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Bahremand M, Talebzadeh Shoushtari M, Marashian F S. Effectiveness of Intensive Short-Term Dynamic Psychotherapy and Existential Therapy on Self-Compassion and Existential Anxiety in Infertile Individuals. Avicenna J Neuro Psycho Physiology 2024; 11 (2) :50-56
URL: http://ajnpp.umsha.ac.ir/article-1-489-en.html
Effectiveness of Intensive Short-Term Dynamic Psychotherapy and Existential Therapy on Self-Compassion and Existential Anxiety in Infertile Individuals
Marjan Bahremand1 , Marzieh Talebzadeh Shoushtari2 , Fatemeh Sadat Marashian1
1- Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran
2- Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran , talebzademarzieh@gmail.com
Keywords: Psychotherapy, Existential therapy, Self-compassion, Anxiety, Infertility
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Background
The turmoil caused by physical and psychological illnesses is an inseparable part of patients' lives; nonetheless, sometimes, individuals react inappropriately to them and experience serious psychological harm [1]. Infertility is one of the disturbances responded to differently in couples' lives, presenting them with numerous psychological problems [2]. Studies have demonstrated a 72% prevalence of psychological harm, including anxiety, in these couples [3]. In Iran, the prevalence of mental disorders in infertile couples has been reported between 25% and 60% [4]. Mental disorders can have a negative impact on couples' chances of fertility [5], and the likelihood of pregnancy may increase with the treatment of mental disorders [6]. This highlights the critical need to study infertility from a psychological perspective. Psychological factors related to infertility include self-compassion, which is likely to decrease due to infertility [7]. Self-compassion is the feeling of kindness and tenderness towards oneself, leading to a non-judgmental attitude towards oneself, especially one's weaknesses [8]. It has a role to play in predicting positive outcomes in the future and making more tremendous efforts to adopt an active self-care approach, which allows life's hardships to be perceived as natural events [9, 10].
Furthermore, anxiety is considered one of the main mental health disorders associated with infertility [11]. Infertile couples may find themselves facing an unexpected life crisis that is associated with failure to reproduce, future planning, and social relationships, and in this context, they may experience high levels of anxiety [12]. Existential anxiety is likely to be one of the types of anxiety experienced by infertile couples, as it occurs when individuals reflect deeply on their existence and fail to find meaning in life [13]. This type of anxiety permeates all aspects of life and concerns three factors: boundaries and nothingness, the emptiness of life, and feelings of guilt and blame [14].
Existential anxiety increases in couples with an emphasis on the importance of addressing loss and grief, as well as treatment failure, from an existential perspective and based on the perception of these experiences as an existential crisis [15]. This issue is exacerbated by cultural experience and psychosocial issues in collectivist cultures, highlighting an urgent need for psychotherapeutic interventions. Given the low population growth rate in Iran, infertility has turned into a serious threat to population aging, presenting very significant social and economic challenges [16]. Therefore, the protective role of self-compassion, along with the harmful role of existential anxiety, justifies the need for further research to identify effective treatment approaches to reduce harmful psychological factors and increase protective factors among infertile couples.
A review of the research literature highlights the importance of studying the therapies that have been less tested for couples' infertility. These therapies include Intensive Short-Term Dynamic Psycho-therapy (ISTDP) and Existential Therapy (ET). The existential approach to marital counseling focuses on the hopes and desires of each partner to become parents, as well as their fears and anxieties about the future, achieving new goals, and finding meaning in life. It also addresses such issues as loneliness, meaninglessness, death, and individual freedom, regardless of culture, religion, ethnicity, and race [17]. On the other hand, the psychoanalytic approach emphasizes the identification of intrapsychic issues related to adjustment and increasing emotional awareness [18]. In this therapy, patients are helped to solve their problems based on disclosure and tactical defenses and face their conflicts and emotions that are the product of early loss, trauma, and emotions that are activated by a stressful event, such as infertility, and can trigger anxieties and defense mechanisms, which can lead to self-defeating patterns and interpersonal problems [19]. Previous research has demonstrated the efficacy of existential and psychodynamic therapies in addressing various psychological challenges. Zadafshar et al. [20] revealed that existential group therapy was beneficial in the mitigation of depressive and stress symptoms among survivors of child sexual abuse. In line with these findings, Alizadeh et al. [21] reported that ET alleviated death anxiety and enhanced the sense of life purpose in recovered COVID-19 patients. Focusing on a psychodynamic approach, Alirezaee et al. [22] observed that ISTDP fostered self-compassion in individuals with cancer. Building on this, Aminifar et al. [23] highlighted the role of ISTDP in enhancing emotional self-awareness, empathy, and self-compassion among psycho-therapy trainees. Furthermore, Naghibi et al. [24] indicated that  ISTDP was an effective intervention for the reduction of psychological distress in patients with atopic dermatitis. Therefore, the present study aimed to assess and compare the effectiveness of ET and ISTDP in an effort to contribute to the development of knowledge and fill the existing research gap.

