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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 90-96

Acceptance and commitment: An intervention for improving family function and emotional problems in informal caregivers of people with severe traumatic brain injury: A randomized clinical trial

1 Department of Clinical Psychology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
2 Department of Biostatistics and Epidemiology, Faculty of Health, Kashan University of Medical Sciences, Kashan, Iran
3 Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran

Date of Submission03-Jan-2022
Date of Decision03-Jul-2022
Date of Acceptance04-Jul-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Zahra Zanjani
Department of Clinical Psychology, School of Medicine, Kashan University of Medical Sciences, Kashan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/atr.atr_4_22

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Background and Objectives: Traumatic brain injury (TBI) is one of the main causes of disability. Since individuals with TBI experience many problems in their daily life, they must be highly supported. Regarding the nature of their problems, their caregivers suffer from many psychological problems. The current study aimed to investigate the effect of group acceptance and commitment therapy (ACT) on the family function, experiential avoidance, and anxiety of the TBI patients' caregivers. Methods: The current study was a randomized clinical trial with waiting list and intervention groups. Forty caregivers of TBI patients who referred to Kashan's Shahid Beheshti Hospital, Iran, since 2017 until 2019 were randomly assigned to the experimental (n = 20) and the waiting list control (n = 20) groups. Both the groups completed a demographic information questionnaire, the Family Assessment Device, the Experiential Avoidance in Caregiving Questionnaire, and the anxiety subscale of the Depression, Anxiety, and Stress Scale in pretest, posttest, 3-month follow-up, and 6-month follow-up. Results: The results of repeated measures analysis of variance showed that ACT program can significantly decrease the anxiety, experiential avoidance, and most of the dimensions of the family functions (P < 0.005). Conclusion: ACT could be utilized to improve the family functions and reduce the experiential avoidance and the anxiety of the TBI patients' caregivers. This trial is registered with the Registry of Clinical Trials: “IRCT20190704044100N1.”

Keywords: Acceptance and commitment therapy, caregivers, experiential avoidance and anxiety, family function, traumatic brain injury

How to cite this article:
Hadavand M, Zanjani Z, Omidi A, Atoof F, Fakharian E. Acceptance and commitment: An intervention for improving family function and emotional problems in informal caregivers of people with severe traumatic brain injury: A randomized clinical trial. Arch Trauma Res 2022;11:90-6

How to cite this URL:
Hadavand M, Zanjani Z, Omidi A, Atoof F, Fakharian E. Acceptance and commitment: An intervention for improving family function and emotional problems in informal caregivers of people with severe traumatic brain injury: A randomized clinical trial. Arch Trauma Res [serial online] 2022 [cited 2022 Nov 30];11:90-6. Available from: https://www.archtrauma.com/text.asp?2022/11/2/90/357563

  Introduction Top

Traumatic brain injury (TBI) is one of the most common head injuries and usually resulted of intense accidents, causing many paralysis and death cases.[1] An average of 1,000,000 individuals in the United States experience TBI yearly and suffer from its consequences. TBI imposes an approximate cost of 40 billion dollars on the health-care systems.[2] According to the studies, Iran is one of the countries with the highest accident incidence rates, and the most damages caused by accident (31%) are related to head, neck, and head injuries.[3] Individuals with TBIs usually suffer from neurological problems, psychological disorders (e.g. anxiety and depression), and skeletal muscles disorders, which may affect their lives for months or years.[4] The disabling nature of TBI makes TBI individuals constantly in need of care and support. For this reason, they become more dependent on the family, and therefore, the family would be excessively pressured by challenges and stress.[2] Therefore, this problem poses challenges for family members of people with TBI and can disturb the balance between family boundaries and roles.[5] Although the many negative effects of TBI on family member, most studies have focused on the problems of TBI patients and few studies have investigated the problems and treatment of family members of TBI individuals.[6] The stress caused by the trauma can severely affect the lives of the patients and their families and these negative psychological effects might worsen if the needs of these individuals take no notice.[7]

It is found that heavy responsibilities of the patients cause the family problems increase and the caregivers do not pay enough attention to their own mental and physical health.[8] Goldstein et al. reported the anxiety of the home caregivers of the patients to be 44%.[9] According to studies, close and long interactions with individuals who suffer from physical or mental problems may lead to anxiety, reduced concentration, chronic fatigue, and sleep disorders.[10] These could increase the risk of being diagnosed with other psychological disorders and might finally increase the occurrence of symptom relapses and pressure the patients and impose more problems on them.[11]

