Effectiveness of Acceptance and Commitment Therapy on Thought Control and Meta Cognitive Beliefs among Females Experienced Extramarital Affairs Trauma

Background & aim: Extramarital affairs negatively influence the marital relationship and marriage quality. Therefore, this study aimed to investigate the efficacy of acceptance and commitment therapy on thought control and meta cognitive beliefs of females who experienced trauma regarding their spouse extramarital affairs. Methods: This was a quasi-experimental pre-post design with control and follow-up (45 days). Samples selected through purposive sampling method among one hundred fifty females (aged between 30-40 years old) complained their spouse infidelity in counseling clinics of Mashhad-Iran. Final samples comprised 30 female who were consented to participate in the study and replaced in control (N = 15) and intervention groups (N = 15) randomly. The Acceptance and Commitment Therapy included eight weekly sessions. The participants in both groups measured in three time frames i.e. pre-intervention, postintervention and 45 days after intervention. They completed standard questionnaires of thought control and meta cognitive beliefs. Gathered data compared through repeated measure ANOVA. Results: The mean score of thought control was 64.46 ± 6.23 and meta cognitive belies 56.20 ± 5.51. The mean score of though control in intervention group after acceptance and commitment therapy in posttest and 45 days after posttest was 60.50 ± 8.02 and 50.13 ± 6.56 respectively. Difference of groups were significant in posttest stage F(1, 27) = 16.13, P > 0.001. The mean score of meta cognation in intervention group after acceptance and commitment therapy in posttest and 45 days after posttest was 85.13 ± 7.12 and 83.93 ± 5.19 respectively. Difference of groups were significant in posttest stage F(1, 27) = 9.12, P > 0.05. Conclusion: The finding of this study highlighted the efficacy of psychotherapy sessions on improvement of thought patterns and meta cognitive beliefs of females suffering from extramarital affairs of their partners.


Introduction
Extramarital affairs is one of the common reasons of separation of couples as it is responsible for intentional deception and irresponsibility which is not acceptable by partner [1].Marital infidelity is potentially complex and painful experience for spouse [2] and results to various problems and complications such as shock, confusion, anger, depression, damaged self-esteem and decreased confidence in personal and sexual matters [3].Some researchers believed these complications are same to post trauma disorder symptoms.In fact, marital crises, dysfunction in parenting and occupation difficulties appeared when they discover their spouse betrayed [4].Beating, killing or suicide commitments are other more serious consequences of infidelity [5].Miller & Maner study showed males shows their emotion as anger and aggression but females shows depression symptoms while searching for reason of infidelity [6].Infidelity in different levels reveals the pathological problems.It seem the main problem is not about engaging husband in special sexual or emotional relationship rather hiding and contusing relationship is extremely irritating for females [7].
Acceptance and commitment therapy is a new approach based on acceptance, commitment, mindfulness, commitment in functions, ideological patterns and behavior changes processes aimed to develop mental flexibility [8].This type of therapy is shaped according functional behaviorism approach which shares many similarities with digital behaviorism and in many context [9].Acceptance and mindfulness approaches called third view while behavior therapy was first and Becks cognitive therapy was considered as second view [10].The third view is not rejected the first or second view but integrates and fills the gaps between these approaches [11].Therefore, today's the therapies appeared based on acceptance therapy models such as mindfulness based cognitive therapy [12], dialectical behavior therapy [13], Behavioral Activation [14], Integrative Behavioral Couples Therapy [15], Functional Analytic Psychotherapy [16], Metacognitive Therapy [17], Schema Therapy [18], cognitive behavioral couple therapy and finally acceptance and commitment therapy [19].
Acceptance and commitment therapy is focused on improvement of emotions and thoughts not changing them [20].Hayes structured the acceptance and commitment therapy, which mainly based on mental flexibility; it implies to ability of functional flexibility between options rather than imposing an action to avoid from dysfunctional thoughts, emotions or memories [21].In this view, our reaction is not directly related to external world rather, internal emotions is responsible mostly for our reaction and behaviors [22].Acceptance and commitment therapy aimed to develop a meaningful life through appropriate distress control, suffering and tensions [11].Wells & Mathews highlighted the role of the metacognitive beliefs through information processing patterns [23].In Self-Regulatory Executive Function Model vulnerability and resistance of disorders is related to cognitive attention.This is attributed to self-review, disrupting the processing of ruminant species beliefs activation and self-regulation strategies.This pattern predicts the role of meta cognition in vulnerability to psychological disorders.
Cognitive dysfunction also may considered as associated with meta cognitive beliefs [17].In information process, the cognition affected by emotion and met cognitive.Therefore, the emotional states manipulation may leads to changes in evaluation and cognations [24].On the other, hand meta cognitive though control strategies are reflection of control of cognitive system activities.In Wells view, emotional disorder is related with treat control strategy.As people use various spectrum of thought control strategies to control unwanted or desperate thoughts [17].Thought control strategies included re-evaluation, discipline, social control, anxiety and distraction [23].Emphasis of metacognition on awareness of what happens within moments, without engaging with them is influenced by Eastern philosophy, which is shared common features of ACT.Finally, acceptance and commitment therapy high focused on acceptance of thoughts, emotions and commitment to regular effort.Burpee & Langer examined the efficacy of acceptance and commitment therapy on 95 couples.The results indicated strong and significant improvement seen on marital satisfaction [25].Carson, Baucom & Gil also used mindfulness, acceptance, and commitment therapy on 44 couples.Findings showed that interventions promoted the communication and individual mental health of participants [26].Peterson et al. (2009) reported effectiveness of therapies based on acceptance and commitment on couples stress [27].More recently, Rajabi et al. revealed that therapy based on acceptance and commitment and integrative behavioral couple therapy are effective on worry and marital adjustment of females with generalized anxiety [28].
Considering previous studies and theories about acceptance and commitment-based therapy on improvement of marital relationship, this study hypothesized that acceptance and commitment therapy is effective on meta cognitive beliefs and thought control of females who newly experienced husband infidelity.

