Volume 8, Issue 1 (February 2021)                   Avicenna J Neuro Psycho Physiology 2021, 8(1): 19-24 | Back to browse issues page

XML Print

Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:

Mohammad Yousefi S, Abbasi G, Emadian S O. Comparison of Effectiveness of Cognitive Behavioral Therapy and Parenting Styles Based on Reality Therapy in Mothers’ Impulse Control, Flexibility, and Empathy. Avicenna J Neuro Psycho Physiology 2021; 8 (1) :19-24
URL: http://ajnpp.umsha.ac.ir/article-1-248-en.html
1- PhD Candidate of Psychology, Sari Branch, Islamic Azad University, Sari, Iran.
2- Assistant Professor, Department of Psychology, Sari Branch, Islamic Azad University, Sari, Iran. , gh_abbasi@iausari.ac.ir
3- Assistant Professor, Department of Psychology, Sari Branch, Islamic Azad University, Sari, Iran.
Full-Text [PDF 1406 kb]   (526 Downloads)     |   Abstract (HTML)  (1445 Views)
Full-Text:   (870 Views)
Mothers play a key role in the growth and learning of their children, and the evidence suggests that the family and home environment and atmosphere are the most effective forces in early childhood learning [1]. Therefore, a healthy and balanced relationship between parents and children is one of the factors affecting their mental health; accordingly, among various factors influencing the development and healthy personality of children and adolescents is the interaction between a child and parent. The ways of interaction are considered the most important and fundamental factors [2]. On the other hand, the socialization of a child should occur within the family which is mainly due to the direct parent-child interaction [3].
Mental disorders have a significant impact on individuals and the family. Depression, anxiety, obsession, aggression, and physical pain are exacerbated by stress, and mothers are more anxious in families with young children. Anxiety is a reaction to an unknown, intrinsic, and ambiguous danger and its origin is unconscious and uncontrolled with many causative factors [4]. Previous studies have usually only examined the effectiveness of cognitive behavioral therapy (CBT) in mothersʼ depression, anxiety, and parenting style, and even most previous studies have only investigated the relationship between these variables in terms of correlation schemes [5, 6]. Therefore, there are many limitations in this regard.
Impulsive behaviors, sometimes referred to as risky behaviors, encompass a wide range of actions behind which there is no thought. Impulsive behaviors are immature with the immediate occurrence and are shown without the ability to focus on a particular task in the absence of proper planning; accordingly, they are high-risk and dangerous [5]. Impulsivity is one of the characteristics of addiction types [5]. Some individuals act impulsively (depending on the trait) in all situations; however, others act impulsively in particular situations [6]. Impulsive behaviors are also displayed by anxious individuals.
Flexibility also means maintaining positive comp-liance despite stressful experiences and achieving
a good recovery after injury or trauma [7]. Psychological flexibility is obtained through six overlapping and interrelated processes, namely acceptance (i.e., the tendency to internalize experiences without attempting to change their frequency or state), cognitive faulting (i.e., the ability to separate thoughts, emotions, physical feelings, and impulses from real situations and choose behaviors fitting the context of the present), consciousness attention (i.e., being perfect at the present moment at all times), self as context (i.e., recognizing that the individual is something beyond his or her inner experiences), values (i.e., personal principles of choice and guidance defining and making sense of one’s life path), and committed action (i.e., behaviors aligning with one’s values and depending on the context in which they are located [8].
In Rosenberg’s view, the best way to control aggression and reduce violence is to cultivate empathic, non-violent, and loving relationships. Empathic and non-violent communication is one of the important emotional abilities the signs of which start in early childhood. Studies have shown that loving and non-violent parenting behaviors and parents’ relationship with children are related to their empathy development. Empathy and non-violent communication are the keys to the formation of non-aggressive and holistic behaviors. In addition, some studies have suggested that there is a positive relationship between non-violent empathy-based communication with self-efficacy and community-based behaviors [9].
