Comparison of the Effectiveness of Acceptance and Commitment Therapy and Emotion-Focused Therapy on the Resilience of Caregivers of Individuals with Dementia

Introduction

Dementia is a condition resulting from brain dysfunction, often characterized by a chronic and progressive course. This disorder leads to changes in an individual's cognitive abilities, personality, and behavior. Patients with dementia frequently experience memory impairments and difficulties in performing daily activities (Fazeli et al., 2023). These patients often forget recent events, repeatedly ask questions, encounter difficulties in communication and social interactions, lose awareness of time and place, and experience reduced motivation, depression, and anxiety (Yaghoubi et al., 2019). Individuals with dementia are generally unable to live independently, make decisions, or carry out daily tasks. The consequences and complications of dementia, including psychological and psychiatric changes, alongside impairments in daily living activities, memory, and other cognitive functions (such as judgment and thinking), necessitate the assistance and supervision of caregivers in their daily activities, to the extent that caregivers themselves require substantial care (Belenguer et al., 2023). Most individuals with dementia have at least one caregiver or supporter, typically a spouse or a family member (Padosi, 2022).

Caregivers of elderly individuals with dementia face numerous challenges, to the extent that caregiving for these patients has been described as a 36-hour day, affecting various aspects of caregivers' lives, including health, employment, and income. Caregiving for dementia patients is a chronic stress process that negatively impacts the physical and mental health of caregivers. Studies have shown that over 80% of caregivers of dementia patients experience high levels of stress (Martin et al., 2023). The caregiving process is associated with anxiety, stress, and depression among caregivers, leading to a decrease in their quality of life and general health (Ghadampour, 2023). Dementia imposes a significant emotional burden on caregivers, affecting their motivation and psychological state (Otobeh et al., 2023). Interacting with dementia patients imposes specific psychological pressures on caregivers, leading to various challenges and issues. Among the critical issues caregivers face, along with accepting the patient, financial difficulties, and medical issues, is their low resilience in coping with the problems arising from the presence of a dementia patient (Rodina, 2019). Reduced resilience leads to increased stress and decreased psychological well-being for those interacting with dementia patients (Seiler et al., 2023). Since enhancing resilience can improve quality of life, caregivers with higher resilience can better cope with life's challenges and maintain greater flexibility in the face of adversity (Sher, 2019). Waller et al. (2020) found that improving resilience reduces stress and enhances the psychological well-being of those interacting with dementia patients.

Caregivers of dementia patients experience various psychological and emotional challenges due to their multiple roles (housekeeping, economic roles, and physical care for the patient). Various theoretical models have been proposed to explain and treat the factors affecting caregivers, including cognitive-behavioral therapy and pharmacological treatments (Sasaki et al., 2023). Each treatment approach faces challenges in terms of treatment duration and the costs imposed on the affected individual, and follow-up in these treatments was neither permanent nor long-term (Sierra et al., 2023). Some therapeutic interventions can significantly reduce depression, anxiety, and stress in family caregivers and provide a foundation for improving the quality of family care for patients (Zehtab et al., 2021). One of the proposed treatments for the issues faced by caregivers of patients is Acceptance and Commitment Therapy (ACT). Increasing engagement in meaningful life activities, even when experiencing negative thoughts and feelings or other challenges, is achieved in ACT by fostering psychological flexibility. This therapy posits that experiential avoidance or unwillingness to engage with distressing events is associated with long-term psychological distress and impaired functioning (Moghbel & colleagues, 2019). In contrast, directly confronting experiences and observing them without judgment reduces psychological distress (Walser, 2018).

Previous studies indicate that ACT effectively increases resilience in caregivers of patients with schizophrenia (Moghbel-Esfahani & Haghighat, 2019), employed women in hospitals (Zarinfard et al., 2020), individuals with multiple sclerosis, and incarcerated women with substance use disorders (Lanza & Menendez, 2013). Furthermore, Fazeli et al. (2018) demonstrated that ACT effectively reduced depression in caregivers of cancer patients. Although some believe that the caregiving role can be accompanied by positive rewards and reinforcements, existing research suggests that the diversity and intensity of caregiving roles may lead to psychological problems in caregivers. If left untreated and without intervention, these individuals, referred to as "hidden patients," experience a decline in their physical and mental health (Edwards, 2023).