Design and setting
This was a quasi-experimental pre-post design with control and follow-up (45 days after intervention).Proposal of study approved by ethical committee of Mashhad University and participants signed consent form.The study population included females referred to three counseling clinics of welfare organization Mashhad-Iran, due to their spouse infidelity during 2015.

Sampling
Sampling method was purposive sampling according to inclusion criteria's i.e. aged 30-40 years old, education at least high school, first marriage, no children, marriage duration between 1-3 years, no previous psychotherapy, agree to participation, spouse infidelity trauma, no chronic illness.Of 152 females referred to clinics of welfare organization Mashhad, 30 cases were included in the study according previous studies [17].The selected sample administered in control (N = 15) and intervention groups (N = 15) randomly.Please see figure 1.

Intervention
The intervention included eight sessions (each session 90 minutes) delivered weekly every Friday (2 pm -4 pm).The sessions conducted in welfare clinics in two randomly assigned smaller groups (group a = 8 cases and group b = 7 cases) by researcher and her supervisor.See table 1.

Tools
The participants accessed via following tools: 1-Thought Control Questionnaire (TCQ) is a 30-item instrument devised by Wells and Davies (1994) to assess the effectiveness of strategies used for the control of unpleasant and unwanted thoughts.The Cronbach Alpha scores (n = 229) obtained for the subscales were as follows: Distraction = 0.72; Social Control = 0.79; Worry = 0.71; Punishment = 0.64; Re-appraisal = 0.67.At six-weeks apart the test-retest correlations ranged from 0.67 to 0.83 for the subscales.With the total score being 0.83, indicating that it is a stable measure [29].Total Cronbach Alpha for total score in present study was 0.75, which indicates appropriate internal reliability.
2-The metacognitions questionnaire (MCQ) measures individual differences in a selection of metacognitive beliefs, judgments and monitoring tendencies considered important in the metacognitive model of psychological disorders.The development and properties of a shortened 30-item version of the MCQ, the MCQ-30, are reported.Construct validity was evaluated by confirmatory and exploratory factor analysis.Overall, the fit indices suggested an acceptable fit to a five-factor model consistent with the original MCQ.Exploratory factor analysis supported a five-factor structure, which was almost identical to the original solution obtained in previous studies with the full MCQ.The five factors are cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger, and beliefs about need to control thoughts [30,31].Shirinzadeh, translated and prepared this scale in Iran.The Cronbach Alpha scores for Iranian samples was as follow; total (0.91), uncontrollable subscale (0.87), metacognitive beliefs (0.86), cognitive confidence (0.81), need to control thoughts (0.71) which implies to appropriate validity and reliability of this questionnaire.In present study, Cronbach Alpha was 0.79 [32].

Statistics
In this study, data interred to SPSS 20 software and analyzed via descriptive and repeated measure ANOVA.Current study is a 3x2 design with the factor time (pre-intervention, post-intervention and follow-up) and the factor group (intervention group and control group).Therefore, repeated measures ANOVA with these two factors performed and main effects of time, group and the interaction of time and group examined in order to test main hypothesis.