Objectives
With full knowledge of the background, the present study sought to investigate the effectiveness of ISTDP and ET in self-compassion and existential anxiety in infertile women.

Materials and Methods
This quasi-experimental study employed a pretest, posttest, control group design with follow-up. The statistical population consisted of infertile couples in Yazd, Iran, in 2023. Using a purposive sampling method, 60 infertile women were selected from among infertile couples referred to Yazd infertility centers who met the inclusion criteria (consent to participate in the study, minimum education of junior high school, minimum of three years of infertility history, and no concurrent receipt of other psychological treatments). The exclusion criteria were unwillingness to continue cooperation and absence from more than two sessions. The subjects were randomly assigned to two experimental groups and one control group (20 subjects in each group). To ensure ethical considerations, subjects were assured of the confidentiality of their information. All subjects completed the Self-Compassion Scale and the Existential Anxiety Questionnaire at pretest, posttest, and follow-up (one month after posttest). The ISTDP and ET experimental groups received the Dynamic Short-Term Dynamic Psychotherapy [25] and Yalom's Existential Psychotherapy [26] couple therapy programs, respectively, in eight 45-minute sessions (once a week), while subjects in the control group received no intervention and were placed on a waiting list. Table 1 presents a summary of the ISTDP and ET therapy sessions.

Research Instruments
1. Self-Compassion Scale (SCS)-Short Form
The SCS-Short Form, a 12-item self-report measure developed by Raes et al. [27], assesses self-compassion. The items are rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree), with total
Table 1. A summary of the ISTDP and ET therapy sessions
Sessions ISTDP ET
1 Session 1 focused on establishing therapeutic parameters and conducting an initial diagnostic assessment utilizing a dynamic sequence approach. This phase facilitated the objective expression of clients' internal experiences. Introduction to group members, establishing group rules, responding to the question "Who am I?" to explore the concept of self-awareness
2 Session 2 involved an in-depth examination of the couple's intrapsychic conflicts, which served to activate underlying defense mechanisms. Tailored therapeutic interventions were implemented based on the identified defense types (tactical or primary) to facilitate a shift from rigid, self-protective defenses to more flexible and adaptive coping mechanisms. Explanation of existential self-awareness and how to increase it, encouraging members to express their feelings and thoughts with a focus on the here and now
3 Session 3 focused on enhancing the client's capacity for anxiety tolerance within their individual limits. Common tactical defense mechanisms were identified and subsequently challenged to promote adaptive coping strategies. Discussing the difference between loneliness and feeling lonely, exploring different types of loneliness, and explaining existential loneliness, healthy interactions, and proper communication
4 Session 4 involved the careful induction of transference phenomena within the client's capacity to facilitate access to unconscious material, which was subsequently interpreted to promote insight. Sharing experiences of loneliness in individuals' lives, teaching active coping and externalizing the fear of existential loneliness.
5 Session 5 focused on addressing the couple's complex emotional dynamics, including anger, guilt, love, and sadness. Concurrently, underlying defense mechanisms were identified and addressed to facilitate healthier emotional expression and conflict resolution. Raising awareness by the leader about the existence of limitations, accepting consequences, and being responsible for them, focusing on existential anxiety.
6 Session 6 centered on exploring the intricate interplay between emotions and the partner relationship. A primary focus was on anxiety management and fostering authentic emotional engagement. Discussion about emptiness and meaninglessness and the meaning of life.
7 Session 7 involved a comprehensive assessment of the presenting problem and the implementation of a dynamic sequence to facilitate problem exploration. This process included the identification, clarification (including functional and dysfunctional aspects), and subsequent challenge of defensive patterns. Existential analysis of death as a complement to life and understanding the importance of awareness of mortality
8 The final session involved a comprehensive synthesis of the therapeutic process, including an evaluation of anxiety symptom severity, defense mechanism utilization, and the client's capacity for insight into underlying emotional states. Explanation of topics, clarification of the connection and connection of self-awareness, loneliness, freedom and responsibility, emptiness and meaning, and death
scores ranging from 12-60. Higher scores are suggestive of greater self-compassion. The Persian SCS-Short Form demonstrated robust internal consistency (Cronbach's α = 0.91) [28]. In the present study, Cronbach's alpha for this scale was 0.87.

