Effectiveness of Mindfulness-Based Compassion Therapy on Despair and Rumination in Older Adults

Kalatian, Marjan; Salehzadeh, Maryam; Bakhshayesh, AliReza

doi:10.18502/ehj.v8i1.9954

Volume 8, Issue 1 (June 2022) Elderly Health Journal 2022, 8(1): 43-48 | Back to browse issues page

‎ 10.18502/ehj.v8i1.9954

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Kalatian M, Salehzadeh M, Bakhshayesh A. Effectiveness of Mindfulness-Based Compassion Therapy on Despair and Rumination in Older Adults. Elderly Health Journal 2022; 8 (1) :43-48
URL: http://ehj.ssu.ac.ir/article-1-254-en.html

Effectiveness of Mindfulness-Based Compassion Therapy on Despair and Rumination in Older Adults

Marjan Kalatian ^*

, Maryam Salehzadeh

, AliReza Bakhshayesh

Department of Psychology, Yazd University, Yazd, Iran , kalatianmarjan@gmail.com

Keywords: Compassion, Mindfulness, Hopelessness, Rumination, Female Elderly

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Effectiveness of Mindfulness-Based Compassion Therapy on Despair and Rumination in Older Adults

Marjan Kalatian^*1, Maryam Salehzade¹, Alireza Bakhshayesh¹

Department of Psychology, Yazd University, Yazd, Iran

Article history
Received 28 Jan 2022
Accepted 26 Jun 2022

A B S T R A C T

Introduction: Hopelessness and negative rumination are among issues the older adults cope with it. Examining effective therapy strategies to decrease them are of great importance. The current study was conducted with regard to understanding the importance of this issue. It aims at examining the effectiveness of mindfulness-based compassion therapy on hopelessness and rumination among the female elderly.

Methods: It was a semi-experimental study with pre-test and post-test and a control group. Statistical population was 70 elderly females of over 60 and above in nursing home in Bojnurd City, North Khorasan Province, Iran, in 2020. Among these people, 30 individuals willing to participate in the study were introduced by the center’s psychologist and randomly assigned into two experimental (15) and control (15) groups. Instrument for collecting data was Beck Hopelessness Scale and Hooksma rumination questionnaire. Data obtained from the questionnaires were analyzed by the covariance analysis test.

Results: Results suggested that mindfulness-based compassion therapy led to a significant decrease on mean scores of hopelessness regarding the experimental group in comparison with the control group (p < 0.01). However, it did not have a significant effect on rumination.

Conclusion: Mindfulness-based compassion therapy may be used for decrease of hopelessness regarding aging, but it is not effective for rumination.

Keywords: Compassion, Mindfulness, Hopelessness, Rumination, Female Elderly

Copyright © 2022 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite.

