Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
The Effectiveness of Mindfulness-Based Cognitive Therapy (MBCT)
Intervention on Mental Ruminations, Metacognitive Beliefs, and
Perfectionism in Patients with Obsessive-Compulsive Disorder in Isfahan
Province
Elham Yousefi
MA in Clinical Psychology
[email protected]
Sayedeh Monireh Azadeh
MA in Clinical Psychology
[email protected]
Zainab Majlesi
MA in Clinical Psychology
[email protected]
Azam Salehi
PNUfaculty, Isfahan
[email protected]
Abstract
Background and aim: the present study is aimed at investigating the effectiveness of mindfulness-based
cognitive therapy (MBCT) intervention on mental ruminations, metacognitive beliefs, and perfectionism
in patients with obsessive-compulsive disorder in Isfahan Province.
Method: the sample of the present quasi-experimental study was randomly selected from patients
referring to centers for psychiatric and psychological services in Najaf Abad Township from December
11, 2015 to January 30, 2016, including 30 patients who were diagnoses to suffer from 0bsessivecompulsive disorder during clinical psychiatric interviews based on the DSM-5 conducted by a
psychiatrist. Then, they were randomly divided into two 15 participant groups: the MBCT group and the
control group. The experimental group received 8 intervention (MBCT) sessions and were assessed in
two pretest and posttest stages using structured interviews, the Wells Metacognitive Inventory, and the
Maudsley Obsessional Compulsive Inventory. Then, the results were analyzed using MANCOVA.
Findings: the results indicated that MBCT is significantly effective on mental ruminations, metacognitive
beliefs, and perfectionism in patients with obsessive-compulsive disorder in Najaf Abad Township
(p<0.05).
Conclusion: mindfulness-based cognitive therapy training is effective on the increase on individuals’
consciousness of the present time via skills such as attention to breath and body, consciousness to here
and now, and then cognitive system and information processing. Therefore, regarding the effectiveness of
this type of training in the field of Obsessive-Compulsive Disorder therapy and increase in the life
quality, its expansive uses are recommended.
Keywords: mindfulness, ruminations, metacognitive believes, perfectionism, ObsessiveCompulsive Disorder.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1943
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
1. Introduction
Obsession is in fact is a thought, word, or image invading human beings, dominating their
psychological organization, and agitating extensive anxiety in them in spite of their wills to
consciousness (Dadsetan, 2009). Compulsion is a repetitive, cliché, and insignificant motor
behaviors which enters individuals’ consciousness in a ruminant way and if individuals do not it,
they face increasing stress and anxiety (Kaplan & Sadock, 2011). Obsessive-compulsive disorder
is one of the relatively prevalent anxiety disorders in Iranian society and is considered a kind of
disorder having significant percentage of the population referring to clinics and counseling
centers. Theories presented in the field of obsession disorder and factors generating it were
established in terms of neither experiential bases nor in terms of effective therapeutic methods in
such a way that by the mid-1960s, obsession disorder was considered as a cureless disease
resistant to therapy requiring lifelong treatment. In fact, instead of curing this problem, one
should learn how to deal with it. But since the late 1960’s, behavioral powerful treatments have
been establishing. Effective strategies such as “confrontation and prevention of responses”
promising to have significant effects have been introduced so that they have been become as the
selective treatment of this disorder (Astkty, 2008). So far, different theories such as biological,
psychometric, psychological-social, cognitive, behavioral, and cognitive-behavioral theories
have been to explain and present therapeutic models for this disorder. The relatively new and
promising theory in explaining and curing obsessive-compulsive disorder in the framework of
psychological approach is the theory of cognitive-behavioral therapy (Schwartz et al. 2005).
Cognitive theories of obsessive thoughts (Salkovskis, 1998) believe that cognitions related to
false evaluations and beliefs are determinative in growing and surviving obsessive-compulsive
disorder. In this regard, it can be said that cognitive therapy models (Carr, 1974 as cited in
Grayson et al., 2003), cognitive model (MacFaul and Vlzhaym, 1998 as cited in Grayson et al.