Emotion-Focused Therapy (EFT) may also impact caregivers' resilience. EFT is an integrated approach combining systematic, humanistic, and attachment theory perspectives. Given the significant role of emotions in attachment theory, EFT emphasizes the importance of emotions and emotional connections in regulating communication patterns, considering emotions as a fundamental factor for change. The goal is to recognize emotions and transform them into understandable messages and constructive behaviors (Friedman et al., 2023). EFT has proven effective both individually and in groups for depression, quality of life, post-traumatic stress disorder, and adaptive functioning, utilizing methods based on activating strong primary emotions within an empathetic relational context. This type of therapy fundamentally serves as a psychological structure and a key determinant for self-organization (Greenberg, 2020).

Evidence has shown that EFT has demonstrated its competence in comparison with all other approaches studied so far. Ebrahimi et al. (2023) found that EFT was effective in enhancing psychological capital and post-traumatic growth in women with multiple sclerosis. Additionally, Sanagouye et al. (2018) found that EFT significantly reduced anxiety and depression symptoms in patients. The results of studies by Heydarian (2020) and Fathi (2020) also indicate the effectiveness of EFT in reducing anxiety, improving psychological well-being, and enhancing resilience.

Given the psychological and emotional challenges faced by caregivers of dementia patients, such as reduced resilience, and considering the efficacy of EFT and ACT in reducing psychological distress and improving cognitive, psychological, and emotional processes in various individuals, this study aimed to compare the effectiveness of these two therapies in enhancing the resilience of caregivers of individuals with dementia. Given the importance of this issue and the fact that any intervention that helps these caregivers improve their resilience is worth pursuing, this study seeks to reduce the problems of caregivers of individuals with dementia using ACT and EFT. While the effectiveness of these two therapies on resilience has been studied in several contexts (Abyar, 2018; Babakhani, 2020; Hosseinzadeh, 2023), the researcher's investigation revealed that no study has yet compared these two therapies regarding resilience among caregivers of individuals with dementia. It remains unclear which of these therapies is more effective in enhancing the resilience of caregivers of individuals with dementia. This study was designed to answer the question: Is there a difference in the effectiveness of ACT compared to EFT on the resilience of caregivers of individuals with dementia?

Methods and Materials

The present study is an applied research study and is quasi-experimental in nature, employing a pre-test, post-test, and follow-up design with a control group. The study's statistical population was selected from among the primary caregivers (female spouses and daughters) of individuals with dementia who visited the Iranian Dementia Association (located in Tehran) in 2023. This study used a convenience sampling method. After ensuring confidentiality, obtaining informed consent, verifying no history of illness, and confirming that participants were not undergoing any drug or psychotherapy treatments, 45 participants were selected from among the primary caregivers of elderly individuals with dementia. Given that group therapy is recommended to consist of no more than 10 to 15 participants (Sanaei, 2005), the number of participants in this study is deemed appropriate. Considering the adequacy of 15 participants per group, 45 caregivers of individuals with dementia who met the inclusion criteria and were willing to participate in the study were non-randomly purposefully selected and then randomly assigned to two experimental groups of 15 participants each and one control group of 15 participants.

