Compassion to Posttraumatic Growth, the Mediating Role of Cognitive Fusion

Journal of Aggression, Maltreatment & Trauma

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The Relationships of Distress Tolerance, Self- compassion to Posttraumatic Growth, the Mediating Role of Cognitive Fusion

Sajjad Basharpoor, Mehri Mowlaie & Leila Sarafrazi

To cite this article: Sajjad Basharpoor, Mehri Mowlaie & Leila Sarafrazi (2020): The Relationships of Distress Tolerance, Self-compassion to Posttraumatic Growth, the Mediating Role of Cognitive Fusion, Journal of Aggression, Maltreatment & Trauma, DOI: 10.1080/10926771.2019.1711279 To link to this article: https://doi.org/10.1080/10926771.2019.1711279

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The Relationships of Distress Tolerance, Self-compassion to Posttraumatic Growth, the Mediating Role of Cognitive Fusion Sajjad Basharpoor , Mehri Mowlaie, and Leila Sarafrazi Department of Psychology, Faculty of Educational Sciences and Psychology, University of Mohaghegh Ardabili, Ardabil, Iran

ABSTRACT ARTICLE HISTORY The present research examined the direct and indirect relation- Received 25 June 2019 ship between distress tolerance, self-compassion, and cognitive Revised 24 October 2019 fusion with posttraumatic growth in a sample of Iranian indivi- Accepted 16 December 2019 duals that had childhood abuse experience. Participants KEYWORDS included 190 Iranian individuals with childhood abuse experi- Cognitive fusion; distress ence (126 women and 64 men). Questionnaires were adminis- tolerance; posttraumatic tered and all of the participants gave written informed consent growth; self-compassion at the pre-assessment. Results showed that there is a positive relationship between distress tolerance, self-compassion, and posttraumatic growth. Another result showed that there is a negative relationship between cognitive fusion and posttraumatic growth. We tested, via structural equation model, whether distress tolerance and self-compassion predicted posttraumatic growth through cognitive fusion. Results showed cognitive fusion mediates the relationship between distress tolerance and posttraumatic growth but could not predict posttraumatic growth via self-compassion. In sum, the results of the present research showed that cognitive fusion is an important mediator factor in the relationships of distress tolerance with posttraumatic growth.

Introduction Childhood maltreatment is a serious problem worldwide (Van der Kooij et al., 2015). Prolonged consequences of childhood abuse are severe and widespread. These consequences related to posttraumatic stress disorder (Follette, Palm, & Pearson, 2006), eating disorders (Burns, Fischer, Jackson, & Harding, 2012), alexithymia (Hund & Espelage, 2006), psychotic disorders (Schäfer et al., 2006), and suicidal ideation (Bahk, Jang, Choi, & Lee, 2017). There are contradictory studies on the relationship between psychological problems and childhood trauma. Some studies show that stressful and traumatic events can lead to psychological consequences such as sleep disorders (Zhou, Wu, An, & Fu, 2014), posttraumatic stress disorder, depression, and

