A Comparative Study of the Effectiveness of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy on Referential Thoughts, Cognitive Flexibility, and Distress Tolerance in Patients with Major Depressive Disorder
Keywords:
Cognitive behavioral therapy, Argumentative thoughts, cognitive flexibility, Distress tolerance, major depressive disorderAbstract
Objective: This study aimed to compare the effectiveness of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) on referential thoughts, cognitive flexibility, and distress tolerance in patients with Major Depressive Disorder (MDD).
Methodology: The research employed a quasi-experimental pretest-posttest design with a control group. The statistical population consisted of patients with MDD referred to psychological clinics in Tehran in 2025. A total of 45 participants were selected using a convenience sampling method and randomly assigned to three groups of 15: CBT, ACT, and control. Data were collected using the Perseverative Thinking Questionnaire (Ehring et al.), the Cognitive Flexibility Inventory (Dennis & Vander Wal, 2010), and the Distress Tolerance Scale (Simons & Gaher, 2005). The CBT protocol was based on Wilhelm and Steketee (2006), and the ACT intervention followed Dahl et al. (2014), each conducted in eight sessions. Data were analyzed using multivariate analysis of covariance (MANCOVA) via SPSS version 24.
Findings: The results revealed significant differences among the three groups in referential thoughts, cognitive flexibility, and distress tolerance (p<0.05). Both CBT and ACT interventions significantly reduced referential thoughts and enhanced cognitive flexibility and distress tolerance compared to the control group. However, CBT demonstrated greater overall effectiveness in improving these variables than ACT.
Conclusion: Both CBT and ACT effectively improved cognitive and emotional indicators among patients with MDD. These therapeutic approaches, by restructuring maladaptive thoughts and enhancing psychological acceptance, can promote cognitive flexibility and distress tolerance. Hence, cognitive-behavioral therapy, in particular, is recommended as an effective psychological intervention for individuals suffering from major depressive disorder.
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Aghili, S. M., & Khoshbakht, F. (2025). The effectiveness of acceptance and commitment therapy on depression, perfectionism, and blood glucose levels in type 2 diabetic patients with psychological and physical anhedonia. Clinical Psychology Achievements, 11(1), 53-69. https://jacp.scu.ac.ir/article_19842.html?lang=en
Ayhan, M. O., & Kavak Budak, F. (2021). The correlation between mindfulness and negative automatic thoughts in depression patients. Perspectives in psychiatric care, 57(4), 1944-1949. https://doi.org/10.1111/ppc.12637
Baniasadi, K., Gerdooie, R., Gorji, M., Shahbazi, G., Babaahmadi, F., Ghafourian, G., & Pourmohammad Ghouchani, K. (2025). Comparison of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy on Enhancing Resilience, Cognitive Flexibility, and Distress Tolerance in Adolescents with Obsessive-Compulsive Disorder. Journal of Adolescent and Youth Psychological Studies (JAYPS), 6(6), 1-10. https://doi.org/10.61838/kman.jayps.6.6.6
Barooti, M., Chin Aveh, M., & Saadi, S. (2023). Comparing the Effectiveness of Schema Therapy and Cognitive Behavioral Therapy on Cognitive Flexibility and Negative Automatic Thoughts in Patients with Major Depression. Journal of Disability Studies, 13, 45. https://sid.ir/paper/1447316/fa
Bernstein, D. P., Keulen-de Vos, M., Clercx, M., De Vogel, V., Kersten, G. C., Lancel, M., & Arntz, A. (2021). Schema therapy for violent PD offenders: a randomized clinical trial. Psychological medicine, 1-15. https://doi.org/10.1017/S0033291721001161
Chang, C. Y., Panjaburee, P., Lin, H. C., Lai, C. L., & Hwang, G. H. (2021). Effects of online strategies on students' learning performance, self-efficacy, self-regulation and critical thinking in university online courses. Educational Technology Research and Development, 70(1), 185-204. https://doi.org/10.1007/s11423-021-10071-y
Chen, Y., Zhang, X., & Wang, L. (2023). Reducing worry in depression: A comparison of schema therapy and cognitive-behavioral therapy
Fries, G. R., Saldana, V. A., Finnstein, J., & Rein, T. (2023). Molecular pathways of major depressive disorder converge on the synapse. Molecular Psychiatry, 28(1), 284-297. https://doi.org/10.1038/s41380-022-01806-1
Garcia, M., Rodriguez, L., & Fernandez, A. (2022). Cognitive-behavioral therapy and schema therapy: Effects on referential thoughts
Jafarzadeh, Z., Seyed Abdolmajid, B., & Shahbazi Zadeh, F. (2022). The Effectiveness of Schema Therapy on Cognitive Emotion Regulation, Cognitive Flexibility, and Maladaptive Worry Strategies in Patients with Depression Disorder. Pars Medical Sciences Journal, 20(3), 9-16. https://jmj.jums.ac.ir/article_701639_en.html
Ji, J. L., Murphy, F. C., Grafton, B., MacLeod, C., & Holmes, E. A. (2022). Emotional mental imagery generation during spontaneous future thinking: relationship with optimism and negative mood. Psychological Research, 86(2), 617-626. https://doi.org/10.1007/s00426-021-01501-w
Karimi, M., Bahrami, F., Amini, K., & Sadeghi, S. (2021). The Effectiveness of Schema Therapy in Reducing Negative Thoughts: A Comparison with Cognitive Behavioral Therapy. Scientific Quarterly Journal of Tehran University, 8(3), 58-72.