2. Existential Anxiety Scale (EAS)
The EAS is a 32-item self-report measure developed by Good and Good [29] to assess existential anxiety. Participants respond using a true/false format, with total scores ranging from 32-64. Higher scores indicate greater existential anxiety. The EAS demonstrated adequate internal consistency in previous Iranian research (α = 0.86) [30]. In the current study, the scale exhibited acceptable internal consistency (α = 0.79).

Data Analysis
The data were analyzed in SPSS software (version 27.0) using repeated measures analysis of variance (ANOVA).

Results
The mean age scores in the ISTDP, ET, and control groups were reported as 36.69±6.74, 37.50±6.41), and 38.12±7.30, respectively. Table 2 demonstrates self-compassion and existential anxiety scores across time for each group. In the intervention groups (ISTDP & ET), self-compassion scores increased, and existential anxiety scores decreased between the pretest and posttest, with no significant changes in the control group. Figure 1 depicts these findings.
Table 2. Mean scores of self-compassion and existential anxiety in the ISTDP, ET, and control groups
Groups Stage ISTDP group ET group Control group
Mean±SD Mean±SD Mean±SD
Self-compassion Pretest 28.00± 6.44 27.50±8.05 26.75±6.91
Posttest 40.50±7.04 42.05±10.21 25.95±7.87
Follow-up 40.30±6.79 42.30±9.84 26.20±6.76
Existential anxiety Pretest 19.25±5.43 21.30 ±8.28 20.20±7.20
Posttest 11.10±5.07 8.20 ±5.15 20.55±6.98
Follow-up 11.15±4.44 8.35±4.60 20.40±7.06
Figure 1. Comparison of the mean scores of self-compassion and existential anxiety between three groups in three evaluation phases
Prior to analysis, data met the assumptions of repeated measures ANOVA (Table 3). Significant main effects were found for time (pretest, posttest, follow-up) on self-compassion (F=44.40, P<0.001, η²=0.43) and existential anxiety (F = 46.38, P<0.001, η²=0.45), indicating changes across phases. In addition, significant interaction effects (group x time) were found for both self-compassion (F=13.07, P<0.001, η²=0.31) and existential anxiety (F=14.45, P<0.001, η²=0.34), suggesting differential changes between groups over time. Finally, significant main effects for the group were found for self-compassion (F=18.92, P<0.001, η²=0.40) and existential anxiety (F=14.53, P<0.001, η²=0.34), indicating overall group differences.
Table 4 displays Tukey's post-hoc comparisons between groups for self-compassion and existential anxiety. At baseline, no significant differences were detected between any groups; nonetheless, both ISTDP and ET demonstrated significant improvements compared to the control group at posttest and follow-up, with no significant difference between the two intervention groups themselves (all P<0.001).