Parents are anxious to feel successful and reach the right level of satisfaction. They need to think about the parenting style and effectiveness of their role because parents who are confident in their parenting abilities perform their parenting duties more effectively and have more positive results regarding their children’s development [10]. Parenting styles are child-rearing activities promoting growth in many areas [11]. Tyrannical parenting styles try to shape and control children’s behaviors and attitudes following a set of standards of conduct that are usually absolutist, belief-driven, and exalted [12]. Nevertheless, powerful parents with great support and scrutiny create democratic conditions [13]. The style of parenting is authoritative and resolute but logical, warm, nurturing, and loving. Relaxing parents provide a calm and welcoming environment for their children, have few demands from their children, and have no control over what they do [14].
The CBT, applied in this study, is a combination of cognitive and behavioral approaches helping the patient identify and modify distorted patterns and dysfunctional behaviors. Much of the treatment is based on the here-and-now approach, and the main purpose of the treatment is to help patients make the best changes in their lives. Therefore, this treatment emphasizes providing an opportunity for new adaptive learning as well as making changes outside the clinical setting. The most important goals of CBT include improving the patient’s motivation, training coping skills, changing attitudes, strengthening the control of painful emotions, improving interpersonal functioning, and enhancing social skills [15].
The theory of choice, as a theory explaining human behavior, is a very new perspective. The theory of choice is about human behavior and explains how we, as human beings, choose what we want to achieve. According to this theory, all humans show behaviors and all behaviors are intentional and triggered within individuals. The theory of choice states that due to scientific reasons humans choose all of what they do and feel, including negative feelings, such as anger, anxiety, depression, and misery [16]. Others cannot make us miserable or happy. All of what humans can get or give is information. However, information alone cannot make individuals feel or act. Information enters the human brain; it is processed there, and then an individual decides what to do [17].
The purpose of the present study was to compare the effectiveness of CBT and teaching parenting styles based on reality therapy in mothers’ impulse control, flexibility, and empathy.
Materials and Methods
This quasi-experimental study was carried out with a pre-test and post-test design and experimental and control groups. The statistical population of this study consisted of all the mothers with adolescents of 11-16 years (n=871) in Babol, Mazandaran, Iran, in the first quarter of 2019. In this study, all of the mothers with children of 11-16 years in Babol were chosen as the study population. Furthermore, 269 individuals were selected as a sample by the cluster sampling method according to Krejcie and Morgan Table, and those with a score lower than the cut-off point of the questionnaire were chosen. In the present study, 75 participants were divided into three groups by simple random sampling (25 subjects in the control group, 25 participants in experimental group 1, and 25 cases in experimental group 2). Among the students, 37, 22, and 16 subjects studied humanities, experimental sciences, and mathematics, respectively.
The inclusion criteria were mothers of children within the age range of 11-16 years, participants who were interviewed, filled out the questionnaire, and scored lower than the cut-off point of the questionnaire, and mothers who lived in Babol. The exclusion criteria were 1) disorder or other illness noticed in the individual during education reducing the psychological variables studied in the individual and preventing the treatment and education process, 2) mental problems and components examined in individuals solved during treatment and group training sessions, and 3) individuals not continuing to receive treatment during the treatment and training period and not attending the sessions.
Beck Anxiety Inventory
This questionnaire was designed by Beck in 1990 for the measurement of the level of anxiety with 21 items. Each item is a reflection of the symptoms of anxiety that is usually experienced by clinically anxious individuals or those who are in an anxious state. Each item in the questionnaire has four options, including never, mild, moderate, and severe, with scores of 0, 1, 2, and 3, respectively. The score of the questionnaire is within the range of 0-63. High scores indicate that anxiety is more severe. The scores of 0 to 21 and 26 to 35 show very low and moderate anxiety, respectively. In addition, scores higher than 36 indicate high anxiety and require follow-up and treatment [18]. Beck [18] reported 0.92 for the reliability of the questionnaire. Kaviani and Mousavi [19] reported 0.72, 0.83, and 0.92 for the validity, reliability, and consistency of the questionnaire, respectively.