2003), and Vitaly’s cognitive model (Vitaly et al. 2002). Vitaly et al. (2002) believed that in
obsessive individuals have beliefs which cause false evaluation of unwanted thoughts and
individuals face problems. These beliefs are giving too much importance to the thoughts,
preoccupation lot of thought control, over estimation of the threat, intolerance of uncertainty and
perfectionism. According to Vitaly’s cognitive model, individuals with obsessions have high
perfectionism and tolerating obscurity and dilemmas is difficult for them. They try to change or
reduce the intensity of these beliefs and thoughts in order to decrease obsessive thoughts in
individuals. Vitaly et al. (2002) believe that cognitive therapies are effective on improving social
performance and depression of patients with obsessive thoughts. Nowadays, in methods of
behavioral therapy of obsession, training patients and informing them about their diseases as well
as their roles in the process of treatment and doing homework are considered significant in such
a way that research shows high degree of its improvement and survival in patients having such
therapeutic programs (Houghton et al. 2006). In addition, to treat this disorder, the cognitive
therapy method based on mindfulness in which patients are informed by internal and subjective
representations can be also employed (Schwartz et al. 2005). In mindfulness, individuals is
conscious in every moment of mental practices and learn skills for identifying more suitable
methods. For mind, two main practices is considered: one is “to do” and the other is “to be”. In
mindfulness we learn to move the mind from one method to another (Kabat- Zinn as cited in
Segall et al. 2002). Mindfulness requires particular behavioral, cognitive, and metacognitive
strategies for concentration of the process of attention resulting in preventing downward spiral of
negative-mood-negative thought-tendency to worrying responses and growth of new views and
http://www.ijhcs.com/index.php/ijhcs/index
Page 1944
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
appearance of pleasant thoughts and emotions (Segall et al. 2002). Mindfulness-based cognitive
therapy has been constructed out of the model of reducing stress based on Kabat- Zinn’s
mindfulness. This type of cognitive therapy includes different meditations such as stretching
yoga, basic training and several practices in cognitive therapy which indicate the relationship
between mood, thoughts, feelings, and bodily senses. By mindfulness, it is the presentation of a
biological-cognitive-behavioral method which gives new information about biological
foundations of obsessive-compulsive disorder to patients in order that their abilities of
controlling anxious responses and resistance against annoying syndromes of obsession increase.
The main principle in creating these abilities is that patients learn the mode of controlling and
managing fear and anxiety created by this disease by real natural of these thoughts and desires.
In fact, managing fear per se provides this possibility for patients to control their behavioral
responses more effectively. Therefore, patients use biological information and cognitive
consciousness for confronting and preventing responses. The aim of concentration on using
mindfulness-based cognitive therapy is providing more consciousness individuals’ thoughts and
emotions. In fact, individuals learn to take their own thoughts as mental events instead of
consider them from their own aspects or a reflection of reality via this therapy. This program
teach skills to individuals in order to free from everyday disturbing cognitive habits particularly
ruminant thought patterns in obsessive-compulsive disorder (Bowman et al. 2010).
2. Research method
2.1.Population
The population of the present research includes all patients referring clinics and psychiatric and
psychological service centers in Najaf Abad Township. According to the diagnoses of
psychiatrist or a clinical psychologist, these patients were suffering from obsessive-compulsive
disorder via psychiatric and psychological clinical interviews based on the Fifth Diagnostic and
Statistical Manual of Mental Disorders.
In the present study, a number of 30 patients suffering from obsessive-compulsive disorder were
selected from among the population using the convenience sampling method. Then, they were
randomly divided into two experimental and control groups and individually received
mindfulness-based cognitive therapy. Participants answered tests in two stages and after
receiving 8 treatment sessions.
2.2.Research instrument
In the present study, to assess characteristics and conditions, demographic forms, clinical
interviews, clinical tests, Wells Metacognitive Inventory, and Maudsly Obsessive Compulsive
Inventory (MOCI).
2.3.Data analysis methods
The data obtained from the present study were analyzed using Statistical Package in Social
Sciences in SPSS-22 in such a way that firstly using descriptive statistics (frequency, mean
scores, and SD) the data were analyzed. Then, using inferential statistics (MANCOVA) the
research group was investigated.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1945
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
3. Findings
Possible explanation for effectiveness of mindfulness-based cognitive therapy on ruminations,
metacognitive beliefs, and perfectionism n patients with obsessive-compulsive disorder is that
mindfulness-based therapy results in cognitive changes in the way of thinking and acting in
patients and enjoys principles of conditioned reinforcement. That is individuals exert their efforts
to see themselves in higher steps. This tendency consistently causes gradual and step-by-step
improvement in patients. In addition to creating calmness and consciousness, it improves
individual conditions and solve problems in face-to-face sessions (Roth et al. 2004). It seems that
practices of mindfulness-based cognitive therapy along with increasing individuals’
consciousness towards the present time, via skills such as attention to breath and body, and
concentration on consciousness to here and now have effects on the cognitive system and
information processing. All subscales are directly scored and higher scores indicate higher levels
in each scales.