Table 3. Results of repeated measures ANOVA in experimental and control groups
Variables Source SS df MS F P η2
Self-compassion Time 2981.68 1.03 2900.79 44.40 0.001 0.43
Group 4501.14 2.00 2250.57 18.92 0.001 0.40
Time × group 1755.26 2.06 853.82 13.07 0.001 0.31
Existential anxiety Time 1936.74 1.02 1889.54 46.38 0.001 0.45
Group 2094.08 2.00 1047.04 14.53 0.001 0.34
Time × group 1206.96 2.05 588.77 14.45 0.001 0.34

Table 4. Tukey test results for comparing ISTDP, ET, and control groups across assessment phases
Variable Groups Pretest Posttest Follow-up
Mean difference P Mean difference P Mean difference P
Self-compassion ET - ISTDP 0.00 0.999 1.55 0.999 2.00 0.999
ET - Control 1.25 0.999 16.10 0.001 16.10 0.001
ISTDP - Control 1.25 0.999 14.55 0.011 14.10 0.001
Existential anxiety ET - ISTDP 2.05 0.999 2.90 0.361 2.80 0.343
ET - Control 1.10 0.999 12.35 0.001 12.05 0.001
ISTDP - Control 0.95 0.999 9.45 0.001 9.25 0.001
Discussion
This study examined the effectiveness of two psychotherapy approaches, ISTDP and ET, in improving self-compassion and reducing existential anxiety in infertile women. The results pointed out that ISTDP was effective in the enhancement of self-compassion in infertile women. These findings are consistent with those of Alirezaee et al. [22] and Aminifar et al. [23], who suggested that ISTDP can lead to increased self-compassion. One explanation for this finding is that the core focus of ISTDP is on emotional or psychological pain, where life is perceived as a difficult and demanding process. The mind constructs defenses or avoidance mechanisms to cope with and tolerate emotional pain. Therefore, individuals with low self-compassion experience inflexible and troubled minds due to their low levels of self-compassion [23]. ISTDP promotes self-awareness in individuals by introducing them to their thoughts, feelings, and emotions, enabling them to change their thoughts and give their coping mechanisms a rational and reasonable direction. It then instills in clients that they can identify and challenge irrational and unreasonable thoughts and beliefs when faced with distressing events. In this way, self-compassion allows us to reach the core of our inner selves and treat ourselves more compassionately when dealing with problems [22].
The findings in the ET group also pointed to the effectiveness of the treatment in improving self-compassion in infertile women. These results are consistent with those reported by Zadafshar et al. [20] and Alizadeh et al. [21]. One explanation for this finding is that in terror management theory, self-compassion is recognized as a protective factor in the level of attention to or avoidance of existential threats existing in individuals in various forms. For individuals with lower levels of self-compassion, acknowledging ultimate predetermined failure associates all efforts for survival with paralyzing anxiety. Nonetheless, for individuals with higher levels of self-compassion, it is perceived that all people are flawed, fail, and make mistakes. As a result, these individuals regulate hardships and pain in the light of shared human experience in a way that prevents them from experiencing existential isolation when facing existential threats [31]. The practice of self-compassion can lead to the development of three essential aspects, including  (1) assuming a non-judgmental perspective of attention to one's failures, (2) creating caring and kind behavior towards oneself, and (3) accepting the reality of perceived experiences [32]. Therefore, ET appears to strive to increase compassionate behavior in infertile couples by promoting mindfulness, a sense of shared humanity, and kindness towards oneself. Awareness of death as an inevitable meaning in existence also increases flexibility and recognition of the psychological content of the client. Moreover, it reduces the effort to change reality and accept the ability to move toward existing values [21].
The findings also indicated that ISTDP was effective in the improvement of existential anxiety in infertile women. These findings are supported by those of Rocco et al. [33], and Mousavi and Naji [34], who suggested that ISTDP therapy is effective in the treatment of existential anxiety. One explanation for this finding is that in ISTDP, full emotional experience is crucial in transference relationships. On the other hand, the use of mechanisms that hinder emotional experience leads to resistance in the transference relationship and may suppress emotions. However, individuals can free themselves from the shadow of negative emotions and the fear of death by expressing suppressed emotions [35]. This therapy attempts to remove major obstacles to emotional experience that cause the formation of existential anxiety symptoms so that individuals can learn to accept, manage, and regulate their emotions to prevent the recurrence of anxiety. Deep emotional experience can also regulate how emotions are expressed by reducing inhibition and maladaptive defenses and creating a realistic understanding of individuals and their capabilities [34]. It appears that the changes resulting from ISTDP are due to the impact of therapy on intrapsychic conflicts and the resulting personality structures that may act as triggers for anxiety symptoms [33].
The obtained results also highlighted the effectiveness of ET in the reduction of existential anxiety. This finding is supported by those of Alizadeh et al. [21] and Ahmadinasab et al. [36]. This finding can be justified on the ground that belief in non-existence and death is an unavoidable concern that every individual will face to varying degrees as a mental struggle and holds a special place in people's worldviews. Therefore, ET focuses on existing existential concerns (fear of death, lack of freedom, isolation, and meaninglessness) and accepts the reality that fear of death is a significant source of anxiety that impacts social, personal, spiritual, and physical domains. Accordingly, this therapy aims to reduce existential anxiety by improving life meaning and modifying existential beliefs [21]. It appears that a richer life meaning is associated with more favorable psychological outcomes. Therefore, a meaning-oriented intervention can bring about increased adaptation to life's failures through re-signifying and reducing anxiety [36]. Suffering is an undeniable part of life, and human life is not complete without suffering. As a result, if humans accept their sufferings, they may find a deep and progressive meaning in life, even in the most challenging circumstances, and experience less anxiety [37].
The present study is subject to several limitations that could impact the robustness of its findings. The small sample size might limit the generalizability of findings. The quasi-experimental design, while necessary, could introduce biases and restrict causal inferences due to the absence of random assignment. The eight-session intervention duration might be insufficient for long-term effects. In addition, the study lacked control over confounding variables, such as sociodemographic factors and concurrent interventions, potentially affecting outcomes. The focus on self-compassion and existential anxiety limited the exploration of other potential outcomes. Building upon these limitations, future research should consider a larger sample, randomized controlled trial design, longer interventions, controlling for confounding variables, and expanding outcome measures to include quality of life, relationship satisfaction, and overall well-being. Qualitative research could offer deeper insights, and comparative effectiveness studies could inform treatment selection. By addressing these issues, future research can enhance understanding of ISTDP and ET for infertile women.