The caregivers of TBI patients encounter intense emotional experiences[12] and sometimes they tend to use maladaptive strategies such as suppressing, controlling, or avoiding the emotional experience.[13] Moreover, the studies have shown that when facing with highly intense emotional situations, a majority of the individuals prefer to use avoidance strategies instead of accepting and solving the problem.[14] According to some theoretical approaches, avoiding of aversive psychological experiences are an important factor in the development and maintenance of many psychological disorders such as anxiety and depression and some research confirmed it.[15],[16] Experiential avoidance is defined as the attempts to escape the negatively appraised thoughts, emotions, memories, and physical sensations. Although this strategy is effective in the short term, it disrupts person's life in the long run.[17]

In 1950, the psychological problems of the caregivers were noticed.[18] Sousa reported that family members of TBI experience many psychological problems.[19] According to the fact that the caregivers of TBI patients are intensely under psychological pressure, it is necessary to pay attention to their problems and treatment, especially about Iranian families that are less supported by the officials than those in Western countries.[20]

Acceptance and commitment therapy (ACT) is one of the psychological treatments that emphasizes the enhancement of quality of life and living a value-driven life.[21] In this approach, it is assumed that instead of making direct efforts to reduce the aversive emotions or thoughts, the individuals need to concentrate on increasing their behavioral efficacy despite experiencing the irritating thoughts and feelings.[22]

Currently, a great body of research has supported the effectiveness of this treatment in a wide range of clinical and nonclinical problems.[23],[24],[25],[26],[27],[28],[29],[30] However, no investigation has examined the effectiveness of ACT on TBI patients' caregivers. Therefore, the current study aims to investigate the effectiveness of ACT on family functions, anxiety, and experiential avoidance in TBI patients' caregivers.

  Methods Top

Trial design

This study was a part of a large parallel-group randomized clinical trial with intervention and waiting list control groups.

Participants and randomization

The population included all of the caregivers of inpatient and outpatient individuals with TBI in Kashan who referred to Kashan's Shahid Beheshti Hospital (Kashan's Trauma Research Center) since 2017 until 2019. Among 92 individuals who were primarily assessed using the anxiety disorders interview schedule (ADIS-IV), 40 individuals were eligible to participate the study according to the inclusion criteria. They were randomly assigned to the waiting list control (n = 20) and the ACT (n = 20) groups [Figure 1]. Randomization was performed using the random numbers generated by the website http://www.randomizer.org/.
Figure 1: CONSORT diagram of the progress through the phases of a parallel randomized trial of two groups (enrolment, intervention allocation, follow-up, and data analysis), CONSORT: Consolidated Standards of Reporting Trials

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Patient selection

The inclusion criteria were having a family member with TBI, being the caregiver of the TBI patient for at least 3 months in a row, being aged between 25 and 50, having at least a secondary school diploma, not being diagnosed with chronic physical conditions (MS, cancer) or severe mental disorders (e.g. psychotic disorders), and having informed consent. The exclusion criteria were absent in the ACT sessions (more than twice), being diagnosed with severe physical or mental illnesses during the study, and the necessity for receiving medication.


After screening the individuals and randomly assign them to the waiting list control and intervention groups, the participants of both the groups completed three questionnaires including the Family Assessment Device (FAD), the Experiential Avoidance in Caregiving Questionnaire (EACQ), and the anxiety subscale of the Depression, Anxiety, and Stress Scale (DASS). The questionnaires also were completed at the end of the program, a 3-month follow-up and a 6-month follow-up by all of the participants and under the supervision of a trained psychologist who was not aware of the allocation of the participants in waiting list control and experimental groups.


To remark the ethical aim, the participants were aware of their whole independence during the plan and their aware consent was received in written form before beginning the study. The questionnaires were completed anonymously by the participants (participant was given encode). This investigation was approved by the Ethics Committee of Kashan University of Medical Sciences “IR.KAUMS.MEDNT.REC.1397.76.”


The therapist was a M.Sc. of clinical psychologist, who had been supervised and trained in the ACT. The therapist received weekly supervision from two clinical psychologist with Ph.D. degree. All of the sessions were audio-recorded and were reviewed weekly by the supervisors who assessed the internal consistency of the intervention.


The intervention group received 10 weekly sessions of ACT that last 1 h each session and run in group format.[31] Treatment was provided to participants at no cost. Each group was composed of five to seven participants.