CONTACT Sajjad Basharpoor [email protected] Department of Psychology, Faculty of Educational Sciences and Psychology, University of Mohaghegh Ardabili, Ardabil, Iran © 2020 Taylor & Francis 2 S. BASHARPOOR ET AL. anxiety symptoms (Fan, Zhang, Yang, Mo, & Liu, 2011). However, all those who have experienced child abuse do not suffer from mental and behavioral disorders and problems. In fact, many adults may exhibit posttraumatic growth symptoms after experiencing trauma (Rzeszutek, Oniszczenko, & Kwiatkowska, 2017; Zhou, Wu, & Zhen, 2018). These contradictory findings led to the question of how these individuals would manage these problems? In response to this question, researchers focused on the role of mediators of posttraumatic growth and psychological harm. Posttraumatic growth is an issue that attracts the attention of clinical psychologists and psychotherapists. Posttraumatic growth refers to changes in perception, relationships with others, philosophy of life, fundamental beliefs, and change in identity after a traumatic event (Gul & Karanci, 2017). Posttraumatic growth is linked to positive outcomes such as increased psychological well-being, lower levels of anxiety, depression, and high quality of life (Siqveland, Nygaard, Hussain, Tedeschi, & Heir, 2015). One of the most important variables related to posttraumatic growth is distress tolerance. Resistance and tolerance of individuals to the disturbances resulting from the childhood traumatic experiences are other important factors in the occurrence or absence of posttraumatic disorders. Distress tolerance refers to the ability to experience and tolerate negative psychological situations (Anestis & Joiner, 2012). Low levels of distress tolerance associated with psychological problems such as posttraumatic stress disorder (Berenz et al., 2017) and borderline personality disorder (Linehan, 1993). Self-compassion is another variable that can act as a protective agent against traumatic experiences and psychological damage. It can also play a role in the improvement of psychological trauma (Bluth et al., 2015) and provide the background for posttraumatic growth (Mitchell, 2017). Self- compassion is related to general well-being, higher life satisfaction, and low levels of worry (Mowlaie, Mikaeili, Agababaei, Ghaffari, & Pouresmali, 2017). It is negatively related to poor mental health such as self-criticism, depression, and anxiety (Neff & McGeheea, 2010). A growing body of research has focused on posttraumatic growth specifi- cally with regards to coping, rumination, posttraumatic stress symptoms, optimism; however, a few studies analyzed the relationships of posttraumatic growth, distress tolerance, and self-compassion. Even less is known about the mechanisms and mediators involved in these relationships. This study analyzed how distress tolerance and self-compassion were related to posttraumatic growth. It is believed that an important mediator is cognitive fusion (Hayes, Strosahl, & Wilson, 2012). In cognitive fusion, individuals are radi- cally engaged with thoughts and that these thoughts dominate their behavior (Gillanders et al., 2014). Over the past two decades, many studies have been conducted to support the role of diagnosis and the vulnerability of this variable as a fundamental process in the etiology of psychological disorders JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 3 such as depression, psychosis (Gaudiano & Herbert, 2006), pain tolerance (Juarascio et al., 2013), substance abuse (Twohig, Shoenberger, & Hayes, 2007), obsessive-compulsive disorder (Twohig, 2009), and anxiety disorders (Zettle, 2003). This study focused on cognitive fusion for two particular reasons. First, as noted by Duarte and Pinto-Gouveia (2017), cognitive fusion triggers experiential avoidance, i.e. an attempt to avoid, modify, reduce, or control internal experiences via improper ways involving the tendency to become fused with disturbing cognitions. Second, cognitive fusion forces one to respond to assumptions and verbal rules rather than reacting to present events. Therefore, it may affect one’s distress tolerance or self-compassion, and, respectively, reduce post-traumatic growth. Individuals with low cognitive fusion can succeed in getting rid of symptoms of mental disorders and gain posttraumatic growth. Furthermore, those who achieved high scores on self-compassion and distress tolerance have low scores on cognitive fusion. Therefore, four major hypotheses were developed: Hypotheses 1 states that posttraumatic growth positively relates to distress tolerance and self-compassion and negatively relates to cognitive fusion. Hypotheses 2 states that there are negative relationships among cognitive fusion, distress tolerance, and self- compassion. Hypotheses 3 states that cognitive fusion mediates the link between distress tolerance and posttraumatic growth. Finally, Hypotheses 4 states that cognitive fusion mediates the link between self-compassion and posttraumatic growth.

Methods Participants and Procedure

Participants included 190 Iranian individuals with childhood abuse experience (66.67% female; 33.33% male). The age ranged from 16 to 40, with a mean of 28 (SD= 6.54). 10.20% of participants experienced physical abuse, 15.1% emotional abuse, 14.3% physical neglect, 18.58% emotional neglect, and 9.18% sexual abuse. This study was approved by the ethics committee of the University of Mohaghegh Ardabili. Prior to testing, informed consent was obtained from the participants. Participation in this study was voluntary and anonymous; all procedures conformed to institutional guidelines.

Materials

Distress Tolerance Scale Distress Tolerance Scale (DTS; Simons & Gaher, 2005) is a 15-item measure composed of four subscales, namely: tolerance, absorption, appraisal, and regulation that were scored on a 5-point Likert scale from 1 (completely 4 S. BASHARPOOR ET AL. agree) to 5 (completely disagree). Alpha coefficients for four subscales were as follows: Tolerance .72, Appraisal .82, Absorption .78, and Regulation .70 (Simons & Gaher, 2005).