Impulse Control Questionnaire
This questionnaire (Eleventh Edition) is developed by Ernest Barth et al. in 2004 and is based on Barth’s personality theory with 30 items. The items are graded as four options (multiple-choice) from rarely to almost always, with the highest and lowest scores as 120 and 0, respectively. The cut-off point of the tool is a score of 60. The reliability of Bart’s impulsivity scale was determined by the internal consistency method, and Cronbach’s alpha coefficient formula was used for this purpose. According to the results, Cronbach’s alpha coefficient was 0.77 of the total scores [20]. The validity and reliability of the Persian version of this questionnaire were evaluated by Ekhtiyari et al. [21]. The results indicated that the validity and reliability of the questionnaire were 0.89.
Flexibility Questionnaire
Dennis and Vander Wal developed this questionnaire in 2010 with 10 items. The main psychometric properties of the original version will be discussed. The results of 2,816 participants in six studies showed that this tool had satisfactory reliability, validity, and construct validity. The questionnaire is scored on a 7-point Likert scale based on agreement (1=never to 7=always). The minimum and maximum scores obtained in this questionnaire are 10 and 70, respectively. The cut-off point of the questionnaire is 45. Higher scores indicate greater psychological flexibility [22]. The reliability and internal consistency of the Iranian version of this questionnaire were 0.71 and 0.86, respectively [23].
Empathy Questionnaire
Davis introduced the Empathy Questionnaire in 1983. The questionnaire consists of 21 items and assesses empathy in individuals. The questionnaire is scored based on a 5-point Likert scale and ranged from strongly agree to disagree strongly. The highest and lowest scores in this questionnaire are 105 and 21, respectively. The cut-off point is the score of 55. Davis reported the reliability of the questionnaire using Cronbach’s alpha as 0.81 [24]. The reliability of this tool was 0.71 reported in the Iranian population [25].
After the collection, the data were analyzed using SPSS software (version 22), and descriptive and inferential statistics were analyzed. Mean and standard deviation (SD) indices were used to describe the data. Furthermore, in inferential analysis, after testing the validity of the underlying assumptions, multivariate analysis of covariance was applied. The present study was approved by Islamic Azad University, Sari Branch, with the ethics code of IR.IAU.SARI.REC.1397.037.
The mean (SD) age of the reality therapy, CBT, and control groups were 36.7±7.4, 35.8±7.9, and 35.1±6.7 years, respectively. The two experimental and control groups were similar in age (F=1.17; P>0.05). The following tables show the mean and SD of sexual intimacy in the pre-test and post-test of the experimental and control groups:
As observed in Table 1, the significance levels of all the study variables in both pre-test and post-test phases in the experimental and control groups are higher than the error level of 0.05. Given the number of significance levels, the data distribution is considered to be following the normal distribution.
As Table 2 tabulates, while controlling for the pre- test effect, there is a significant difference between
Table 1. Mean and standard deviation of the scores of dependent variables studied in pre-test and post-test cognitive behavioral therapy and parenting styles based on reality therapy
Post-test Pre-test Statistical variable
Experimental Control Experimental Control
Standard deviation Mean Standard deviation Mean Standard deviation Mean Standard deviation Mean
8.41 24.4 5.86 24.2 6.28 12.2 6.21 25.7 Impulse control Cognitive behavioral therapy
1.36 24.3 7.33 21.6 7.85 21.88 7.65 22.2 Flexibility
9.23 54.3 9.41 33.2 1.06 33.84 1.06 33.6 Empathy
6.96 46.6 5.86 25.2 4.79 26.1 6.21 25.7 Impulse control Parenting education
9.86 45.1 7.33 21.6 6.44 21.3 7.65 22.2 Flexibility
7.87 56.7 9.41 33.2 7.50 32.9 1.06 33.6 Empathy
the post-test scores of the experimental and control groups in terms of impulse control, flexibility, and empathy. Table 2 shows the effect of CBT on
impulse control (F=53.50; P<0.0001), flexibility (F=22.17; P<0.0001), and empathy (F=63.87; P<0.0001).
Table 2. Results of covariance analysis between control and experiment groups regarding impulse control, flexibility, and empathy scores
Eta squared P F MS df SS Source of variance
0.52 0.0001 53.50 2812.50 1 2812.50 Impulse control
0.31 0.0001 22.17 2664.50 1 2664.50 Flexibility
0.57 0.0001 63.87 5554.58 1 5554.58 Empathy