The first experimental group received ACT, and the second experimental group received EFT, while the control group did not receive any treatment. A post-test was administered, and three months later, during the follow-up phase, the tests were conducted again. The inclusion criteria were: 1) caregivers must be the female spouse or daughter of a dementia patient; 2) caregivers must be female (studies by Bastani et al., 2010; Lesada et al., 2010; Krog et al., 2006; Mahoney et al., 2005; Kenagie & Caltabiano, 2005, showed that women comprise a higher percentage of caregivers and experience more psychological effects from caregiving); 3) participants must have at least a middle school education (due to the active and participatory nature of the treatments and the need to complete tasks, a certain level of cognitive ability to identify thoughts and emotions is necessary); 4) participants must have no history of mental illness; 5) participants must complete an informed consent form to participate in the study; 6) participants must not be undergoing any other psychological treatments or interventions during the study. Exclusion criteria included: 1) missing more than two therapy sessions; 2) use of psychiatric medications or substances within the past three months; 3) diagnosis of a severe physical illness such as cancer or multiple sclerosis.

After obtaining permission from the university, a list of caregivers of dementia patients from 2023 who volunteered to participate in therapy sessions was compiled. Based on the inclusion and exclusion criteria, 45 participants were randomly assigned to two experimental groups and one control group. The first experimental group participated in 10 sessions of ACT (Hayes et al., 1999), with each session lasting one and a half hours and occurring weekly at predetermined times coordinated with the Dementia Association. The validity of this protocol was confirmed by its creators and has demonstrated strong face and content validity (Hayes, 1999). The second experimental group also participated in 10 sessions of EFT, each session lasting one and a half hours and occurring weekly at predetermined times coordinated with the Dementia Association. The days and times for both groups remained consistent throughout the protocol. The remaining 15 participants were assigned to the control group and received no therapy but completed the questionnaires as part of the pre-test, post-test, and follow-up assessments, similar to the experimental groups. The follow-up assessments were conducted approximately three months after the intervention.

Measures

Resilience

This questionnaire, consisting of 25 items, was developed by Connor and Davidson (2003) to measure the ability to cope with stress and adversity. Each item is rated on a five-point Likert scale, ranging from 0 (not true at all) to 4 (true nearly all the time). The questionnaire includes 25 statements scored on a Likert scale from 0 (not true at all) to 4 (true nearly all the time). Scores on this scale range from 0 to 100, with higher scores indicating greater resilience. Factor analysis of this scale has revealed five factors: personal competence, trust in one's instincts, tolerance of negative affect, positive acceptance of change, secure relationships, control, and spiritual influences. The statements corresponding to each subscale are as follows: personal competence: items 25, 24, 23, 17, 16, 12, 11, 10; trust in one's instincts and tolerance of negative affect: items 20, 19, 18, 15, 14, 7, 6; positive acceptance of change and secure relationships: items 8, 5, 4, 2, 1; control: items 22, 21, 13; spiritual influences: items 9, 3. Connor and Davidson reported a Cronbach's alpha coefficient of .89 for this scale, with test-retest reliability of .87 over a four-week interval. The scale was normed in Iran by Mohammadi (2005), who reported a Cronbach's alpha coefficient of .89 for reliability. The scale's scores were positively correlated with Kobasa's Hardiness Scale and negatively correlated with Sheehan's Perceived Stress Scale and Vulnerability to Stress Scale, indicating concurrent validity. The CD-RISC scores were not significantly correlated with the Arizona Sexual Experience Scale at the start or end of the study, demonstrating divergent validity. The scale's validity was assessed by calculating the correlation of each item with the total score, followed by factor analysis. All items, except item 3, showed correlations between .41 and .64 with the total score. Factor analysis was performed using the principal components method, and the KMO measure was .87, with Bartlett's test of sphericity yielding a chi-square value of 5556.28, indicating sufficient evidence for factor analysis. Samani, Jokar, and Sahragard (2006) reported a reliability coefficient of .93 in a study among students, and validity (using factor analysis and convergent and divergent validity) was confirmed by the test developers in both normal and at-risk groups. Pardalan et al. (2013) reported a split-half reliability coefficient of .88, indicating good reliability. The validity and reliability of this instrument were re-evaluated in the present study. Face and content validity were confirmed, and Cronbach's alpha coefficient was calculated at .82.