Self-Compassion Scale Self-Compassion Scale (SCS; Neff, 2003a) is a 26-item measure and consisting of six sub-scales: kindness (5items), self-judgment (5items), common humanity (4items), isolation (4items), mindfulness (4items), and over-identification (4items). Responses are rated on a 5-point Likert-type scale, from 1 (almost never) to 5 (almost always). Higher scores indicate greater self-compassion. The SCS demonstrated excellent reliability with alpha at .93 (Neff, 2003a, 2003b). Cronbach’s alpha for the SCS, in the present study, was at .89.

Posttraumatic Growth Inventory Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) is a 21- item scale with 5 subscales includes: new possibilities, relating to others, personal strength, spiritual change, and appreciation of life. This scale has the ability to determine how successful individuals coping with the aftermath of trauma are in reconstructing or strengthening their perception of self, others, and the meaning of events. The posttraumatic growth inventory is modestly related to optimism and extraversion (Tedeschi & Calhoun, 1996). Cronbach’s alpha for the PTGI in the present study was at .79.

Cognitive Fusion Questionnaire Cognitive Fusion Questionnaire (CFQ; Gillanders et al., 2014) is a 7-item measure that assesses cognitive fusion. Responses are rated from 1 (never true) to 7 (always true), where a higher score indicates higher cognitive fusion. The CFQ showed strong positive correlations with measures of experiential avoidance, frequency of negative thoughts, depression and anxiety symptoms, and burnout. Conversely, CFQ scores showed negative correlations with measures of mindfulness skills and life satisfaction. Gillanders et al. (2014)found that the CFQ was uni-factorial and that scores on the items evidenced good internal consistency (as ranging from .88 to .93). In the present research, the internal consistency with Cronbach’s alpha was at .80.

Childhood Trauma Questionnaire Childhood Trauma Questionnaire (CTQ; Bernstein et al., 2003)isa28-item assesses emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Each scale is presented on a 5-point Likert-type scale ranging from 5 to 25. The total CTQ score indicates the severity of multiple forms of abuse and neglect. The internal consistency coefficients of the original version ranged from .61 (physical neglect) to .95 (sexual abuse) (Bernstein et al., 2003). JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 5

Results Table 1 shows means and standardized deviation as well as bivariate correlations of the study variables. Distress tolerance and self-compassion were positively correlated with posttraumatic growth and negatively with cognitive fusion. Also, cognitive fusion was negatively correlated with posttraumatic growth. Path analysis was performed to examine the mediating role of cognitive fusion in the relationship of distress tolerance and self-compassion to posttraumatic growth (Figure 1).

Discussion This study examined the relationships of distress tolerance and self- compassion with posttraumatic growth as well as the mediating role of cognitive fusion. This study is the first to examine the mediating role of cognitive fusion in the relationships of distress tolerance and self-compassion with posttraumatic growth. We found a positive relationship between distress tolerance with posttraumatic growth in addition to a negative relationship with cognitive fusion, confirming hypotheses 1 and 2 which is consistent with previous studies (e.g. Vujanovic et al., 2013). Zhou et al. (2018) showed that control and regulate excitement have direct relationships with posttraumatic growth. Other researchers found that childhood maltreatment had a relationship with lower distress tolerance (Berenz et al., 2017); individuals with high distress tolerance were more capable of approaching negative emotions of stressful situations and accepting them. Therefore, growth and development are more likely to occur after experiencing stressful and traumatic events to them. Consequently, distress tolerance may affect a variety of processes involved in many aspects of behavior affecting the deployment of attention, appraisals of distress, and modulation of responses to distress (Simons & Gaher, 2005). Moreover, as hypotheses 1 and 2 proposed, self-compassion was positively related to posttraumatic growth and negatively related to cognitive fusion, something which was consistent with previous studies (Gillanders, Sinclair, MacLean, & Jardine, 2015). It is fair to state that those who are mistreated in childhood have lower self-compassion and in adolescence suffer more from both emotional regulation difficulties (Vettese, Dyer, Li, & Wekerle, 2011) and mental disorders (Tanakaa, Wekerle, Lou Schmuckc, & Paglia-Boak, 2011). Self-compassionate individuals tend to use more adaptive strategies to cope with negative life experiences in stressed situations and can more easily cope with trauma (Allen & Leary, 2010). They also tend to have a positive attitude toward their life experiences. In life-crisis, they are more likely to seek meaning in life with this type of thinking which facilitates posttraumatic growth. Furthermore, a negative relationship was found 6 .BSAPO TAL. ET BASHARPOOR S.