Waiting list control group

The waiting list control group received their routine care and was contacted by the research team to complete questionnaires at the end of the program, a 3-month follow-up and a 6-month follow-up. After that, they were offered the opportunity to use the ACT intervention following the 6-month follow-up assessment. No placebo was used in this study.


The anxiety disorders interview schedule for diagnostic and statistical manual-IV

The Anxiety Disorders Interview Schedule-IV (ADIS-IV) is a semi-structured clinical interview for the diagnoses of anxiety disorders which assesses mood disorders, somatoform disorders, psychotic disorders and substance use disorders and is utilized for differentiating between the clinical and sub-clinical diagnoses. This scale was developed by Brown et al. in 1994.[32] The clinician severity rating (CSR) of ADIS-IV is scored between 0 (no symptom) to 8 (severely disruptive). In consequential research where ADIS-IV is used, the CSR is utilized as an index for examining the recovery after completing the therapeutic programs and follow-up assessments.[32] The content validity of the Persian version of this scale including the test–retest reliability coefficient has been confirmed to be 0.83.[33]

The depression, anxiety, and stress scale

This scale was developed by Lovibond and Lovibond.[34] The short version of DASS includes 21 items by which the psychological structures of anxiety, depression and stress are examined. According to Lovibond and Lovibond, the internal consistency coefficients (Cronbach's alpha) for depression, anxiety, and stress are 0.91, 0.81, and 0.89 respectively.[34] The 21-item form of DASS has been validated for the Iranian population by Sahebi et al. The test–retest validity coefficient for stress, depression, anxiety, and the total scale is calculated to be 0.80, 0.81, 0.78, and 0.82, respectively.[35]

Family assessment device

FAD is a 60-item questionnaire developed in 1983 by Epstein, Baldwin, and Bishop.[36] This scale can determine the structural, professional, and interactive characteristics of the family and also six dimensions of the family function. Moreover, FAD assesses the ability of the family in coping with the family responsibilities on a 4-point Likert scale: (from strongly agree = 1 to strongly disagree = 4) 36). The validity of FAD was reported in numerous studies.[37] The general validity of the scale was suitable.[38]

Experiential avoidance in caregiving questionnaire

This 15-item scale was designed by Losada et al. in 2014 and consists of three subscales including active avoidant behaviors, intolerance of negative thoughts and emotions toward the relatives, and apprehension concerning negative internal experiences related to caregiving. The internal consistency (Cronbach's alpha) of the total scale was 0.70. The reported Cronbach's alpha for the subscales is as follows: 0.63 for active avoidant behaviors, 0.71 for intolerance of negative thoughts and emotions toward the relatives, and 0.60 for apprehension concerning negative internal experiences related to caregiving.[39] The internal consistency (Cronbach's alpha) of the Persian version EACQ in this study was suitable (α = 0.85).

Data analysis

To assess potential differences between the two groups at baseline, independent t-tests were conducted to compare the groups on all continuous variables. Chi-square test was used for categorical variables and repeated measures analysis of variance was used to evaluate the effects of the group ACT intervention. All analyses were conducted using SPSS (version 25) for Windows (International Business Machines Corporation (IBM)),New York, United States).

  Results Top

The mean age of participants was 32.70 (standard deviation = 3.24) and 100% of the participants in the control group and 80% in the ACT group were female. Groups had no significant difference in terms of their demographic characteristics [Table 1].
Table 1: Comparison of demographic characteristics between the study groups

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Before applying the repeated measures ANOVA, the required preassumptions such as M Box's test, Mauchly's test of sphericity, and Levene's test were considered. According to the results of Levene's test, the necessary pre-assumptions for applying the repeated measures ANOVA for the dependent variables in all the three variables of the control and ACT groups were confirmed (P > 0.05). The Box's M test results were not significant for any of the variables; therefore, the homogeneity of variance–covariance was confirmed between the groups (P > 0.001). Mauchly's test of sphericity for the equality of variance–covariance was not confirmed for any of the variables (P < 0.05); therefore, to analyze the obtained data, the Greenhouse–Geisser tests were applied.