Interventions

Acceptance and Commitment Therapy (ACT)

The ACT intervention is designed to help participants develop psychological flexibility by encouraging them to accept their thoughts and feelings rather than struggling against them. Over ten sessions, participants learn to engage with their emotions and experiences in a way that promotes resilience and committed action towards their values. The intervention progresses from understanding the nature of anxiety and stress to the application of mindfulness and value-based living.

Session 1: The first session introduces the participants to the therapist and each other, setting the stage for the therapy. The therapist explains the concept of ACT, the structure of the sessions, and the ground rules for participation. Participants discuss their experiences with anxiety and stress in daily life, providing a baseline for the work ahead.

Session 2: This session focuses on "creative hopelessness," where participants gain insight into the futility of their usual control strategies for anxiety. The session challenges these strategies and introduces the concept of accepting painful events instead of struggling against them.

Session 3: The concept of acceptance is introduced as a replacement for control and avoidance. Participants learn the difference between tolerance and acceptance and are taught techniques for willingness to experience negative emotions and thoughts, including the "Healing Hands" exercise.

Session 4: Participants explore the concepts of cognitive fusion and defusion. Through experiential exercises, they learn how to recognize when they are fused with their thoughts and practice observing without judgment, thus beginning the process of cognitive defusion.

Session 5: This session introduces mindfulness, teaching participants techniques to remain present and engaged with the current moment. The concept of self as context is also introduced, helping participants understand their broader sense of self beyond their thoughts and feelings.

Session 6: Values clarification is the focus of this session. Participants distinguish between goals and values, identify barriers to living according to their values, and practice exercises related to satisfaction and dissatisfaction with life’s struggles.

Session 7: The concept of committed action is introduced. Participants define specific goals and identify committed actions that align with their values. They begin to plan how to maintain commitment to these actions in pursuit of a value-driven life.

Session 8: The session continues discussing committed actions and the activity cycle, emphasizing mindful engagement with daily activities. Participants are given exercises to practice contentment with life’s difficulties.

Session 9: Participants engage in exposure exercises while walking and continue clarifying their values. The session focuses on empowering participants to apply what they have learned to real-life situations.

Session 10: The final session focuses on fostering motivation for committed action combined with acceptance of mental experiences. Participants review their progress and discuss strategies for maintaining these practices moving forward.

Emotion-Focused Therapy (EFT)

The EFT intervention is designed to help participants understand and process their emotions to improve psychological well-being. Over ten sessions, participants engage in activities that facilitate emotional awareness, expression, and regulation. The therapy integrates systematic, humanistic, and attachment-based approaches to address emotional and relational difficulties.

Session 1: The first session establishes a therapeutic relationship based on empathy and emotional feedback. The therapist assesses participants' expectations and concerns and begins educating them about the nature of the therapy. Emotional education materials and emotion tracking sheets are distributed.

Session 2: Participants start to explore their emotional awareness. The session includes distributing and explaining the use of emotion tracking sheets, helping participants identify and understand their emotional experiences and intelligent emotional thoughts.

Session 3: This session focuses on emotional processing, where participants are guided through stages of awareness, acceptance, and emotional regulation. The therapist observes and supports participants as they process their emotions within the group context.

Session 4: Participants begin to differentiate between primary, secondary, and instrumental emotions. Techniques such as the "empty chair" exercise are introduced to facilitate the expression of deep-seated emotions.

Session 5: The session continues to identify and work through underlying adaptive and maladaptive emotions. Participants practice recognizing, representing, and regulating their emotional experiences.

Session 6: The focus shifts to identifying and addressing emotional blockages that prevent access to primary emotions. Participants also explore potential object-related themes and imagery that influence their emotional responses.

Session 7: Participants continue to work on emotional markers and explore remaining images using expressive arts techniques, such as bodywork, music, and movement, to facilitate emotional expression and processing.

Session 8: The session emphasizes gaining insight through the representation of objects, helping participants understand how new meanings can lead to the creation of a new self.

Session 9: Participants assess how new emotional meanings contribute to the creation of a new self-concept. The session focuses on how these insights can shape future behaviors and interactions.