Table 1. Means, standard deviation, and correlations among study variables. M±SD123456 7 891011121314 1. Posttraumatic growth 53.90 ± 17.63 1 2. Cognitive fusion 31.73 ± 9.73 −.36** 1 Distress tolerance 3. Tolerance 6.89 ± 2.96 .31** −.33** 1 4. Abbsorption 6.82 ± 2.98 .47** −.39** .69** 1 5. Appraisal 14.35 ± 4.63 .34** −.37** .64** .67** 1 6. Regulation 7.90 ± 2.90 −.03 −.06 .26** .23** .33** 1 7. Total 35.97 ± 10.67 .61** −.38** .82** .82** .89** .55** 1 Self-compassion 8. self-kindness 8.47 ± 3.82 .58** −.40** .26** .25** .23** −.10 41** 1 9. Common humanity 7.06 ± 3.51 .47** −.40** .24** .29** .33** −.01 .21* .54** 1 10. Mindfulness 8.24 ± 2.86 .44** −.23** .21* −.27** .22** −.21 .25** .40** .31** 1 11. Self-judgment 15.55 ± 2.25 −.31** .50** −.29** .32** −.33** −.02 −.32** −.32** −.28** −.13 1 12. Isolation 12.55 ± 1.81 −.32** −.32** −.34** .27** −.31** .06 −.29** −.28** −.22* −.04 .52** 1 13. Over identification 12.36 ± 3.26 −.04 .18* −.09 −.12 −.09 −.05 −.11 .10 −.11 −.10 .38** .24** 1 14. Total 35.78 ± 11.05 .36** −.53** .31** .37** .37** −.06 .32** .81** .70** .48** −.61** −.56** −.04 1 *p < .05. **p < .01. JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 7

Figure 1. Standardized parameter estimates of final structural model. Path diagram represents the relationships of distress tolerance and self-compassion to posttraumatic growth through cognitive fusion. The dotted line is not significant, while solid lines indicate significance at p < .05. Note: PGI, post-traumatic growth; RO, relating to others; NP, new possibilities; PS, personal strength; SC, spiritual change AL, appreciation of life; TO, tolerance; AP, appraisal; AB, absorption; RE, regulation;OID,over-identification;ISOL,isolation;SJ,self-judgment;SK,self-kindness;CH,common humanity; MF, mindfulness.

between cognitive fusion and posttraumatic growth as hypothesized. Cognitive fusion is one of the factors affecting the quality of life. In fact, it is able to predict the quality of life (Gillanders, Ashleigh, Margaret, & Kirsten, 2015). Those with high cognitive fusion are more likely to experience posttraumatic stress disorder (Bardeen & Fergus, 2016). Structural equation model showed that cognitive fusion mediated the relationship between distress tolerances with posttraumatic growth, according to hypothesis 3. In other words, cognitive fusion mediated negatively the relationship between distress tolerance and PTG. Theoretically; distress tolerance may affect or be affected by a number of processes related to self-regulation, includ- ing attention, cognitive assessments of emotional or physical distress. For example, individual differences in the experience of emotions – both their intensity and their frequency – may affect the nature of distress tolerance. People with lower levels of distress may be subject to a maladaptive response to distress and distress-inducing conditions. It should be noted that cognitive fusion is a fundamental structure within acceptance and commitment therapy and seems to have a crucial role in the development and maintenance of psychopathology (Pinto-Gouveia, Dinis, Gregório, & Pinto, 2018), and 8 S. BASHARPOOR ET AL. inflexibility (Tyndall, Waldeck, Riva, Wesselmann, & Pancani, 2018). According to the study conducted by Soltani, Hosseini, and Naghizadeh (2018), cognitive fusion is the strongest predictor of anxiety which leads to the inability to perceive cognitive issues from different perspectives, emotional reactions to thoughts and behavior excessively modified by cognition, over analyzing situations, and evaluation and judgment of thoughts. These processes may affect distress tolerance and reduce of anxiety and capacity of an individual to cope with the vicissitudes and, respectively, reduce posttraumatic growth. The final results did not support hypotheses 4. In fact, they indicate that cognitive fusion did not mediate the relationship between self-compassion and posttraumatic growth. One reason that it did not significantly predict cognitive fusion lies in the important and essential components of self- compassion. Self-kindness, mindfulness, and common humanity are significant factors against negative thoughts (Neely, Schallert, Mohammed, Roberts, & Chen, 2009). In addition, Self-compassion serves as a buffering factor against worry and negative thoughts (Mowlaie et al., 2017). All of these components help people be warmhearted toward themselves. Suffering and personal failure are among shared human experiences and also require a balanced approach to negative emotions so that feelings are neither sup- pressed nor exaggerated in pain and traumatic events. Therefore, cognitive fusion was unable to mediate the effects of self-compassion on PTG. There were a few research constraints. First, all variables were measured by self-reported scales. It is recommended that future studies use other psychometricinstrumentssuchasinterviewsandshortversionsof questionnaires. Second, this study was conducted on people who experienced sexual, physical, and emotional abuse. Therefore, external validity might be affected. Generalization to other groups of people with different traumatic experiences must be conducted with caution. It could be useful in future to study other groups to test the generalizability of our findings. Third, we examined only cognitive fusion as a mediating factor. Future studies could also analyze whether other variables operate in the same manner as cognitive fusion. Despite these limitations, this study provided new knowledge to previous researches on the relationships between distress tolerance, self-compassion, cognitive fusion, and PTG. The research findings were in line with other studies expanding the applicability of these variables in therapy and psychological interventions, especially for people who had traumatic experiences. Therapies based on distress tolerance and self-compassion can help these people to better cope with their stressful and traumatic experiences.