To investigate the effectiveness of mindfulness-based cognitive therapy on rumination,
metacognitive beliefs, and perfectionism, MANCOVA was used.
Firs assumption of MANCOVA: the first assumption of MANCOVA is interval and relativity of
covariate and dependent variables. As mentioned in the scoring method of the three
questionnaires, scales are interval in nature; as a result, for the first assumption of MANCOVA is
realized.
Second assumption of MANCOVA: for investigation of the normality of pretest and posttest
distribution, their distribution normality was investigated using the Kolmogorov – Smirnov Test.
Table 1: the Kolmogorov – Smirnov Test for investigating pretest-posttest distribution normality
of the research scales
Mean
Scales
Test type
No.
Value
Sig.
scores
Pretest
15
55.37
0.73
0.60
Ruminations
Posttest
15
49.47
0.87
0.71
Pretest
15
47.52
0.65
0.73
Metacognitive
beliefs
Posttest
15
42.11
0.81
0.82
Pretest
15
109.47
0.62
0.83
Perfectionism
Posttest
15
113.19
0.83
0.46
Table 1 indicated that p-value in the Kolmogorov – Smirnov Test is bigger than 0.05. Regarding
the results of data distribution according to normal distribution and the second assumption of
MANCOVA is appropriately observed.
Table 2: Levine test for investigating the homogeneity of variances in covariate and dependent
Homogeneity of covariate and
F
df 1
df 2
Sig.
dependent groups
Rumination
3.07
http://www.ijhcs.com/index.php/ijhcs/index
1
26
0.08
Page 1946
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
Metacognitive beliefs
1.21
1
26
0.27
Perfectionisms
0.26
1
26
0.61
As indicated in table 2, it can be identified that none of the significance level of scales are
smaller than 0.05 and the null hypothesis of Levine Test stating homogeneity between covariate
and dependent groups was confirmed and all these paired groups are homogenous. As a
consequence, the conditioned assumption for MANCOVA is provided.
Main hypothesis: mindfulness-based cognitive therapy is effective on rumination, metacognitive
beliefs, and perfectionism.
To investigate the effectiveness of mindfulness-based cognitive therapy on rumination,
metacognitive beliefs, and perfectionism, MANCOVA was used. In this analysis, an
experimental group and a control group were used in two pretest and posttest stages. The results
of Box’s M Test for investigating homogeneity of the matrix are presented in table 3.
Table 3: the Box’s M Test for variables of rumination, metacognitive beliefs, and perfectionism.
Box’s M
F
df1
df2
Sig.
29.86
1.34
21
3341.65
0.23
Regarding the significance of the Box’s M Test, the null hypothesis of homogeneity of matrices
is rejected and with insignificance of this test at the significance level 0.05, variance-covariance
matrices are homogenous. Values of Wilks Lambda test are presented in table 4.
Table 4: Wilk’s Lambda test for investigating difference in mean scores of scales under study
Statistical
Eigenvalues
F
df
Sig.
Eta
power
Wilk’s
0.38
27.01
6
0.01
0.77
1.00
Lambda
Regarding table 4, value 0.38, and value F=27.01, with deletion of the effect of covariate
variable, the mindfulness period has been effective at least on one of the scales of rumination,
metacognitive beliefs, and perfectionism at the level p<0.01. In table 5, ANCOVA of group
mindfulness cognitive therapy is investigated.
Table 5: ANCOVA of difference in effectiveness of group cognitive therapy on mindfulness
of
squares
df
Mean Square
F
Sig.