Session 10: The final session aims to stabilize the new self-concept and generalize these insights to future situations. Participants discuss how they can apply their new understanding of emotions in everyday life to maintain emotional health.

Data analysis

Descriptive and inferential statistics were used in this study. The descriptive analysis included frequency, percentage, mean, and standard deviation. In the inferential analysis, assumptions for covariance analysis were examined using the Shapiro-Wilk test for normality, Levene's test for homogeneity of variance, and Box's M test for homogeneity of covariance matrices in the multivariate case. The research hypotheses were tested using univariate and multivariate covariance analysis, and the effect size was calculated using the eta coefficient. Post hoc Bonferroni tests were used to clarify differences between the groups. The above tests were conducted using SPSS version 27.

Findings and Results

The descriptive statistics related to the study variables, specifically the resilience of the participants in the study, are presented in Table 1.

Before conducting inferential analysis, the primary assumptions for the multivariate analysis of covariance (MANCOVA) were examined: 1) normality of score distribution, 2) homogeneity of variance, 3) equality (homogeneity) of the variance-covariance matrix, and 4) homogeneity of regression slopes.

To assess the assumption of normality, the Kolmogorov-Smirnov test was used. The results indicated that the null hypothesis of normal distribution of scores in the three groups for the pre-test, post-test, and follow-up was not rejected. Therefore, the assumption of normality for the pre-test, post-test, and follow-up scores in the experimental and control groups was confirmed (p ≥ .05). Additionally, Levene's test was used to examine the assumption of homogeneity of variance, and the results showed that the assumption of equal variances was confirmed for all study variables in the post-test and follow-up stages (p ≥ .05). To assess the assumption of equal covariances or the relationships among dependent variables, Box's M test was utilized. The results indicated that the condition of homogeneity of the variance-covariance matrix was met (M Box = 124.63, F = 1.23, p = .06). To assess the homogeneity of regression slopes, the interaction between the pre-test and group for each dependent variable was calculated. The results showed that the interaction between the group and pre-test was not significant for any of the dependent variables (p ≥ .05), indicating that the assumption of homogeneity of regression slopes was met for all study variables.

Based on the results in Table 2, after controlling for the pre-test scores, the differences between the mean post-test scores for resilience in the two experimental groups (ACT and Emotion-Focused Therapy) and the control group were significant (p ≤ .001). In other words, the results indicate that the differences between the adjusted post-test mean scores for resilience across the groups were significant (p ≤ .001). The effect size of this improvement in resilience at the post-test stage was 75%. Additionally, according to the results in the table, after controlling for the pre-test scores, the differences between the mean follow-up scores for resilience in the experimental groups and the control group were significant (p ≤ .001). In other words, the results indicate that the differences between the adjusted follow-up mean scores for resilience across the groups were significant (p ≤ .001). The effect size of this improvement in resilience at the follow-up stage was 72%. To further investigate the differences between the experimental and control groups in terms of resilience at the post-test and follow-up stages, pairwise comparisons using the Bonferroni test were conducted on the adjusted mean scores, with the results presented in Table 6.

The results in Table 3 indicate that both the Acceptance and Commitment Therapy and Emotion-Focused Therapy interventions resulted in significant differences in resilience compared to the control group at both the post-test and follow-up stages (p ≤ .001). Additionally, the results suggest that the Emotion-Focused Therapy had a greater impact on the resilience of female caregivers and daughters of individuals with dementia compared to the Acceptance and Commitment Therapy. Specifically, the Emotion-Focused Therapy group demonstrated an increase in resilience scores of 5.90 at the post-test stage and 2.84 at the follow-up stage compared to the Acceptance and Commitment Therapy group.

Discussion and Conclusion

The present study aimed to compare the effectiveness of Acceptance and Commitment Therapy (ACT) and Emotion-Focused Therapy (EFT) on the resilience of caregivers of individuals with dementia. The findings showed that both interventions significantly improved resilience compared to the control group at both the post-test and follow-up stages. Moreover, the results indicated that EFT had a greater impact on resilience than ACT among the female caregivers and daughters of individuals with dementia. Specifically, the EFT group showed a greater increase in resilience scores compared to the ACT group at both the post-test and follow-up stages.