Results
The final sample included 30 cases (control group = 15 female, intervention group = 15 females) there was no drop in this study during three assessment stages of pre test, post test, 45 days after intervention (Table 2).
In term of results of repeated measure for though control Mauchly test indicated that the assumption of sphericity had been violated χ 2 (2) = 0.21, P > 0.05 , therefore degrees of freedom were corrected using Greenhouse-Geiseer estimates of sphericity (ϵ = 0.505).The results show that there was significant effect of intervention on case group F(1.01, 28.01) = 10.6,P = 0.003.
In term of results of repeated measure for though control Mauchly test indicated that the assumption of sphericity had been violated χ 2 (2) = 0.11, P > 0.05 , therefore degrees of freedom were corrected using Greenhouse-Geiseer estimates of sphericity (ϵ = 0.503).The

Discussion and Conclusion
The findings of this study generally indicates that acceptance and commitment therapy approach improved thought control strategies and meta cognitive beliefs of females experiences spouse infidelity trauma.The hypothesis of the study approved which implies this approach is suffusion to improve the consequences of desperate thoughts and meta cognitive beliefs.The same results persisted during follow up.This results is similar to findings of Honarparvaran [33] and Atkins [34], which showed that the partners with extramarital affairs experience higher conflict than other couples.
Hafmann & Asmundson [22] believed that acceptance and commitment therapy help couples to associate with their real life values.In this view, avoidance from experiences is a pathological process, which develops marital conflicts.
When a woman discovers an extramarital affair of her spouse, ruminates thoughts and disappointedly tries to release from this annoying thoughts.This is the point that thought control is beneficial to help the females in this situation in order to overcome to their unhelpful repeating thoughts.On the other hand, flexible meta cognitive beliefs helps to discover the negative and positive points and controlling cognations to challenge with unhelpful thoughts efficiently.Acceptance and commitment therapy targets thoughts in order to a substantial disclose and experiencing instead to controlling or changing negative evaluations, which increase thought control and cognitive flexibility.
Georg [35] believed that acceptance leads to substantial changes on discussions of family and provides a space to experience their thoughts and emotions without challenges for change.Carmody and Olendzki [36] states that this trainings helps to individuals to face with stressful situations to feel their emotions.In this case, the partners allow each other to experience emotions.However in first stage of discovery, thought control and meta cognitive beliefs dose not works but during sessions these strategies is beneficial in controlling thoughts and beliefs regarding fear, treats, worry, distraction, punishment and need to control in different context.Similarly, Baruch et al. [37] also believes interventions based integrated cognitive, mindfulness and acceptance significantly boosted sexual arousals in different aspects and decreased sexual turmoil among females which leads to more adjustment in relationship.
Extramarital affairs negatively affect the quality and satisfaction of marriage, which may lead to anxiety, depression, stress even suicide.During sessions, they find out most of strategies already used to thought control and beliefs were destructive and made the situation worthier.
In conclusion, this study conducted to improvement of females who experience infidelity trauma to enhance their thought control ability and meta cognation beliefs efficacy.This study involved some limitations such as difficulty in generalization of results to other samples because of non-homogeneity of samples a non-randomized sampling.In addition, the families with extramarital affairs experience many conflicts and disturbances.This suggested to include children and couples involved with problem during sessions, which helps to acceptance, based interaction and commitment among family members.In this case, members develops personal and family values.This will provide an appropriate content to comprehensive training of suffering spouse and her family members in addition to her family support.The family supports in this situation decreases the communication issues among members.Finally, it is suggested to integrate this therapy with other therapies in same content to examine the efficacy of techniques and therapies on recovery of females who received infidelity trauma.
This study involved with some limitations such as small sample size, short follow up, self reported questionnaires, non-homogeneity of samples in some aspects such as economical level.

Table 1 :
Context of sessions.1 Ice breaking exercises Asking them to explain why they seek treatment, what they hope and expect Conceptualization and rational of therapy Targets and commitments to targets Asking females t to describe problem one by one and how they interfere with their life explains the process of recovery and that it may 2 Review last session explain contexts in which problem occur for client Identify the negative impact of attempts to control situation 3 Help foster defusion by using the Physicalizing exercise and having client draw a picture of this object 4 Introduce acceptance as an alternative to control using the Two Scales metaphor &Trauma on Paper exercise using the picture giving the infidelity some type of meaning and helping the client realize why the infidelity occurred 5 Review acceptance by demonstrating that the willingness to experience Enhancing self as context Identify opportunities for acceptance from out of session practice Behavioral commitments to engage in value-based activities 6 Forgiving others Forgiving self Help the client be present with their inner experiences using the Awareness of Inner Experiences and Leaves on a Stream exercise Identify the importance of being present while not being heavily attached to inner experiences using Kindergarten Teacher metaphor Having a Thought versus Buying a Thought activity Behavioral commitments to engage in value-based activities 7 Identify the self as the context where inner experiences occur Explain that the client does not choose what inner experiences occur, but that they can choose what to do with them Contact with Present Moment Watching Thoughts on a Screen Increased behavioral commitments to engage in valued living based on recent values work Foster committed action by reviewing any processes that still need attention Rewriting life story 8 Review sessions Summarize the treatment Discuss end of treatment and apply ACT processes to termination Suggest a workbook for continued progress

Table 2 :
Demographic and descriptive information of participants.