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Rasaei S, Ebrahimi M E. Effectiveness of Internet Attachment-Based Compassion Therapy on Rumination and Fear of Coronavirus Disease in Elderly Women during Coronavirus Epidemics. Avicenna J Neuro Psycho Physiology 2022; 9 (1) :37-44
URL: http://ajnpp.umsha.ac.ir/article-1-368-en.html
1- Department of Psychology, Faculty of Humanities, Hamadan Branch, Islamic Azad University, Hamadan, Iran
2- Department of Psychology, Faculty of Humanities, Hamadan Branch, Islamic Azad University, Hamadan, Iran , Mse58_2007@yahoo.com
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The new coronavirus disease (COVID-19) first emerged on December 12, 2019, in Wuhan, China. The virus spread rapidly in neighboring countries and across the world after three months of the initial outbreak, and the World Health Organization declared its outbreak as an “epidemic” on March 11, 2020 [1]. Although less information is available on severe risk factors of the disease, the available data show that elderly people and those with serious underlying conditions are at greater risk of infection with the virus [2]. In other words, the elderly people who are susceptible to the virus and have to tolerate the imposed quarantine are the most vulnerable population during the COVID-19 epidemics  [3].
In this regard, studies have shown that during the first wave of the COVID-19 in China, 20% of mortalities were over 60 years old [4]. Currently, due to the higher severity and mortality of coronavirus in the elderly, it has many psychosocial consequences for them [5]. Similar to other epidemics, the coronavirus epidemic has caused global anxiety and stress [6].
On the other hand, rumination is one of the most important variables during the coronavirus epidemic due to facing traumatic challenges [7]. The research has shown that rumination may affect mental health. Bravo et al. [8] reported that rumination increases negative moods, such as depression [9, 10]. In addition, rumination can make post-traumatic stress disorder (PTSD) when the person faces a traumatic event [11]. On the other hand, due to the nature of the coronavirus epidemic and its relatively high mortality rate, people naturally become anxious and fearful when they get in contact with people who are infected with the virus [12, 13]. Fear of the coronavirus can lead to experiencing social deprivation in patients, survivors, their families, and other persons who may have contact with the diseased people. This in turn increases the risk of mental health problems, such as emotion dysregulation and depression [14, 15].
In addition, high fear of the coronavirus may lead to unreasonable and uncertain thoughts [16]. Therefore, it is necessary to make interventions in this field to prevent the consequences of these fears. One of the most effective treatments for psychological problems is compassion-based therapy intervention [17-20], which is a new protocol of compassion [21] and its new version was distributed online due to the quarantine and traffic restrictions imposed during the epidemics [22-24].  
In attachment-based compassion therapy, there are many compassion meditation techniques and compassion methods, such as self-compassion. In addition to the positive effects of this therapy on the psychological well-being of healthy individuals, it can also be used for the treatment of psychological disorders, such as depression and fibromyalgia with acceptable effectiveness [25]. Training affection and compassion-based meditation can increase acceptance in patients with personality disorders [26]. In addition, research has shown that self-compassion training reduces negative thoughts and feelings after a stressful event [27, 28]. On the other hand, attachment styles affect the way a person deals with stressful situations. People with safe attachment easily ask for help from others while accepting the situation [29, 30]. According to studies, elderly women are more likely to develop insecure attachment styles. Ilaei, Ahmadi Khatir, Azimi Lolti, and Yazdanicherati have shown that ambivalent attachment style was the most common attachment style in elderly women [31]. In another study, Fagundes, Jaremka, Malarakey, and Kiecolt-Glaser [32] concluded that avoidant attachment style was the most common attachment style in elderly women [33]. Based on the research, people with secure attachments have a higher level of mindfulness than people with insecure attachments [34].
Moreover, fewer studies on psychological problems have been observed during the COVID-19 epidemics in the elderly [35]. Therefore, it is necessary to do early interventions in this regard. Therefore, the researcher in the present study seeks to answer the question “whether Internet attachment-based compassion therapy is effective on rumination and fear of COVID-19 in older women during the epidemic?

The present study aimed to investigate the effect of Internet Attachment-based Compassion Therapy on rumination and fear of COVID-19 in elderly women during the epidemic.