Conflict of Interest The authors declare that they have no conflicts of interest. JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 9

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki decoration and its later amendments or comparable ethical standards.

Funding

This research was supported by the University of Mohaghegh Ardabili University [Project No. 21199], [1727].

ORCID

Sajjad Basharpoor http://orcid.org/0000-0002-2920-2605

References

Allen, A. B., & Leary, M. R. (2010). Self-compassion, stress, and coping. Social and Personality Psychology, 4(2), 107–118. Anestis, M. D., & Joiner, T. E. (2012). Behaviorally-indexed distress tolerance and suicidality. Journal of Psychiatric Research, 46(6), 703–707. doi:10.1016/j.jpsychires.2012.02.015 Bahk, Y. C., Jang, S. K., Choi, K. H., & Lee, S. H. (2017). The relationship between childhood trauma and suicidal ideation: Role of maltreatment and potential mediators. Psychiatry Investigation, 14(1), 37–43. Bardeen, J. R., & Fergus, T. A. (2016). The interactive effect of cognitive fusion and experiential avoidance on anxiety, depression, stress and posttraumatic stress symptoms. Journal of Contextual Behavioral Science, 5(1), 1–6. doi:10.1016/j.jcbs.2016.02.002 Berenz, E. C., Vujanovic, A., Rappaport, L. M., Kevorkian, S., Gonzalez, R. E., & Chowdhury, N. (2017). A multimodal study of childhood trauma and distress tolerance in young adulthood. Journal of Aggression, Maltreatment &trauma, 1(1), 1–16. Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., … Zule, W. (2003). Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abuse & Neglect, 27(2), 169–190. doi:10.1016/S0145-2134(02) 00541-0 Bluth, K., Roberson, P. N. E., Gaylord, S. A., Faurot, K. R., Grewen, K. M., Arzon, S., & Girdler, S. S. (2015). Does self-compassion protect adolescents from stress? Journal of Child and Family Studies, 25(4), 1098–1109. doi:10.1007/s10826-015-0307-3 Burns, E. E., Fischer, S., Jackson, J. L., & Harding, H. G. (2012). Deficits in emotion regulation mediate the relationship between childhood abuse and later eating disorder symptoms. Child Abuse & Neglect, 36(1), 32–39. doi:10.1016/j.chiabu.2011.08.005 Duarte, C., & Pinto-Gouveia, J. (2017). The impact of early shame memories in Binge Eating Disorder: The mediator effect of current body image shame and cognitive fusion. Psychiatry Research, 258, 511–517. doi:10.1016/j.psychres.2017.08.086 Fan, F., Zhang, Y., Yang, Y., Mo, L., & Liu, X. (2011). Symptoms of posttraumatic stress disorder, depression, and anxiety among adolescents following the 2008 Wenchuan earthquake in China. Journal of Traumatic Stress, 24(1), 44–53. doi:10.1002/jts.20599 10 S. BASHARPOOR ET AL.