Due to the novelty of this research and the lack of similar studies, the results cannot be directly compared with other studies. However, the findings align with parts of the results from studies by Azandariani (2022), Ebrahimi (2022), Toukoli (2021), Zehtab (2021), Moghbel Esfahani (2019), Al Yasin (2019), and Fathi (2020). Interacting with individuals with dementia imposes specific psychological pressures on caregivers, leading to various challenges and problems. Among these issues, low resilience in the face of challenges posed by the presence of a dementia patient is a significant concern. Resilience does not imply the absence of risk factors in life but rather the presence of supportive psychological factors that can lead to positive outcomes in life. For example, when individuals face life's challenges, supportive factors such as positive thinking, self-confidence, and control over negative emotions can reduce the negative impacts of life's pressures (Toukoli, 2021).

In explaining the effectiveness of ACT on resilience among caregivers of individuals with dementia, it can be argued that the goal of ACT is not to change the content of thoughts but rather to use behavioral techniques such as mindfulness, acceptance, and cognitive defusion to increase psychological flexibility. Effective, open, and non-defensive communication training leads caregivers to pay attention to and observe their environment and internal experiences without judgment or valuation (Shirazi Pour, 2021). Mindfulness exercises in ACT are used to focus the client's attention on the environment as directly experienced rather than through mental constructs. This therapy, by enhancing individuals' ability to respond adaptively and flexibly to life events in the presence of threatening thoughts and feelings, leads to improved resilience among caregivers of individuals with dementia.

Furthermore, one of the key reasons for the improvement in resilience among the experimental group was likely the reduction of avoidance behaviors through exposure-based components in therapy sessions, as avoidance of accepting dementia patients often perpetuates a negative cycle. The frequent occurrence of experienced thoughts among caregivers also leads to avoidance behaviors. Therefore, in addition to the exposure component, attention was also given to experienced thoughts that could lead to avoidance (Taraqi, 2020). Consequently, changes in cognitive fusion were targeted through acceptance and cognitive defusion components. These techniques helped caregivers in the experimental group understand that they should not let their thoughts influence their behavior and reactions, as this could lead them away from their values.

On the other hand, EFT, as a structured and step-by-step therapeutic approach, showed greater effectiveness than ACT. This therapy, by focusing on attachment styles, enhancing emotional awareness, and improving emotional expression, helps caregivers increase their resilience by fostering secure and adaptive attachment patterns through care, support, and mutual attention (Bagheri, 2016). The capabilities of EFT allow caregivers of individuals with dementia to increase their emotional awareness and control negative emotions such as anger, anxiety, stress, and depression, thereby enhancing their resilience.

In summary, EFT, by improving the ability to symbolize emotions, reduces abnormal psychological reactions and enhances self-care and self-regulation, leading to a reduction in the intensity of negative emotions. Those who received EFT were better able to identify, describe, and manage their emotions when faced with stressful life situations. Since emotions play a significant role in people's lives, EFT, as a therapeutic method that moderates emotions, effectively addresses stressful situations and promotes increased activity in response to social situations. Therefore, EFT can play a significant role in resilience by raising awareness of both positive and negative emotions, and promoting their timely acceptance and expression.

Limitations & Suggestions

One limitation of this study was the lack of control over certain variables such as the duration of the patient's illness and the psychological condition of the caregivers, which may have influenced the results. Based on the findings of this study, which demonstrated the effectiveness of EFT on the dependent variables, it is recommended that workshops and programs be conducted in psychological and counseling centers, as well as other centers that work with chronic patients, to raise awareness and provide more comprehensive education in this area.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants. This study was approved by the Islamic Azad University, Gorgan branch (IR.IAU.CHALUS.REC.1402.016).

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

All authors equally contributed in this article.