaches related to behavior change were used, and finally, by using them, the subjects were able to obtain more reinforcers from the environment. The role of the behavior activation therapist was similar to that of a coach. In other words, when the client was trying to implement activation techniques, the therapist provided specialized assistance to successfully implement these techniques. Also, during the treatment, the therapist tried to summarize the client's problems in small formats in order to increase the possibility of solving them.

In general, the results showed that behavioral activation therapy was more effective than metacognitive therapy in reducing rumination in women with major depressive disorder. Therefore, behavior activation therapy can be used as an effective psychological intervention in treating the problems of women with major depressive disorder. It is suggested that behavioral activation therapy group sessions be held in Islamic counseling centers and that this program and related techniques be taught to help the mental state of women with major depressive disorder in the form of knowledge-enhancing workshops. It is also suggested that future studies compare the effectiveness of behavioral activation therapy with other therapeutic approaches, including third wave therapies such as commitment and acceptance. Finally, it is suggested that in future studies, in order to generalize the results, research should be conducted on people with major depressive disorder in other cities and other people with various mental disorders.

Research limitations

The limitations of the research include the quasi-experimental nature of the research; that is, the groups were selected purposefully (women with major depressive disorder referring to psychological clinics), but people were randomly assigned, and the lack of control over the duration of major depressive disorder as an influencing variable in the effectiveness of the intervention pointed to a larger number of samples due to limited access.

Ethical considerations

This article is taken from the doctoral dissertation of the first author in the field of psychology at the Islamic Azad University, Khomein branch, which was approved by the university's research council on 10/01/2020. In this research, ethical considerations such as the full consent of the sample, compliance with the principle of confidentiality and confidentiality of information have been observed, and the researcher has conducted the research process after obtaining approval from the ethics committee with the ID IR.IAU.ARAK.REC.1400.011.

Conflict of interest

The authors also declare that there is no conflict of interest in the results of this research.

Aknowledgement

We would like to thank all the women who participated in this research and the respected professors who guided and advised.