Introduction

    Old age is not always ideal and soothing and the elderly undergo a great deal of hopelessness in this period (1). Hopelessness is a negative feeling happening frequently among the older adults and is usually related to the failure of doing the activities they can’t deal with as they did when they were younger (2).They soon stop working due to fear of failure (3). Old age is accompanied by feeling of rejection, depression, decrease of mood and social interaction and waiting for death (4). They feel hopeless about many things and are emotionally offended and discouraged (5). Hopelessness is among the most important factors predicting depression especially among the elderly (6, 7). Hopelessness is also a feature of depression during which the person feels incompetent and worthless (8-10). It negatively affects the feeling of functionality, self-esteem, suitable interaction with others, achieving life goals and finally, leads to depression (2, 11, 12). Therefore, hopelessness is a common problem among the elderly accompanied by serious and inevitable consequences. To decrease them, it is essential that various educational and therapeutic programs be considered.
    Another variable increasingly considered in recent years as an important and effective component on depression is rumination. Rumination is distinguishable from other cognitive processes and products such as negative automatic thoughts, self-focused attention, personal awareness and worry (13). Rumination is defined as an intellectual style with features like repetitive, recurrent, disturbing, and uncontrollable thoughts (14) that distract the person's attention from given issues and current goals. Rumination blocks adaptive solving problem and, finally, leads to the increase of negative thoughts (15). These thoughts cause abnormality in the people’ cognitive underpinnings and may lead to mental incompatibility, negative feelings like anger and stress (16), psychological and emotional distress, worry, negative metacognitive beliefs (17) and decrease of mental-social abilities among the elderly (14). So, rumination and hopelessness are two concerns among the elderly. According to their physical-psychological consequences, the necessity of planning suitable psychological interventions in this regard is obvious. One new therapy that can be useful in this context is compassion-focused therapy accompanied by mindfulness (14).
    Compassion is self - and others’ non-judgmental perception, self- and others’ non-conditional acceptance and finally, self and others’ forgiveness and a method to encounter pain and suffering. This can lead to the improvement of the quality of social communication and inter-personal intimacy (18) and understanding evolutionary framework of the elderly’s challenges (20). Mindfulness is also non-judgmental and a balanced feeling of awareness that helps to see clearly and accept emotional and physical changes as they happen. It is a way to decrease negative emotions (stress, anxiety) by breathing and thinking (20). Research indicated that mindfulness led to decrease of psychological distress and anxiety symptoms (20) and improvement of mental, physical, emotional, spiritual and self-efficacy welfare (21). Moreover, it decreases depression symptoms of the elderly females (9, 10). On the other hand, studies demonstrated that compassion-based therapy is effective on the ability to tolerate ambiguity and death’ anxiety (22); hence, it can be said that mindfulness-based compassion therapy plays a key role on decrease of hopelessness and rumination among the elderly while the issue was not much considered in previous studies. Overall, one can say that rumination and depression symptoms are interrelated (13) and their combination leads to various non-compensatory consequences such as suicidal thoughts. With regard to their prevalence among the elderly (3), investigating effectiveness of suitable therapeutic models is very important; therefore, the current study, by understanding the importance of the issue, seeks to answer if mindfulness-based compassion therapy is effective on decrease of hopelessness and rumination among the elderly.