Materials and Methods
The present study was a quasi-experimental research with a pre-test, post-test design, and a control group. Group therapy was adopted in this study for which we needed between 12 and 20 people in each group. Therefore, considering the attrition rate, a total of 16 people were selected for each group. However, since no attrition occurred, the sample size in each group remained to be 16 people. It is worth mentioning that the study samples included elderly women in the age range of 60-65 years who lived in Hamedan city of Iran, in 2020. These women were invited to participate in this study if they had self-reported fear of coronavirus disease and were willing to receive therapy. Invitation to the study was sent online through social media (e.g., WhatsApp and Instagram) due to quarantine and travel restrictions imposed due to the COVID-19 epidemics.

Inclusion criteria
Criteria for entering the study include married women in the age range of 60-65 years, Iranian nationality, ability to speak Persian, not suffering from neuropsychological disorders that lead to drug use (self-reporting), minimum education level of middle school, and willingness to attend the study. However, those with a history of undergoing psychological and psychiatric interventions during the past six months or women who used psychiatric medications or left the therapy sessions were excluded from the study. The pre-test stage was performed and the research tools were sent to them electronically after the voluntary selection of the participants. Individuals who obtained questionnaire scores above average and higher than other individuals were selected as the study samples. They were randomly divided into two groups of the experiment (n=16) and controls (n=16). Internet attachment-based compassion therapy was provided to the experiment group, followed by a post-test. After one month, the follow-up retest was taken to evaluate the stability of the therapy, and the data were analyzed using SPSS software (Version 25) in two levels of descriptive statistics (presented by mean±SD) and inferential statistics.

Coronavirus Fear Scale
This scale consists of 5 items that have been designed and standardized to measure fear of suffering from coronavirus in adults by Weissi, Imani, Behrooz, and Imani [36]. This scale is scored based on a 5-point Likert scale (1=very low grade, 2=low grade, 3=medium grade, 4=high grade, and 5=very high grade). The designers of the Scale of Fear of Coronavirus Disease used the Dark Future Scale to evaluate the convergence validity of this scale. Pearson correlation coefficient was obtained at 0.59 and using a death phobia scale, it was estimated at 0.58 [36]. The validity of the questionnaire was calculated using Cronbach’s alpha coefficient of 0.81. In the present study, the validity of the questionnaire was obtained using Cronbach’s alpha coefficient of 0.79.

Ruminative Response Scale (1991)
The Ruminative Response Scale was designed by Nolen, Hoeksema, and Morrow [37] to assess the negative mood response. This questionnaire includes 22 items that are stored in a Likert scale from never [1] to often [4]. The validity of this questionnaire in Iran was evaluated in the study conducted by Bagherinejad, Salehi Federdi, and Tabatabai [38] using Cronbach’s alpha coefficient which was estimated at 0.88, indicating the internal consistency of the test. The retest correlation coefficient for ruminative responses was obtained at 0.67 (Laminate, 2004). In a study performed by Golzar, Aflakir, and Molazadeh [39] each item was correlated with the total score
of the scale to evaluate the scale validity. The results showed that all items had a significant correlation with the total score of the scale, and the correlation coefficients were obtained between 0.30 and 0.72 (P<0.001)

Internet Attachment-Based Compassion Therapy Model
Internet attachment-based compassion therapy model [22] consisted of eight group sessions. Each session took 2 h (1 session per week) and included formal meditation and compassion training and exercises (breathing and body meditation, mindful yoga meditation, and body checking meditation), informal meditation (eating, walking, showering consciously), compassion methods, such as self-compassion, compassion to friends and people with problems, identification of self-attachment and the way it affects people’s current interpersonal relationships, and daily homework that took 15 to 20 minutes. This content was provided through text, audio, videos, observation, and interactive exercises. Downloadable PDF files were available for users to study offline. Formal practices (guided meditations) were provided through the audio systems with specific guides and instructions for each meditation. In addition, copies of each guided meditation were available in form of downloadable PDF files. In addition, during the therapy sessions, the therapist made video calls to the members of the experiment group through cyberspace at the specified time, and the techniques mentioned in the following table were taught.