According to the obtained findings of the present study, CBT was effective in controlling the anxious mothers of adolescents within the age range of 11-16 years which is in line with the findings of a study by Whiting et al [24]. It can be concluded that CBT is effective in improving the control of the impulse of anxious mothers. Cognitive restructuring, also known as logical empiricism, helps mothers to use logical reasoning to test the content of their anxiety-filled thoughts against the reality of their own life experiences, identify the flow of thoughts filled with their anxiety, and even test their dominant anxiety thoughts (i.e., testing the reality of the probability of something happening that causes them to be anxious) [14].
Based on the results of the current study, CBT influenced the flexibility of anxious mothers of adolescents within the age range of 11-16 years which is consistent with the findings of studies by Whiting et al. [24] and Raes et al. [22]. This finding suggests that the cognitive behavioral approach to anxious mothers, who often have cognitive errors, irrational beliefs, and destructive beliefs in their lives, has led to increasing the individuals’ awareness of documents and irrational beliefs. In addition, conducting training sessions and out-of-session assignments helps to correct false beliefs and attributions reducing the flexibility of anxious mothers. The modification of individuals’ beliefs, irrational expectations, and false attributions have increased flexibility and recognition of the positive aspects of each other’s behaviors [10, 11].
According to the obtained findings of the present study, CBT affected the empathy of anxious mothers of adolescents within the age range of 11-16 years which is in line with the results of studies carried out by Chambless [1]. In explaining this finding, it can be reported that ineffective negative thoughts are images or cognitions that are reported by the individual as a result of cognitive schema
or fundamental beliefs activated in a particular situation [1]. These images and thoughts reflect the meaning that an individual attaches to a particular situation and is closely related to the emotional and behavioral response to that situation. Furthermore, self-reflections play an important role in the healing process, are used as preferred pathways to access the cognitive system, and help to perceive the beliefs underlying several psychological disorders.
Low empathy is due to processing errors. These errors can cause receptions and perceptions of the experience to be compromised. In addition, these beliefs overwhelm mothers’ empathy expectations, perceptions, and destructive and illogical documents; therefore, cognitive training can correct miscon-ceptions and attributions, eliminate misunder-standings, reduce anger, give attention to positive aspects of each other’s behavior, and lead to improved empathy of distressed mothers [24].
The current study had several limitations. Firstly, the statistical population of the study consisted of a specific group of mothers, namely mothers with children of 11 to 16 years, which makes it impossible to generalize the results to other populations. In this study, the training was only for mothers, and better results would be achieved if both parents participated in this study. The use of two methods of instruction might affect disrupting the curriculum for the researcher. The study design was semi-experimental and did not have the benefits of real experimental designs. Because these reports are prone to distortion due to unconscious defenses, there would be bias in response, self-presentation methods, and overall social desirability.
It can be concluded that CBT and parenting styles based on reality therapy were effective in the impulse control, flexibility, and empathy of the distressed mothers with adolescents within the age range of 11-16 years in Babol. Parenting styles based on reality therapy were more effective in distressed mothers’ impulse control, flexibility, and empathy than CBT.
Compliance with ethical guidelines
All ethical principles were considered in this study. The participants were informed about the purpose of the study and implementation of the stages. In addition, informed consent was obtained from all the study subjects. The participants were also assured of the confidentiality of their information. Moreover, the subjects were free to withdraw from the study at any time, and the results of the study would be available to them if desired.
The authors would like to express their gratitude to the participants who greatly cooperated in conducting the study.
Authorsʼ contributions
Conceptualization [Sekineh Mohammad Yousefi]; Methodology [Ghodratollah Abbasi]; Investigation [Ghodratollah Abbasi]; Writing Original Draft [Seyedeh Olia Emadian]; Writing, Reviewing, and Editing [All authors]; Funding Acquisition [All authors]; Resources [All authors]; Supervision, [Ghodratollah Abbasi]
The present study did not receive any specific grant from funding agencies in public, commercial, or not-for-profit sectors.
Conflicts of Interest
The authors declare that there is no conflict of interest.
  1. Chambless DL. Adjunctive couple and family intervention for patients with anxiety disorders. Journal of Clinical Psychology. 2012; 68(5):548-60. [DOI:10.1002/jclp.21851] [PMID]
  2. Glasner-Edwards S. Assessing mindfulness and acceptance processes in clients: illuminating the theory and practice of change. Drug and Alcohol Review. 2011; 30(1):112. [DOI:10.1111/j.1465-3362.2010.00284_2.x]
  3. Friedberg RD, Gorman AA, Wilt LH, Biuckians A, Murray M, Garcia JH. Cognitive behavioral therapy for the busy child psychiatrist and other mental health professionals: Rubrics and rudiments. London: Routledge; 2012. [DOI:10.4324/9780203830390]
  4. Gerdes KE, Segal EA, Jackson KF, Mullins JL. Teaching empathy: a framework rooted in social cognitive neuroscience and social justice. Journal of Social Work Education. 2011; 47(1):109-31. [DOI:10.5175/JSWE.2011.200900085]
  5. Settipani CA, Kendall PC. The effect of child distress on accommodation of anxiety: relations with maternal
    beliefs, empathy, and anxiety. Journal of Clinical Child