Method
Study design and participants
    Current study is an applied one that was done by semi-experimental in 2020. The statistical population of the study was all the old people residing in nursing home of Bojnord, North Khorasan Province, Iran. In the center, there were 70 elderly females. Among them, 30 individuals who volunteered to participate in the study were introduced by the center’s psychologist. They were randomly assigned into two experimental (15) and control (15) groups.
    Willingness to participate in the study, ability to speak Persian (with regard to being multi-language), non-addiction to drugs, cigarette, etc., and lack of psychological disorders (amnesia, dementia, Alzheimer), relative motor and speech ability and not having sensory-motor diseases were the inclusion criteria of the study. Lack of cooperation to answer questions, experiencing undesirable conditions during therapy or hospitalization, and being absent more than one week were the exclusion criteria.
Instruments
    Beck Hopelessness Scale (BHS): The questionnaire was developed by Aaron T Beck in 1979. It is a 20-item scale with true (0) or false (1) answers. The scale assesses three aspects of hopelessness: Person’s feeling toward future (questions 1, 4, 6, 10, 13, 15 and 19), lack of motivation (questions 2, 3, 9, 11, 12, 16, 17 and 20) and expectations (5, 7, 8, and 14). It is designed for people from 18- to 80. A Chronbach’s Alpha of 0.96 was reported by the designer. In Iran, Gharayi in his study, while obtaining face and content validity by retest method equal to original model, obtained the scale reliability as 0.93 (23). In the current study, the Chronbach’ Alpha coefficient was 0.82.
    Rumination questionnaire: It is a 22-item scale developed by Nolen-Hoeksema et al. in 1991. The questionnaire assesses three aspects of rumination: distraction (questions 1, 2, 3, 4, 6, 8, 9, 14, 17, 18, 19 and 22), contemplation (questions 7, 11, 12, 20 and 21), and self-immersion (questions 5, 10, 13, 15 and 16). Questions are scored based on a 4-point Likert scale (newer = 1, sometimes = 2, often = 3, always = 4). In the test, the range is between 22 and 88 (cut point = 55). The scale's credibility is between 0.88 and 0.92 regarding Chronbach’ alpha coefficient. This suggests high internal consistency of the scale. To assess validity, intra-class consistency was reported as 0.75. Also, retest correlation for the time period of more than 12 months was reported as 0.67 (24). Also, in a study by Hooshi et al., the given questionnaire was validated and done among Iranian aged population (25). In another Iranian study that was done among older adults, Chronbach’ alpha was reported as 0.90. In the present study also Chronbach’ alpha coefficient was obtained as 0.90.
Intervention
    Eight 90-minute group sessions were assigned for the experimental group. Therapy method was based on the compassion therapy package (9, 24), compassion-focused therapy book (18, 20) along with mindfulness exercises (23), and their summary which are provided in the following:
    First session: Conceptualizing self-compassion training
    Second session: Mindfulness training along with respiration and physical examination exercise, familiarity with the concept of depression and hopelessness and coping with them.
    Third session: Compassion toward others, growing warm feelings, self-kindness, understanding the fact that others have also problems and deficiencies, being mindful of a, the effect of mindfulness on breathing on facilitate the possibility of increased focus.
    Forth session: Self-consciousness and examining one's personality as a person with or without compassion, compassionate mind development exercises, forgiveness training, the importance of living in the moment, and how to free mind from past and future concerns and regrets.
    Fifth session: Exercises for compassionate mind development and problem acceptance training.
   Sixth session: Practical exercises to make a compassionate imagination, training methods to express compassion and apply the methods in daily life.
    Seventh session: Writing compassionate letters for oneself and others, daily recording, considering a compassionate-based real setting, and self-care.
    Eighth session: Training and exercising skills and conclusion.
Statistical analysis
    For data analysis, the authors used statistics and covariance analysis indices by SPSS-24 software.
Intervention
    Eight 90-minute group sessions were assigned for the experimental group. Therapy method was based on the compassion therapy package (9), compassion-focused therapy book (20) along with mindfulness exercises (26), and their summary which are provided in the following:
    First session: Conceptualizing self-compassion training
    Second session: Mindfulness training along with respiration and physical examination exercise, familiarity with the concept of depression and hopelessness and coping with them.
    Third session: Compassion toward others, growing warm feelings, self-kindness, understanding the fact that others have also problems and deficiencies, being mindful of a, the effect of mindfulness on breathing on facilitate the possibility of increased focus.
    Forth session: Self-consciousness and examining one's personality as a person with or without compassion, compassionate mind development exercises, forgiveness training, the importance of living in the moment, and how-to free mind from past and future concerns and regrets.
    Fifth session: Exercises for compassionate mind development and problem acceptance training.
   Sixth session: Practical exercises to make a compassionate imagination, training methods to express compassion and apply the methods in daily life.
    Seventh session: Writing compassionate letters for oneself and others, daily recording, considering a compassionate-based real setting, and self-care.
    Eighth session: Training and exercising skills and conclusion.
Ethical Considerations
    To observe ethical consideration, all participants were attended into the study with informed consent; they were free to exit the study whenever they want.
    All participants in the study received codes and their names and characteristics were not archived. Furthermore, the current study was conducted by receiving ethics code with number IR.YAZD.REC.1400.038 from University of Yazd.