Summary of sessions
Session Content Time
First Introduction:The participants were thought about the concept of compassion, applications of compassion, the structure, and logic of attachment-based compassion, informal and formal meditation compassion, tips on meditation practice (when, where, how much, and how to meditate), the importance of performing compassion exercises and homework. 120 minutes
Second The participants were thought how to use compassion for coping with difficult situations and problems and how to write daily notes of self-expression rather than self-criticism. 120 minutes
Third This session was spent on an in-depth investigation of terms of compassion and meditation conditions, terms related to compassion, fear of compassion, presentation, practice, and the meditation of compassion-based affection, the introduction of secure attachment, what makes one feel good, daily notes of compassion exercises and writing a companionate letter to oneself. 120 minutes
Forth The session aimed to teach participants about the way compassion acts, how to increase self-compassion, different attachment styles, people with secure attachment, the importance of these attachment styles in daily life, and identification of attachment styles 120 minutes
Fifth This session aimed to increase one’s ability to receive affection (friend, carefree person, and enemy) letters from parents, and observe self-attachment styles in daily life as homework. 120 minutes

The importance of affection to oneself and others, practicing expressing affection to friends and others, expressing self-compassion and self-affection, practicing self-loving, noting three positive aspects and three negative aspects of parents. 120 minutes
Seventh The participants were though about the concept of forgiveness, the stages of forgiveness, the psychological benefits of forgiveness, identification of resistances to forgiveness, forgiving oneself and others, practicing compassion and forgiveness in daily life. 120 minutes
Eighth The session was about one’s values ​​and their relationship with compassion, the benefits of positive communication with others, ways to improve positive relationships, and a review of the contents of past sessions. 120 minutes

In the present study, a total of 32 participants were divided into experimental (n=16) and control groups (n=16). In this study, all participants were elderly women in the age range of 60-65 years. Table1 presents the descriptive indicators of rumination and fear of coronavirus variables.
The results of the table1 show a difference between the scores of variables of rumination and fear of coronavirus in the two experimental groups in the post-test and follow-up, compared to the pre-test. However, no difference was observed for the control group in the post-test and follow-up levels.
As indicated in Table 2, normal distribution of scores and homogeneity of variances were obtained in both study groups. Table 4 presents the results of a multivariable test to evaluate the effectiveness of Internet attachment-based compassion therapy on rumination and fear of coronavirus.

Table 1. Mean±SD of pre-test, post-test, and follow-up of rumination and fear of coronavirus variables in groups of experiment and control
Variable Group Pre-test Post-test Follow-up
Rumination Experimental 875 .59 6.141 46.312 7.217 45.875 7.338
Control 60.250 7.037 60.562 6.250 58.937 6.318
Fear of coronavirus Experimental 18.937 3.275 12.937 4.250 12.00 4.472
Control 18.875 3.612 19.125 3.721 19.562 3.741

Table 2. Results of Shapiro-Wilk test for normal distribution of data and homogeneity of variances with Levene’s test.
Variable Group Statistic DF Sig Levene’s Test Sig
Rumination Pre-test Experimental 0.967 16 0.795 0.905 0.349
Control 0.889 16 0.053
Rumination Post-test Experimental 0.952 16 0.517 0.534 0.471
Control 0.927 16 0.220
Rumination Follow-up Experimental 0.969 16 0.821 0.293 0.592
Control 0.963 16 0.722
Fear of disease Pre-test Experimental 0.946 16 0.434 0.526 0.447
Control 0.926 16 0.213
Fear of disease Post-test Experimental 0.952 16 0.524 0.385 0.540
Control 0.962 16 0.707
Fear of disease Follow-up Experimental 0.953 16 0.533 0.621 0.437
Control 0.944 16 ./0

Considering the significance of the effect of time, the data presented in Table 5 indicate a significant difference between the mean of the pre-test, post-test, and follow-up of rumination and fear of coronavirus scores in both experimental and control groups. In other words, in this group, a significant difference was observed between scores of pre-test, post-test, and follow-up levels (P<0.001).
The results indicate the effectiveness of therapy on rumination and fear of disease. Therefore, the level of rumination and fear of disease was significantly decreased in the
experiment group
. Bonferroni post hoc test was used to compare binary groups (Table 6).

The scores of rumination and fear of coronavirus in the experimental group and the post-test level were less than those in the control group (Table 6).
These results also show that rumination and fear of disease in follow-up were significantly reduced in the experiment group, compared to the control group. This means that the changes in the experimental group have remained stable after one month of follow-up.