Conclusions
The findings demonstrated significant improvements in both self-compassion and reductions in existential anxiety for participants who received either ISTDP or ET compared to the control group. These positive effects were maintained at the follow-up stage, suggesting the lasting benefits of interventions. No statistically significant difference was observed between the ISTDP and ET groups, indicating that both therapies may be equally effective in addressing these mental health concerns in infertile women. These findings contribute to the growing body of research supporting the use of psychotherapy for the enhancement of mental well-being in infertile populations. Both ISTDP and ET appear to be promising interventions for promoting self-compassion and reducing existential anxiety, which are crucial aspects of coping with infertility-related distress. Future research could explore the specific mechanisms of change within each therapy modality to better understand how they produce these positive outcomes.

Compliance with ethical guidelines
The research received ethical approval from the Ethics Committee of Islamic Azad University, Ahvaz Branch, with the ethical reference code IR.IAU.AHVAZ.REC.1402.011.

Acknowledgments
This article was extracted from a part of the PhD dissertation of the first author in the Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran. The researchers wish to thank all the individuals who participated in the study.

AuthorsΚΌ contributions
M.B: Study concept and design, acquisition of data, analysis and interpretation of data, and statistical analysis. M.T.S: Administrative, technical, and material support, study supervision. F.S.M: Critical revision of the manuscript for important intellectual content.

Funding/Support
This study did not receive any funding.

Conflicts of Interest
No conflict of interest to declare.

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Article Type: Research Article | Subject: Anxiety and Stress
Received: 2024/06/27 | Accepted: 2024/08/10 | Published: 2024/06/21
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