Results
    This study was performed on thirty elderly females > 60 years old in a nursing home in Bojnord. Two individuals among them were retired and others did not receive salary from any entity.
    Mean age of participants was 77.93 (6.22) and the education level of them was as academic 3.3%, high school and diploma 6.6%, elementary 53.3% and illiterate 36.6% and 93.3% lived alone because of spouse death and only 3.3% were married.
    To test the study's hypothesis, multivariable covariance analysis was used, results of which are presented in table 1.
    Four multivariable covariance analysis tests, “Pilay Effect”, “Wilks lambda”, “Hotling Effect”, and “the Largest Root” were calculated. The significance level of all four tests (0.001) was less than 0.01. This suggested minimum difference between a dependent variable (hopelessness and rumination) in experimental and control groups. In other words, mindfulness-based compassion therapy had a positive effect at least on one dependent variable.
    Table 2 demonstrates that there is a significant difference between two experimental and control groups in the post-test phase regarding hopelessness among the elderly (p < 0.01), but not rumination (p = 0.456 > 0.01). In general, according to the findings, it can be said that mindfulness-based compassion therapy had a significant effect on hopelessness among the elderly, but not on rumination. With regard to partial eta squared, mindfulness-based compassion therapy can explain 40.2 percent of hopelessness among the elderly. Moreover, results of table 3 indicates that mindfulness-based compassion therapy explains 31.2 percent of the lack of motivation and 28 percent of expectations; however, mindfulness-based compassion therapy does not affect a person’s feeling toward future. As partial eta squared (0.021) revealed, the level of predicting and explaining rumination through mindfulness-based compassion therapy is near zero.
    Table 3 demonstrates that there isn't a significant difference between two experimental and control groups in post-test phase with respect to distraction, contemplation and self-immersion among the elderly (p > 0.01).

Table 1. Multivariable covariance analysis tests

Tests	Value	F	Hypothesis df	Error df	p
Pilay Effect	0.974	335.759	3	27	0.001
Wilks lambda	0.026	335.759	3	27	0.001
Hotling Effect	37.307	335.759	3	27	0.001
Largest Root	37.307	335.759	3	27	0.001

Table 2. Covariance analysis test results regarding effectiveness of mindfulness-based compassion therapy for hopelessness and rumination among the elderly

Variable	Change sources	Total square between groups	df	Mean of squares	F	p	Partial eta squared
Hopelessness	Group	98.591	1	98.591	18.158	0.001	0.402
Hopelessness	Error	146.603	27	5.430	18.158	0.001	0.402
Rumination	Group	11.272	1	11.272	0.573	0.456	0.021
Rumination	Error	530.989	27	19.666	0.573	0.456	0.021

Table 3 Covariance analysis test results regarding effectiveness of mindfulness-based compassion therapy for aspects of hopelessness and rumination among the elderly

Variable		Change sources	Total square between groups	df	Mean of squares	F	p	Partial eta squared
Hopelessness	The person’s feeling toward future	Group	2.548	1	2.548	2.533	0.123	0.086
		Error	27.167	27	1.006
	Lack of motivation	Group	20.028	1	20.028	12.246	0.002	0.312
		Error	44.258	27	1.635
	Expectations	Group	15.144	1	15.144	10.490	0.003	0.280
		Error	38.981	27	1.444
Rumination	Distraction	Group	43.353	1	43.353	4.646	0.40	0.147
		Error	251.924	27	9.331
	Contemplation	Group	1.993	1	1.993	0.623	0.437	0.023
		Error	86.332	27	3.197
	Self-immersion	Group	21.012	1	21.012	5.427	0.28	0.167
		Error	104.543	27	3.872