Table 3. Presumption results of homogeneity of covariances of rumination and fear of coronavirus variables, based on Mauchly’s sphericity test
Dependent variables W Mauchly Chi-squared DF Sig
Rumination 0.822 5.672 2 0.059
Fear of disease 0.862 4.316 2 0.116

Table 4. Results of multivariable test for the evaluation of the effectiveness of Internet-Based Compassion Therapy on rumination and fear of coronavirus
Tests Value F Sig Statistical power
Pillai’s Trace 0.817 30.212 0.001 0.817 1
Wilks Lambda 0.183 30.212 0.001 0.817 1
Hotelling’s Trace 4.476 30.212 0.001 0.817 1
Roy’s Largest Root 4.476 30.212 0.001 0.817 1
Table 5. Repeated measures analysis of variance  for the comparison of pre-test, post-test, and follow-up variables of rumination and fear of coronavirus in the groups of experiment and control
Scale Source of effect SST DF MSE F Sig
Rumination Time 1104.771 2 552.385 40.247 0.001 0.573
Time*Group 946.396 2 473.198 34.477 0.001 0.535
Error 823.500 60 13.725 -
Fear of disease Time 193.00 2 96.500 45.441 0.001 0.602
Time*Group 264.250 2 132.125 62.217 0.001 0.675
Error 127.417 60 2.124 -


Table 6. Results of Bonferroni post hoc test for the comparison of rumination and fear of coronavirus
Variable Group Levels MD SE Sig
Rumination Pre-test Post-test 6.625 0.940 0.001
Follow-up 7.656 1.076 0.001
Post-test Pre-test -6.625 0.940 0.001
Follow-up 1.031 0.730 0.504
Fear of disease Pre-test Post-test 2.875 0.386 0.001
Follow-up 3.125 0.406 0.001
Post-test Pre-test -2.875 0.386 0.001
Follow-up 0.250 0.290 1

The present study aimed to investigate Internet attachment-based compassion therapy on rumination and fear of COVID-19 disease in elderly women during the epidemic. The results showed that the Internet attachment-based compassion therapy has been effective on rumination and fear of coronavirus and the results were stable after one month of follow-up.
These results are consistent with the findings of Montreo-Marin et al. [25], Garcia et al.[21], and Macintosh et al. [24] on the effectiveness of attachment-based compassion therapy. In addition, the findings of this study are consistent with many studies that support the benefits of using the Internet in providing evidence-based interventions [22; 41-40].
In the explanation of this finding, it can be said that training compassion-based kindness and meditation can increase the acceptance level [26]. On the other hand, attachment styles affect the way a person deals with stressful situations, and people with safe attachment easily ask for help while accepting the situation [29]. Therefore, elderly women in the stressful condition of the coronavirus epidemic, which can cause more rumination, learn to accept the critical condition of the pandemic after the therapy sessions. Moreover, rather than engaging in repetitive thoughts that exacerbate fear and anxiety, they learned to seek help and practice self-care to maintain health and stop anxiety over diseases, such as coronavirus. In fact, they learn to improve their health by loving themselves, instead of engaging in repetitive and useless thoughts.
In explaining the effectiveness of attachment-based compassion therapy on the fear of coronavirus, one can explain that although all pain can not be resolved or treated, all sufferings can be relieved by compassion. In fact, one can face the problems and sufferings of life through meditation techniques and gain the ability to effectively deal with them with compassion [42]. On the other hand, compassion exercises reduce the frequency of negative thoughts and feelings after a traumatic event [27]. Therefore, during and after therapy sessions, elderly women learned that rather than avoiding fearful thoughts of disease, they can reduce cortisol levels by short-term self-compassion training when experiencing stress. In addition, this training increase heart rate variability, which is associated with higher ability of self-relaxation during a stressful situation [43]. Therefore, it is normal for elderly women in the experiment group to reduce their stress response after therapy sessions by decreasing cortisol levels, which would in turn reduce their fear of disease. On the other hand, people can control their fear of the coronavirus by identifying their attachment style and correcting inappropriate attachments by improving their relationship with others, using appropriate coping strategies.
Regarding the limitations of the present study, one can refer to the fact that this study was conducted on a group of elderly women in Hamedan city, Iran.

Therefore, the generalization of results to other people in different cities with different cultures should be done with caution. It is recommended that similar studies should be conducted in different cities. Moreover, the study results can be used to facilitate planning for psychological interventions in critical conditions of coronavirus or psychological disorders, such as PTSD, obsessive-compulsive disorder, and other anxiety disorders.
Compliance with ethical guidelines
Following ethical guidance, written informed consent was obtained from the participants.

The authors would like to thank all the elderly women who participated in this study.

Authorsʼ contributions
All authors contributed to the preparation of the study manuscript.

None declared

Conflicts of Interest
The authors declare that they have no conflicts of interest regarding the publication of this study.

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Article Type: Research Article | Subject: Health Education and Promotion
Received: 2020/12/9 | Accepted: 2021/07/17 | Published: 2022/02/25

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