شجاعت، خوددلسوزی و ارزش ها در اختلال وسواسی- اجباری
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|38911||2013||6 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Contextual Behavioral Science, Volume 2, Issues 3–4, 15 October 2013, Pages 68–73
Abstract New interventions such as Acceptance and Commitment Therapy (ACT) have shown early promise in the treatment of OCD, focusing on aspects of psychological flexibility including valued living, mindfulness, and committed action. However, research is needed to explore the relationship between the various components of ACT and OCD. The present study sought to investigate the relationship between values (i.e., self-compassion, courage, and the Valued Living Questionnaire [VLQ; the extent to which one has values and is living out values in everyday life]) and OCD severity. Participants (N=115) who self-reported meeting criteria for OCD completed an online survey assessing levels of different values as well as ratings of importance and consistent living within these values. Analyses yielded significant relationships between OCD severity and self-compassion, courage, and the VLQ. A multiple regression analysis revealed the VLQ and courage to be significant predictors of OCD severity. Interpretation of the results and their implications is considered.
1. Introduction Obsessive-Compulsive Disorder (OCD) is characterized by obsessions and/or compulsions that cause marked distress, are time consuming, and significantly interfere with an individual's normal routine, occupational functioning, or usual social activities or relationships with others (American Psychiatric Association, 2000). Interventions such as cognitive behavioral therapy using exposure and response prevention (ERP) and pharmacological treatments have proven to effectively reduce obsessive–compulsive symptoms; yet 20–60% of patients with OCD refuse, dropout, or fail to benefit from treatment (Abramowitz, 2006, Abramowitz et al., 2005, Fisher and Wells, 2005 and Pallanti and Quercioli, 2006). In light of this, further research is needed to improve the treatment of OCD. Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is a relatively new form of therapy that has shown promise as an effective treatment for OCD (Twohig et al., 2010). One of the primary goals of ACT is to help individuals make meaningful, values-based actions in spite of the presence of negative affect. In ACT, the goal is to help the individual increase psychological flexibility and engage in values-guided behavior rather than pursuing a primary goal of controlling one's private events (i.e., escape or avoidance of negative affect). ACT principles may enhance ERP as “exposure from an ACT perspective… is for the purpose of increasing willingness to experience private events, as they are, so the person can live a more valued life (an approach that, ironically, often results in a decrease in negative content)” (p. 11; Twohig, Hayes, & Masuda, 2006). This shift from symptom reduction to what is important to the client (i.e., values) may lead to an increased willingness to exposures (Levitt, Brown, Orsillo, & Barlow, 2004). Thus, values are of interest in OCD treatment and may prove beneficial to improving outcomes and decreasing dropout rates. Wilson and Dufrene (2008) define values as “freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself” (p. 66). Dahl, Plumb, Stewart, and Lundgren (2009) present a similar view adding that one chooses values based behavioral patterns linked to a sense of meaning that can guide behavior over long time periods (e.g., acting caring to a spouse). In addition values are never achieved or completed; rather they provide meaning and direction for behavior. If goals are a destination, then values are a direction. Values are chosen personally and can vary greatly from individual to individual with domains of parenting and friendship important to one person, while spirituality and recreation may be important to another. The role that people's values play in the severity of their anxiety is relatively unknown. A recent study provided evidence that individuals with generalized anxiety disorder (GAD) describe themselves as living more inconsistently from their values compared to non-anxious individuals (Michelson, Lee, Orsillo, & Roemer, 2011). This finding suggests that how closely one is guided by values may play an important role in the level of one's anxiety (or that one's anxiety impacts the extent to which they live according to their values). Values may also play an important role in the treatment of anxiety disorders. Eifert and Forsyth (2005) proposed that values might help those with anxiety reclaim their lives and give them a reason to work to overcome their anxiety. In a recent study of individuals with GAD, Hayes, Orsillo, and Roemer (2010) found that values and acceptance increased in parallel over 16 sessions while worry decreased at a similar rate. By focusing on values rather than anxiety symptom reduction, the energy exerted in treatment is generated from what matters most to people. This leads to the question of whether people with OCD engage in certain values that may help them change the context in which they experience anxiety. Eifert and Forsyth (2005) state that, “some clients find it difficult to focus on what matters to them because their mind tells them anxiety control is what matters” (p. 153). This difficulty in focusing on values could result in their underdevelopment. Pauley and McPherson (2010) give an example of underdevelopment of self-compassion (i.e., a potential value for self-care) in people with depression or anxiety. They state: Although participants reflected at length on the concept of compassion, they did not mention self-compassion until prompted to do so. This finding suggests that individuals with psychological disorders either