Discussion
    The purpose of this study is to examine effective therapy strategies to decrease hopelessness and negative rumination among the elderly females. This was carried out by examining the effectiveness of mindfulness-based compassion therapy on hopelessness and rumination among them. As the results illustrated, mindfulness-based compassion therapy is effective on decrease of hopelessness among the elderly; but it doesn’t significantly affect rumination. The obtained findings are consistent with some previous studies (19, 20, 22, 28). At the same time, other studies, such as those by Noorbala et al. (24) and Ghanavati et al. (27) suggested that compassion-based therapy could decrease the level of clients’ rumination, worry, anxiety, and stress. This is inconsistent with the current study.
    To explain the given results, it can be said that aging necessitates preparation. Adjusting to it, therefore, requires special expectations and priorities (28). People with high self-compassion are kind with themselves. Besides, they are more responsible when facing problems and more easily accept life events. Compassion-based therapy, by developing and improving compassion by providing compassion-based techniques, recognizing self-kindness thoughts, and also removing compassion barriers, protect the person against negative feelings and improve and increase positive feelings. As compassion increases, motivation also increases and this, in turn, leads to acceptance of negative thoughts and modifying them (18). Compassionate and mindfulness-based cognitive therapy, by increasing the level of self-compassion, facilitates emotional change for more care and self-support, increases the ability of discomfort acceptance, and decreases emotional distress (3). In addition, compassion-based therapy develops new positive thoughts, emotions and behaviors that are opposite with negative thoughts and emotions accompanied by depression, anxiety and self-criticism. On the other hand, nature and content of exercises of mindfulness-based therapy should be addressed. In these exercises, relaxation, peaceful and compassionate mind, and mindfulness are confirmed. They can play a significant role on the person’s peace and hopelessness especially among the elderly. To increase compassion against effects of negative events, individuals should act as a fighter. People with high self-compassion, have self-assessment, are not hard on themselves, and cope more easily with negative problems in life (22). Therefore, they have more self-compassion, less self-blame and criticism, and decrease their own negative thoughts (19).All of these lead to the decrease of hopelessness and increase of ambiguity tolerance.
    With regard to non-effectiveness of mindfulness-based compassion therapy on the aspects of rumination (distraction, contemplation, and self-immersion) among the elderly, rumination aims at decreasing emotional distress (13) and keeps people in the highest level of emotional wave. When people judge themselves, they hope to resolve their deficiencies and mistakes. In reality, however, they experience higher dysfunctionality and chronic depression (14). On the other hand, mindfulness-based compassion therapy approach, by increasing subjects’ level of self-compassion, can facilitate emotional change for more self-care and support, increase the ability to accept discomforts and decrease emotional distress. In fact, by training emotional self-discipline and emotional control, therapy can help people to adjust with their unsuitable behavior and improve their mental health (18). This is while it has less effect on cognitive and intellectual categories and these aspects have deeper thought roots. Accordingly, its effect is not significant on rumination.

Conclusion
   With regard to the findings, the authors suggest that for the elderly, especially those without a spouse and caregiver, special counseling and support services and suitable therapies and educations be designed and accomplished to decrease problems such as hopelessness. Mindfulness-based compassion therapy is recommended for this purpose.

Study limitations
   One limitation of the current study is that self-report instrument (questionnaire) was merely used. Besides, it is always possible that data obtained from self-report can be affected by social desirability biases and the study's participants may not report their real ideas and behaviors. More objective measurements are recommended for future studies.

Conflict of interest
   There was no conflict of interest. Authors had no financial relationships relevant to this paper. None of the authors received support for this work influencing its outcome.

Acknowledgments
    The authors are most grateful for the assistance given by facilitators and participants.

Authors’ contribution
  Marjan Kalatian, author: article design, draft preparation, article’s review and modification. 60%.
    Maryam Salehzadeh, co-author: Cooperation in the study design and data analysis and interpretation, cooperation in the study's draft preparation and its accurate review and modification. 20%.
    Alireza Bakhshayesh, co-author: Cooperation in the study design and data analysis and interpretation, cooperation in draft preparation and modification. 20%.