The results showed that groups had no significant difference in the baseline in terms of family function, anxiety, and experimental avoidance, but they indicated a significant difference on posttest and first and second follow-up (P < 0.05). The ACT group had a downward trend from the pretest to posttest. However, there was a slight increase in the follow-up time. The results indicated that although groups didn't have difference in baseline anxiety, they had a significant difference in the later stages [Table 2] and [Table 3]. As shown in [Table 3], the highest score of anxiety was for the second follow-up of the control group and the lowest scores belonged to the posttest assessments of the ACT group.
Table 2: The mean, standard deviation and comparison of the family function subscales in two groups according to the assessment stages

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Table 3: The mean, standard deviation and comparison of the experiential avoidance and anxiety for the acceptance and commitment therapy and control group according to the assessment stages

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The results of the repeated measures ANOVA for all of the variables of the study are shown in [Table 4]. These results demonstrated that group effect was significant in all components of family functions except the components of roles and behavioral control (P > 0.05). Furthermore, the analysis of experiential avoidance scores revealed a significant time × group for the first and third factors (P < 0.05). The results of analysis of the anxiety scores also indicated a significant effect of group, time, and time × group. Therefore, ACT has significantly affected the severity of anxiety levels (P < 0.05).
Table 4: The results of the repeated measures ANOVA for examining the effectiveness of acceptance and commitment therapy on the family function, experiential avoidance and anxiety of the traumatic brain injury patients' caregivers

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  Discussion Top

The current study aimed to assess the effectiveness of the group ACT on the family functions, anxiety, and experiential avoidance of the TBI patients' caregivers. In general, the results of this study indicated that ACT can significantly improve the anxiety, experiential avoidance, and most of the dimensions of the family functions. The findings of this study were in line with a number of studies which had demonstrated that other kinds of psychotherapies could significantly reduce anxiety, experiential avoidance and the family functions of the TBI patients' caregivers.[27],[28],[29]

TBI patients' families, due to their problems with the TBI patients, keep experiencing disturbance and unbalance in their family functions. By centralizing the families on clarifying and reaffirming the values, identifying the challenging situations and urging the families, ACT plays a remarkable role in making effective changes to improve the family functions.[40] One of the therapeutic principles in ACT is focusing on the diffusion of the tension provoking situations. By this technique, TBI patients' caregivers learn observe situations without judgment instead of engaging in emotional states experienced this situations and the psychological problems related to it.[41] Therefore, this principle could improve the efficacy and functioning of the families and individuals.[26]

The possible explanations for the mechanisms through which ACT has reduced experiential avoidance, could be offered by mentioning that the ACT theoreticians believe that the experienced distress by the individuals roots in their cognitive inflexibility which has been generated by the cognitive fusion and experiential avoidance. According to what was mentioned, the tendency to avoid the distressing situations is a cause of the formation and maintenance of the psychological problems.[42] By changing the relationship between the disturbing thoughts and feelings, ACT paves the way for the individuals to revise their reactions after understanding the harmless nature of this relationship.[43] Instead of instructing the individuals to use more strategies for altering or reducing the unwanted thoughts and feelings, ACT prepares them to skillfully become aware of their negative thoughts and feelings, and to observe them as they are.[44]

The other finding of the current research was that ACT led to reductions in anxiety levels of the TBI caregivers. It seems that ACT through broadening the capacity of the individual's psychological acceptance of the mental experiences, encourages the individuals to make more efforts and decrease their anxiety levels, and this, is a step toward enhancements in mental health. To clarify the findings of this study, it could be mentioned that in this treatment, instead of emphasizing the importance of exposure, what has been highlighted is the tendency of the individuals to accept their internal experiences as they are. They are also taught to only experience their anxiety-provoking thoughts and avoid fighting or struggling with them; and instead get involved in the activities that contain their life values. After experiencing the therapeutic effects of ACT and by separating themselves from the tense struggles and the unpleasant inner circumstances, the clients can finally experience being in the present moment. This ability can get them independent from their displeasing reactions, memories, and thoughts.[45]

  Conclusion Top

ACT can be a suitable option for increasing family function and decreasing the psychological problems caused by the trauma of the TBI patients in their caregivers. However, it seems that more sessions are needed to reduce the impairments in two of the components of the family functions (roles and behavioral control).


The limitations of this study included using self-report scales, and the fact that only female participants were recruited. Therefore, the results should be generalized cautiously. The small sample size was another limitation of the present study.


We would like to thank the staffs and clients of mental health centers in Kashan for their cooperation. This trial is registered with the Iranian Registry of Clinical Trials: IRCT20190704044100N1.

Financial support and sponsorship

This trial was supported by Kashan University of Medical Sciences, Vice Chancellor for Research and Technology (GR: 97117).

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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