have not ever had a sense of self-compassion or that this has been lost at some point during their experience of either depression or anxiety (p. 139). OCD sufferers may overlook values that could potentially play a role in their recovery as obsessing and rituals are typically in the service of reducing anxiety and not cultivating functional values. By helping clients move toward values that are intrinsically, positively reinforcing and that produce lasting rather than fleeting reinforcement, their quality of life may be positively affected. Due to potential issues with pliance (e.g., demand characteristics of the session, trying to please the therapist), the typical ACT approach, including ACT for OCD, (Twohig, 2004 and Twohig, 2009) does not suggest the therapist provide examples of values that may be functional when living with OCD. While there are many studies that have examined the relationship between OCD and quality of life (cf. Norberg, Calamari, Cohen, & Riemann, 2008), there is no research that has examined the relationship between OCD and values. Many current studies investigating values use the Valued Living Questionnaire (VLQ; Wilson, Sandoz, Kitchens, & Roberts, 2011) to identify clients' values as well as discrepancies between values and their actual lifestyle. The VLQ addresses many life domains (e.g., family, education, spirituality) which may motivate behavior. However, we propose that valuing certain personal characteristics also may be important for individuals with OCD as they have the potential to increase contextually motivated behavior. Specifically, we hypothesize that valuing the characteristic of self-compassion may increase acceptance and contact with the present moment and that valuing courage may lead to committed action in the face of unwanted private events. We will outline these relationships below. Self-compassion is essentially compassion toward oneself. A person acting in the service of self-compassion is able to turn compassionate feelings inward with care, kindness, and the desire to help oneself. According to Neff (2003a), self-compassion entails three main components: (a) self-kindness—being kind and understanding toward oneself in instances of pain or failure rather than being harshly self-critical, (b) common humanity—perceiving one's experiences as part of the larger human experience rather than seeing them as separating and isolating, and (c) mindfulness—holding painful thoughts and feelings in balanced awareness rather than over-identifying with them. Acting with self-compassion has been shown to be related to psychological health and flexibility. In fact Raes (2010) hypothesized that self-compassion may counteract dysfunctional repetitive thinking (e.g., depressive ruminations and worrying) and another study found self-compassion to be positively related to happiness, optimism, and positive affect and negatively associated with neuroticism (Neff, Rude, & Kirkpatrick, 2007). Self-compassion has been shown to help buffer against anxiety and is associated with increased psychological well-being (Neff et al., 2007). There is also evidence that self-compassion is a better predictor of symptom severity and quality of life than mindfulness in people with anxiety and depression (Van Dam, Sheppard, Forsyth, & Earleywine, 2011). Further, Thompson and Waltz (2008) found a significant negative correlation between self-compassion and avoidance in students who had experienced a traumatic event. Another recent study of individuals with OCD found a significant strong positive correlation (r=.72) between self-compassion and psychological flexibility, indicating that individuals with high levels of self-compassion are less avoidant and more psychologically flexible ( Wetterneck, Steinberg, Little, Phillips, & Hart, 2012). Self-compassion may be specifically useful for symptom dimensions of OCD that relate to one's moral character and shame about one's thoughts. For example, many with OCD believe they will be responsible for harm to others either indirectly (e.g., accidentally causing harm by being careless, contaminating an object that others will encounter) or directly (e.g., molesting their own child, stabbing a loved one). The capacity to observe these experiences with self-kindness and from an observer perspective may help one to better cope with these shaming thoughts, rather than over-identifying and becoming fused with them. This proposed increase in psychological flexibility would allow one to focus effort on moving toward values rather than focusing on symptom reduction, resulting in greater functioning. Based on these findings, we posit that self-compassion will be inversely correlated with OCD severity. Acting in the service of courage is another area that has received limited research attention. Woodard and Pury (2007) suggest that the lack of research on courage may be attributed to difficulties in establishing a clear and concise definition of the construct. They provide the following definition of courage: “the voluntary willingness to act, with or without varying levels of fear, in response to a threat to achieve an important, perhaps moral, outcome or goal” (p. 136). Similarly, Rate, Clarke, Lindsay, and Sternberg (2007) conceptualize courage as: (a) a willful, intentional act, (b) executed after mindful deliberation, (c) involving objective substantial risk to the actor, (d) primarily motivated to bring about a noble good or worthy end, (e) despite the presence of the emotion of fear. Further, Rate and colleagues' delineation that courageous acts are performed despite the presence of fear elucidates why courage may be an important construct for those with elevated anxiety. Hannah, Sweeney, and Lester (2007) propose that courage is related to personality traits such as openness to experience, hope, and resiliency. These traits