References
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2. Kaleta K, Mróz J. The relationship between basic hope and depression: forgiveness as a mediator. Psychiatric Quarterly. 2020; 91(3): 877-86.
3. Rezende MC, Bast DF, Huziwara EM, Bortoloti R. The implicit relational assessment procedure as a measure of hopelessness in the elderly: an exploratory study. The Psychological Record. 2021; 71(2): 313-7.
4. Collado-Navarro C, Navarro-Gil M, Pérez-Aranda A, López del Hoyo Y, Garcia-Campayo J, Montero-Marin J. Effectiveness of mindfulness-based stress reduction and attachment-based compassion therapy for the treatment of depressive, anxious, and adjustment disorders in mental health settings: A randomized controlled trial. Clinical Trials in Depression and Anxiety. 2021; 38(11): 1138-51.
5. Farrokhzadian AS, Mirderekvand F. The effectiveness of self-compassion-focused therapy on increasing psychological well-being and reducing depression in the elderly. Aging Psychology. 2018; 3(4): 293-302. [Persian]
6. Penninx BW. Depression and cardiovascular disease: epidemiological evidence on their linking mechanisms. Neuroscience & Biobehavioral Reviews. 2017; 74(B): 277-86.
7. Dunn SL, Dunn L, Goodyke M, DeVon HA, Vander Berg L, Tintle NL. Abstract P312: high state and trait hopelessness levels predict lower home-based exercise participation in patients with coronary heart disease. Circulation. 2017; 135(suppl_1): 312.
8. Whisman MA, du Pont A, Butterworth P. Longitudinal associations between rumination and depressive symptoms in a probability sample of adults. Journal of Affective Disorders. 2020; 260: 680-6.
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11. Haghdust Z, Mobayen M, Omidi S. The relationship between spiritual experiences and life expectancy and death anxiety in burn patients. Journal of Isfahan Medical School. 2021; 38(598): 811-7.
12. Raphi F, Bani S, Farvareshi M, Hasanpour S, Mirghafourvand M. Effect of hope therapy on psychological well-being of women after abortion: a randomized controlled trial. BMC Psychiatry. 2021; 21(1): 1-10.
13. Watkins E, Roberts H. Reflecting on rumination: consequences, causes, mechanisms and treatment of rumination. Behavior Research and Therapy. 2020; 127: 103573.
14. Smith KE, Mason TB, Lavender JM. Rumination and eating disorder psychopathology: a meta-analysis. Clinical psychology review. 2018; 61: 9-23.
15. Ahmadi ML. Structural relationship of dysfunctional thoughts and rumination with eating disorder symptoms mediated by avoidance performance. Journal of Thought and Behavior in Clinical Psychology. 2019; 14(53): 47-56.
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17. Zemestani M, Mehrabian T, Mosalman M. Prediction of the amount of worrying based on meta-cognitive beliefs and rumination in students. iranian journal of psychiatric nursing. 2016; 4(3): 51-7.
18. Gluschkoff K, Oksman E, Knafo-Noam A, Dobewall H, Hintsa T, Keltikangas-Järvinen L. The early roots of compassion: From child care arrangements to dispositional compassion in adulthood. Personality and Individual Differences. 2018; 129: 28-32.
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25. Hooshi N, Khodabakhshi Koulayi A, Falsafinejad M. The effectiveness of mindfulness-based group counselling on the quality of sleep and rumination among the elderly. Journal of Assessment and Research in Counselling and Psychology. 2020; 2(1): 35-51. [Persian]
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Type of Study: Research | Subject: General
Received: 2022/01/28 | Accepted: 2022/06/26 | Published: 2022/06/29

References

1. Williamson V, Stevelink SA, Greenberg K, Greenberg N. The prevalence of mental health disorders in elderly US military veterans: a meta-analysis and systematic review. The American Journal of Geriatric Psychiatry. 2017; 25(5): 534-45.

2. Kaleta K, Mróz J. The relationship between basic hope and depression: forgiveness as a mediator. Psychiatric Quarterly. 2020; 91(3): 877-86.

3. Rezende MC, Bast DF, Huziwara EM, Bortoloti R. The implicit relational assessment procedure as a measure of hopelessness in the elderly: an exploratory study. The Psychological Record. 2021; 71(2): 313-7.

4. Collado-Navarro C, Navarro-Gil M, Pérez-Aranda A, López del Hoyo Y, Garcia-Campayo J, Montero-Marin J. Effectiveness of mindfulness-based stress reduction and attachment-based compassion therapy for the treatment of depressive, anxious, and adjustment disorders in mental health settings: A randomized controlled trial. Clinical Trials in Depression and Anxiety. 2021; 38(11): 1138-51.

5. Farrokhzadian AS, Mirderekvand F. The effectiveness of self-compassion-focused therapy on increasing psychological well-being and reducing depression in the elderly. Aging Psychology. 2018; 3(4): 293-302. [Persian]

6. Penninx BW. Depression and cardiovascular disease: epidemiological evidence on their linking mechanisms. Neuroscience & Biobehavioral Reviews. 2017; 74(B): 277-86.