Eta
Power
of test
Rumination
group
Error
952.58
1332.12
270.34
1
1
24
952.58
1332.12
87.26
12.78
29.84
--
0.01
0.01
--
0.45
0.55
--
0.98
1.00
--
Metacognitive
beliefs
187.40
161.05
1
1
187.40
161.05
30.39
45.63
0.08
0.01
0.21
0.65
0.19
1.00
Resource
Sum
http://www.ijhcs.com/index.php/ijhcs/index
Page 1947
Special
May
Issue
2016
group
Error
Perfectionism
Group
Error
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
84.70
24
3.53
--
--
--
325.07
763.96
297.29
1
1
24
12.96
325.07
142.05
31.19
80.18
--
0.01
0.01
--
0.58
0.77
--
0.99
1.00
--
Regarding table 5, the group mindfulness cognitive therapy period is effective on rumination,
metacognitive beliefs, and perfectionism at the level p<0.01. The power of the test confirms the
adequacy of the sample size. Considering the obtained results, the main hypothesis stating the
effectiveness of group mindfulness cognitive therapy on rumination, metacognitive beliefs, and
perfectionism is confirmed.
4. Discussion and conclusion
The results of MANCOVA in table 5 indicated that group mindfulness cognitive therapy is
effective on rumination, metacognitive beliefs, and perfectionism in patients with obsessivecompulsive disorder (p<0.05). It means that in mindfulness metacognitive therapy period is able
to decrease obsessive patients’ rumination, increase positive beliefs of patients with obsessivecompulsive disorder, decrease their negative beliefs about uncontrollability, increase beliefs
about cognitive adequacy, decrease general negative metacognitive beliefs, decrease
metacognitive beliefs about cognitive consciousness, decrease the patients’ perfectionism, and
enhance the quality of interpersonal relationship between patients. These results are consistent
with findings of studies conducted by Borjali, 2013; Abedini, 2013; Abdi Khan, 2014; Kazemini
et al. 2011; Faramarzi, 2010; Sajjadian, 2008; Yousefi, 2015; Gol Pourchaman Kouhi, 2011;
Arianpour, 2012; Bohlmeijer, 2010).
5. Suggestions for further research
The present study was individually conducted on a sample size with 30 subjects suffering from
obsessive-compulsive disorder; therefore, it is recommended that in future studies, the same
issue can be investigated on more subjects and in group. Regarding the fact that in these
researches subjects who were at different educational levels were selected using the convenience
sampling method, it should be noted that treatment methods and sessions can be applied using
face-to-face training by therapists for patients with obsessive-compulsive disorder or even those
with little literacy.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1948
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
References
Abolghasemi, A. et al. (2010). Comparing metacognitive beliefs and dimensions of
perfectionism in patients with obsessive disorder and post-traumatic stress in interaction with
uncertainty. Journal of Psychology. 12 (1). Pp. 20-35.
Andouz, Z. (2006). Wells' metacognitive model of efficiency and effectiveness in the treatment
of Obsessive-Compulsive Disorder. Journal of Thoughts and Behavior. 12 (1), pp. 66-59.
Babapour, Kh. et al. (2012). Relationship of metacognitive and mindfulness components with
obsessive beliefs about students. Journal of School Psychology. 1 (4), pp. 38-23.
Biabangard, A. (2009). Analysis of meta-cognition and cognitive therapy. Cognitive Science
News, 4 (4).
Bowman. L. C., & Sabbagh, M. A. (2010). Dopaminergic functioning and preschoolers theory of
mind. Neuropsychologia. 48 (6), 1767-1774.
Clark, D. A., & Purdon, C. (1993). New perspectives for a cognitive-theory of obsessions.
Australian Psychologist, 28, 161–167.
Clarke, D. and Forborn, K. (2004). Knowledge and application of cognitive behavioral therapy.
Second edition. H. Kaviani (Trans.). Tehran: Sana Publication.
Dadsetan, P. (2009). Psychopathology transition from childhood to adulthood. Vol. I, Tehran:
Organization of Study and Compilation of Humanities Books (SAMT).
Davilson, G. C., Neol, J. M. (2005). Abnormal Psychology. Eith edition. New York: John weily
& sons inc.
Gol Pourchaman Kouhi, R. Amini, M. (2012). The effectiveness of mindfulness-based stress
improving and increasing assertiveness in students with test anxiety. Journal of School
Psychology. Issue 1.
Houghton, K. et al. (2006). Cognitive behavioral therapy. First vol. H. A. Ghasemzadeh (Trans.).
Arjmand Publication.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients
based on the practice of mindfulness meditation Theoretical considerations and preliminary
results. General Hospital Psychiatry, 4, 33-47.