have been shown to negatively correlate with OCD symptoms ( Hjemdal et al., 2011, Lysaker et al., 2006 and Wetterneck et al., 2011). As conceptualized, engaging in courageous behavior would be of great potential benefit to those participating in exposure-based therapies for several reasons. The aversive nature of ERP requires an individual to willfully expose themselves to fears in an attempt to reduce future suffering and/or live a more valued life. It seems likely that individuals with higher levels of courage would more successfully engage in exposure therapies, resulting in better outcomes. Courage may also play an important role in moving toward chosen values. Once an individual has successfully identified meaningful values he or she then faces the often arduous task of behaving in a manner consistent with these values. Courage may be the difference between simply identifying values and truly living a life that is in accordance with them. Increased courage may improve the likelihood of committed action in the face of unwanted private events, perhaps functioning as an establishing operation that leads to actions in the service of valued living. For example, a woman with OCD fears of contamination who has identified with the value of being a caring, loving mother to her children would greatly benefit from acting in a courageous manner in order to behave in ways that are consistent with her value. Actions such as working to provide for her children, taking her children to social events, or providing them with physical affection may be avoided due to the anxiety and discomfort that is associated with them. In her case, acting courageously may help orient her toward being more psychologically flexible, increasing the likelihood of making the bold moves and committed action that may at times be required to live a values consistent life despite these negative feelings. Thus, we predict courage to be negatively correlated with OCD severity. Valued behavior in the service of courage and self-compassion may have the potential to transform the function of unpleasant stimuli into something more tolerable. For example, a man with intrusive violent thoughts may avoid situations that could be in line with his values (e.g., social functions, family, and/or work). Yet, if he could learn to pursue courage or self-compassion (i.e., act courageously or treat oneself with compassion), it could change the context in which he perceives and responds to his OCD symptoms, therefore making it more likely to embrace rather than avoid or merely tolerate his private events. His perspective may change from only anticipating fear and anxiety in these situations to viewing them as opportunities to act in courageous or self-compassionate ways. This change in perspective would have the effect of increasing his psychological flexibility in these situations allowing him to increase acceptance and committed action toward a values driven life. The current study aims to examine if people with OCD show deficits in the specific values of self-compassion and courage, and the extent to which they are living in accordance with their overall values. Further, it attempts to explore the relationship between OCD severity and one's overall valued living as well as the personal values of self-compassion and courage. We hypothesize that valued living in general and specific values of self-compassion and courage will be significantly inversely related to OCD severity. In addition, we aim to explore these constructs to better determine if they may be useful targets in treating OCD.
نتیجه گیری انگلیسی
3. Results Mean scores for each of the measures are presented in Table 1. In regard to OCD severity, findings from both the Y-BOCS-SR and the OCI-R indicate that on average the participants had moderate, clinical levels of OCD. The sample endorsed below average self-compassion scores, based on Neff's (2003b) classification. For the overall VLQ, participants rated their values as moderately important (M=6.16) and reported to moderately pursue their values in a consistent manner (M=5.73). Although there are no designated cutoffs for the courage measure, the mean scores also hold some utility in better understanding the current participants' courage levels, which were rated as slightly below average. Table 1. Mean scores for measures. Mean sd Y-BOCS-SR total 20.98 7.37 OCI-R total 28.15 14.71 SCS total 2.26 .65 Courage total 43.97 14.09 VLQ composite 37.30 19.46 Table options Results from Pearson's correlations are presented in Table 2. The findings indicated significant inverse relationships between the VLQ, courage, and self-compassion and OCD severity. These significant negative correlations between the different values and the Y-BOCS-SR support our hypotheses of relationships between low levels of values and high OCD severity. Table 2. Correlations between OCD severity and values measures. 1 2 3 4 1. Y-BOCS-SR total 1 2. SCS total −.30⁎ 1 3. Courage total −.45⁎ .33⁎ 1 4. VLQ composite −.47⁎ .29⁎ .44⁎ 1 ⁎ p<.01. Table options A subsequent multiple regression was conducted predicting OCD severity from the VLQ, courage, and self-compassion, which were all significantly associated with OCD severity in the prior correlation analysis. Results indicated a statistically significant prediction model, F (3, 111)=16.29, p<.001, with an R2 of .31 and an Adjusted R2 of .29. Evaluation of the main effects indicated that only the VLQ and courage were statistically significant. Results are presented in Table 3. The VLQ and courage were both significant predictors of OCD severity indicating that values in both a global and a specific personal area are potentially important areas to further explore. Table 3. Multiple regression predicting YBOCS scores. β t p VLQ composite −.32 −3.59 <.001 Courage −.27 −2.99 <.01 Self-compassion −.12 −1.35 n.s