7. Dunn SL, Dunn L, Goodyke M, DeVon HA, Vander Berg L, Tintle NL. Abstract P312: high state and trait hopelessness levels predict lower home-based exercise participation in patients with coronary heart disease. Circulation. 2017; 135(suppl_1): 312.

8. Whisman MA, du Pont A, Butterworth P. Longitudinal associations between rumination and depressive symptoms in a probability sample of adults. Journal of Affective Disorders. 2020; 260: 680-6.

9. Kakavand A. The effectiveness of mindfulness on dysfunctional attitudes and depressive symptoms in elderly women with depressive disorder. Aging Psychology. 2016; 2(2): 101-91. [Persian]

10. Tian M, Yan S, Wang N. Evaluating the effectiveness of Snyder's theory-based group hope therapy to improve self-efficacy of university students in finance. NeuroQuantology. 2018; 16(6): 118-24.

11. Haghdust Z, Mobayen M, Omidi S. The relationship between spiritual experiences and life expectancy and death anxiety in burn patients. Journal of Isfahan Medical School. 2021; 38(598): 811-7.

12. Raphi F, Bani S, Farvareshi M, Hasanpour S, Mirghafourvand M. Effect of hope therapy on psychological well-being of women after abortion: a randomized controlled trial. BMC Psychiatry. 2021; 21(1): 1-10.

13. Watkins E, Roberts H. Reflecting on rumination: consequences, causes, mechanisms and treatment of rumination. Behavior Research and Therapy. 2020; 127: 103573.

14. Smith KE, Mason TB, Lavender JM. Rumination and eating disorder psychopathology: a meta-analysis. Clinical psychology review. 2018; 61: 9-23.

15. Ahmadi ML. Structural relationship of dysfunctional thoughts and rumination with eating disorder symptoms mediated by avoidance performance. Journal of Thought and Behavior in Clinical Psychology. 2019; 14(53): 47-56.

16. Raines AM, Vidaurri DN, Portero AK, Schmidt NB. Associations between rumination and obsessive-compulsive symptom dimensions. Personality and Individual Differences. 2017; 13: 63-7.

17. Zemestani M, Mehrabian T, Mosalman M. Prediction of the amount of worrying based on meta-cognitive beliefs and rumination in students. iranian journal of psychiatric nursing. 2016; 4(3): 51-7.

18. Gluschkoff K, Oksman E, Knafo-Noam A, Dobewall H, Hintsa T, Keltikangas-Järvinen L. The early roots of compassion: From child care arrangements to dispositional compassion in adulthood. Personality and Individual Differences. 2018; 129: 28-32.

19. K R. Compassion-focused therapy in simple language. Tehran: Danjeh Publications. 2016.

20. Seabrook E, Kelly R, Foley F, Theiler S, Thomas N, Wadley G, et al. Understanding how virtual reality can support mindfulness practice: mixed methods study. Journal of Medical Internet Research. 2020; 22(3): e16106.

21. Du J, Kerkhof P, van Koningsbruggen GM. The reciprocal relationships between social media self-control failure, mindfulness and wellbeing: A longitudinal study. PloS One. 2021; 16(8): e0255648.

22. Baharvandi B, Kazemianmoghadam K, Haroon Rashidi H. The Effectiveness of Compassion-Focused Therapy on Ambiguity Tolerance and Death Anxiety in the Elderly. Aging Psychology. 2020; 6(1):13-26. [Persian]

23. Aghayousefi A, Kharbu A, Hatami H. The role of rumination on psychological well-being and anxiety the spouses' cancer patients. Quarterly Journal of Health Psychology. 2015; 4(14): 79-97. [Persian]

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25. Hooshi N, Khodabakhshi Koulayi A, Falsafinejad M. The effectiveness of mindfulness-based group counselling on the quality of sleep and rumination among the elderly. Journal of Assessment and Research in Counselling and Psychology. 2020; 2(1): 35-51. [Persian]

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