    and Adolescent Psychology. 2017; 46(6):810-23. [DOI:10.1080/15374416.2015.1094741] [PMID]
  6. Sasaki N, Somemura H, Nakamura S, Yamamoto M, Isojima M, Shinmei I, et al. Effects of brief communication skills training for workers based on the principles of cognitive behavioral therapy: a randomized controlled trial. Journal of Occupational and Environmental Medicine. 2017; 59(1):61-6. [DOI:10.1097/JOM.0000000000000924] [PMID] [PMCID]
  7. Levy KN, McMain S, Bateman A, Clouthier T. Treatment of borderline personality disorder. The Psychiatric Clinics of North America. 2018; 41(4):711-28. [DOI:10.1016/j.psc.
  8. Button ML, Norouzian N, Westra HA, Constantino MJ, Antony MM. Client reflections on confirmation and disconfirmation of expectations in cognitive behavioral therapy for generalized anxiety disorder with and without motivational interviewing. Psychotherapy Research. 2019; 29(6):723-36. [DOI:10.1080/10503307.2018.1425932] [PMID]
  9. Flynn HA. Setting the stage for the integration of motivational interviewing with cognitive behavioral therapy in the treatment of depression. Cognitive and Behavioral Practice. 2011; 18(1):46-54. [DOI:10.1016/j.cbpra.2009.09.006]
  10. Lang JM, Ford JD, Fitzgerald MM. An algorithm for determining use of trauma-focused cognitive-behavioral therapy. Psychotherapy. 2010; 47(4):554-69. [DOI:10.1037/a0021184] [PMID]
  11. O'Connor KJ, Schaefer CE, Braverman LD. Handbook of play therapy. 2nd ed. New Jersey: John Wiley & Sons; 2015. P. 1-701.
  12. Germer CK, Neff KD. Self-compassion in clinical practice. Journal of Clinical Psychology. 2013; 69(8):856-67. [DOI:10.1002/jclp.22021]
  13. Deblinger E, Pollio E, Dorsey S. Applying trauma-focused cognitive-behavioral therapy in group format. Child Maltreatment. 2016; 21(1):59-73. [DOI:10.1177/107755
  14. Fonseca A, Pereira M, Araújo-Pedrosa A, Gorayeb R, Ramos MM, Canavarro MC. Be a mom: formative evaluation of a web-based psychological intervention to prevent postpartum depression. Cognitive and Behavioral Practice. 2018; 25(4):473-95. [DOI:10.1016/j.cbpra.2018.02.002]
  15. Hudson JL, Kendall PC, Chu BC, Gosch E, Martin E, Taylor A, et al. Child involvement, alliance, and therapist flexibility: Process variables in cognitive-behavioural therapy for anxiety disorders in childhood. Behaviour Research and Therapy. 2014; 52(1):1-8. [DOI:10.1016/
    [PMID] [PMCID]