Karyotaki, E., Efthimiou, O., Miguel, C., genannt Bermpohl, F. M., Furukawa, T. A., Cuijpers, P., & Forsell, Y. (2021). Internet-based cognitive behavioral therapy for depression: a systematic review and individual patient data network meta-analysis. JAMA Psychiatry, 78(4), 361-371. https://doi.org/10.1001/jamapsychiatry.2020.4364
Katayama, N., Nakagawa, A., Umeda, S., Terasawa, Y., Abe, T., Kurata, C., & Mimura, M. (2022). Cognitive behavioral therapy effects on frontopolar cortex function during future thinking in major depressive disorder: A randomized clinical trial. Journal of affective disorders, 298, 644-655. https://doi.org/10.1016/j.jad.2021.11.034
Kim, H., Choi, Y., & Jung, S. (2023). A comparative analysis of cognitive-behavioral therapy and schema therapy on negative thoughts in major depressive disorder
Lee, S., Kim, J., & Park, H. (2021). Impact of cognitive-behavioral therapy and schema therapy on negative thoughts in depression. University of Tokyo.
Lipsett, M., & Berkman, E. (2025). A randomized controlled trial of an acceptance and commitment therapy-informed diabetes prevention program reduces body shame and distress. Health Psychology, 44(5), 549. https://doi.org/10.1037/hea0001434
Pacheco, C. S., & Herrera, C. I. (2021). A conceptual proposal and operational definitions of the cognitive processes of complex thinking. Thinking Skills and Creativity, 39, 100794. https://doi.org/10.1016/j.tsc.2021.100794
Peeters, N., van Passel, B., & Krans, J. (2022). The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda. British Journal of Clinical Psychology, 61(3), 579-597. https://doi.org/10.1111/bjc.12324
Pilkington, P. D., Spicer, L., & Wilson, M. (2022). Schema therapists' perceptions of the influence of their early maladaptive schemas on therapy. Psychotherapy Research, 1-14. https://doi.org/10.1080/10503307.2022.2038804
Rezaei, A., Jafari, P., Mousavi, S., & Tehrani, M. (2022). Comparing the Effectiveness of Schema Therapy and Cognitive Behavioral Therapy in Reducing Worry and Negative Thoughts. Scientific Quarterly Journal of Isfahan University, 9(4), 110-125.
Sohrabnejad, S., Mehrabaninasab, M., Nazari, H., Sohrabnejad, A., & Nazari, G. (2025). The Effectiveness of Acceptance and Commitment Therapy on Suicidal Thoughts, Sensation Seeking and, Distress Tolerance among Substance Users. Journal of Basic Research in Medical Sciences, 12(2), 1-10. https://doi.org/10.61186/jbrms.12.2.1
Tavakoli, S., Abbasi, F., Heydari, B., & Akhondzadeh, M. (2024). Comparing the Effectiveness of Cognitive Behavioral Play Therapy and Gestalt Play Therapy on Vandalistic Behaviors, Impulsivity, and Cognitive Flexibility in Aggressive Male Elementary Students. Journal of Assessment and Research in Applied Counseling (JARAC), 6(3), 28-36. https://doi.org/10.61838/kman.jarac.6.3.4
Teng, C., Liu, T., Zhang, N., Zhong, Y., & Wang, C. (2022). Cognitive behavioral therapy may rehabilitate abnormally functional communication pattern among the triple-network in major depressive disorder: a follow-up study. Journal of affective disorders, 304, 28-39. https://doi.org/10.1016/j.jad.2022.02.050
Zarei, R., Firouzbakht, M., Shirazi, T., & Khoshnavis, J. (2024). The Impact of Cognitive Behavioral Therapy and Schema Therapy in Reducing Negative Thoughts and Worry: A Comparative Study. Scientific Quarterly Journal of Tabriz University, 10(2), 95-107.
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Copyright (c) 2025 Mahsa Allahmoradi (Translator); Mina Yaghoobi, Fatemeh Ebrahimi, Kamran Pourmohammad Ghouchani, Zahra Norouziani (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