Kabat-Zinn, J. (1990). Full Catastrophe living: Using the wisdom of your body and mind to face
stress, pain and illness. New York: Dell.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1949
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
Clinical Psychology: Science & Practice, 10, 144-156.
Kabat-Zinn, J., Lipsorth, L., Burney, R. (1985). The Clinical use of mindfulness meditation for
the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163-190.
Kabat-Zinn, J., Massion, A., Kristeller, J., Paterson, L. (1992). Effectiveness of meditation based
stress reduction program in the treatment of anxiety disorders. American Journal of
Psychiatry, 149, 936-943.
Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, Z., Scharf, M. J., Cropley, T. g., Hosmer, D., &
Bernhard, J. D. (1998). Influence of a mindfulness meditation based stress reduction
intervention on rates on skin clearing in patients. Psychosomatic Medicine, 60, 625-632.
Kaplan, H. and Sadock, B. (2013). A summary of psychiatry and behavioral sciences, clinical
psychiatry. Second edition. H. Rafiei and Kh. Sobhanian. Tehran: Roshd Publication.
Kaplan, K., Coldenberg, D., Galvin-Nadeau, M. (1993). The impact of meditation based stress
reduction program on fibromyalgia. General Hospital Psychiatry, 15, 284-289.
Langer, E. (2005). Well-being: Mindfulness versus positive evaluation. In C. R. Snyder & S. J.
Lopez (Eds.), Handbook of Positive Psychology, (pp.214-230). London: Oxford University
Press.
Langer, E. J. (1989). Mindfulness. New York: Addison-Wesley Publishing.
Langer, E. J., & Moldoveanu, M. (2000). The construct of mindfulness. Journal of Social Issues,
56, 1-9.
Masoumi, F. (2011). Evaluating the effectiveness of training mindfulness in reducing depression
and anxiety, female students in city neighborhoods, master's thesis in clinical psychology,
Faculty of Education and Psychology, University of Isfahan.
Mohmmad Khani, Sh. and Farjad, M. (2009). Relationship between metacognitive beliefs and
thought control strategies with clinical symptoms of obsessive-compulsive. Journal of Clinical
Psychology. Vol. 1, Number 3, pp. 51-35.
Mokammeli, Z. and Abedi, M. R. (2006). The effectiveness of exposure and inhibition of
response to individual and group practices to reduce the symptoms of obsessive-compulsive
disorder. Journal of Psychology. Vol. 5, No. 2, Ss180-169.
Momeni, Kh. and Abedi, M. R. (2003). Clinical appearance of obsessive-compulsive disorder.
Journal of Research in Psychology. Issue 17, pp. 41-56.
Narimani, M. et al. (2011). The effectiveness of mindfulness and emotion regulation training on
psychological and physical well-being of chemical devotees. Journal of Medical Sciences. Vol.
15, No. 2, pp. 118. 107.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1950
Special
May
Issue
2016
INTERNATIONAL JOURNAL OF HUMANITIES AND
CULTURAL STUDIES ISSN 2356-5926
Sadock, B. and Sadock, V. (2012). An introduction to clinical psychiatry. F. Rezaei (Trans.).
Tehran: Arjemand Publication.
Sadock, B. and Sadock, V. (2012). An introduction to clinical psychiatry. N. Pourafkari (Trans.).
Tehran: Azadeh Publication.
Sajjadian, A. et al. (2008). The effects of mindfulness training on the symptoms of obsessivecompulsive disorder among women in Isfahan. Psychology and Education Studies. 9 (1), pp.141127.
Steketee, G. S. (2012). Cognitive Therapy for Obsessive-Compulsive Disorder: A Guide for
Professionals. H. Touzandeh Jani and Kamalpour, N. (Trans.). Mashhad: Astan Quds Razavi
Publication.
Taherkhani, H. et al. (2003). Investigating the effect of yoga in the treatment of obsessivecompulsive patients treated with standard drugs. Journal of Thought and Behavior. 9 (1), pp. 4752.
Wells, A. (2009). A practical guide to meta-cognitive therapy of anxiety and depression. Sh.
Mohammadkhani (Trans.). Tehran: Varayeh Danesh Publication.
http://www.ijhcs.com/index.php/ijhcs/index
Page 1951