  16. Romero‐Martínez Á, Lila M, Gracia E, Moya‐Albiol L. Improving empathy with motivational strategies in batterer intervention programmes: results of a randomized controlled trial. British Journal of Clinical Psychology. 2019; 58(2):125-39. [DOI:10.1111/bjc.12204] [PMID]
  17. Ehrenreich-May J, Bilek EL. The development of a transdiagnostic, cognitive behavioral group intervention for childhood anxiety disorders and co-occurring depression symptoms. Cognitive and Behavioral Practice. 2012; 19(1):41-55. [DOI:10.1016/j.cbpra.2011.02.003]
  18. Woods-Jaeger BA, Kava CM, Akiba CF, Lucid L, Dorsey S. The art and skill of delivering culturally responsive trauma-focused cognitive behavioral therapy in Tanzania
    and Kenya. Psychological Trauma. 2017; 9(2):230-8. [DOI:10.1037/tra0000170] [PMID] [PMCID]
  19. Azar ST. A cognitive behavioral approach to understanding and treating parents who physically abuse their children. Child Abuse: New Directions in Prevention and Treatment Across the Lifespan. 1997; 4:79-101. [DOI:10.4135/9781
  20. Friedberg RD, Brelsford GM. Training methods in cognitive behavioral therapy: tradition and invention. Journal of Cognitive Psychotherapy. 2013; 27(1):19-29. [DOI:10.1891/
  21. Bruce NG, Manber R, Shapiro SL, Constantino MJ. Psychotherapist mindfulness and the psychotherapy process. Psychotherapy. 2010; 47(1):83-97. [DOI:10.1037/a0018842] [PMID]
  22. Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the self-compassion scale. Clinical Psychology & Psychotherapy. 2011; 18(3):250-5. [DOI:10.1002/cpp.702] [PMID]
  23. Kirby JN. The role of mindfulness and compassion
    in enhancing nurturing family environments. Clinical Psychology: Science and Practice. 2016; 23(2):142-57.
  24. Whiting DL, Deane FP, Simpson GK, McLeod HJ, Ciarrochi J. Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment
    in acceptance-based therapies: a conceptual review. Neuropsychological Rehabilitation. 2017; 27(2):263-99. [DOI:10.1080/09602011.2015.1062115] [PMID]
  25. Ghorbani N, Watson PJ, Hamzavy F, Weathington BL. Self-knowledge and narcissism in Iranians: Relationships with empathy and self-esteem. Current Psychology. 2010; 29(2):135-43. [DOI:10.1007/s12144-010-9079-5]

Article Type: Research Article | Subject: Mother and child health
Received: 2020/04/4 | Accepted: 2020/07/12 | Published: 2021/02/2

Add your comments about this article : Your username or Email:

Send email to the article author

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

© 2024 CC BY 4.0 | Avicenna Journal of Neuro Psycho Physiology

Designed & Developed by : Yektaweb