Follette, V., Palm, K. M., & Pearson, A. N. (2006). Mindfulness and trauma: Implications for treatment. Journal of Rational-emotive and Cognitive-behavior Therapy, 24(1), 45–61. doi:10.1007/s10942-006-0025-2 Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: Pilot results. Behavior Research and Therapy, 44(3), 415–437. doi:10.1016/j.brat.2005.02.007 Gillanders, D., Ashleigh, K. S., Margaret, M., & Kirsten, J. (2015). Illness cognitions, cognitive fusion, avoidance and self-compassion as predictors of distress and quality of life in a heterogonous sample of adults, after cancer. Journal of Contextual Behavioral Science, 4 (4), 300–311. doi:10.1016/j.jcbs.2015.07.003 Gillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., & Remington, B. (2014). The development and initial validation of the cognitive fusion questionnaire. Behavior Therapy, 45,83–101. doi:10.1016/j.beth.2013.09.001 Gillanders, D. T., Sinclair, A. K., MacLean, M., & Jardine, K. (2015). Illness cognitions, cognitive fusion, avoidance and self-compassion as predictors of distress and quality of life in a heterogeneous sample of adults, after cancer. Journal of Contextual Behavioral Science, 4, 300–311. doi:10.1016/j.jcbs.2015.07.003 Gul, E., & Karanci, A. N. (2017). What determines posttraumatic stress and growth following various traumatic events? A study in a Turkish community sample. Journal of Traumatic Stress, 30(1), 54–62. doi:10.1002/jts.22161 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford. Hund, A. R., & Espelage, D. L. (2006). Childhood emotional abuse and disordered eating among undergraduate females: Mediating influence of alexithymia and distress. Child Abuse &Neglect, 30(4), 393–407. doi:10.1016/j.chiabu.2005.11.003 Juarascio, A., Shaw, J., Forman, E., Timko, C. A., Herbert, J., Butryn, M., & Lowe, M. (2013). Acceptance and commitment therapy as a novel treatment for eating disorders: An initial test of efficacy and mediation. Behavior Modification, 37(4), 459–489. doi:10.1177/ 0145445513478633 Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford press. Mitchell, E. (2017). Posttraumatic Growth, the Physically Active Body, and Self-Compassion. Dissertation (Doctor of Philosophy (Ph.D)). Oregon State University Citeable URL. Mowlaie, M., Mikaeili, N., Agababaei, N., Ghaffari, M., & Pouresmali, A. (2017). The relationships of sense of coherence and self-compassion to worry: The Mediating role of personal intelligence. Current Psychology, 36(3), 630–636. doi:10.1007/s12144-016- 9451-1 Neely, M. E., Schallert, D. L., Mohammed, S. S., Roberts, R. M., & Chen, Y. J. (2009). Self- kindness when facing stress: The role of self-compassion, goal regulation, and support in college students’ well-being. Motivation and Emotion, 33,88–97. doi:10.1007/s11031-008- 9119-8 Neff, K. D. (2003a). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2,85–102. doi:10.1080/15298860309032 Neff, K. D. (2003b). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223–250. doi:10.1080/15298860309027 Neff, K. D., & McGeheea, P. (2010). Self-compassion and psychological resilience among adolescents and young adults. Self and Identity, 9,225–240. doi:10.1080/15298860902979307 Pinto-Gouveia, J., Dinis, A., Gregório, S., & Pinto, A. M. (2018). Concurrent effects of different psychological processes in the prediction of depressive symptoms–the role of cognitive fusion. Current Psychology,1–12. doi:10.1007/s12144-017-9767-5 JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 11

Rzeszutek, M., Oniszczenko, W., & Kwiatkowska, B. (2017). Stress coping strategies, spirituality, social support and posttraumatic growth in a Polish sample of rheumatoid arthritis patients. Psychology, Health & Medicine, 22(9), 1082–1088. doi:10.1080/13548506.2017.1280174 Schäfer, I., Harfst, T., Aderhold, V., Briken, P., Lehmann, M., Moritz, S., & Naber, D. (2006). Childhood trauma and dissociation in female patients with schizophrenia spectrum disorders: An exploratory study. The Journal of Nervous and Mental Disease, 194(2), 135–138. doi:10.1097/01.nmd.0000198199.57512.84 Simons, J. S., & Gaher, R. M. (2005). The distress tolerance scale: Development and validation of a self-report measure. Motivation and Emotion, 29(2), 83–102. doi:10.1007/s11031-005- 7955-3 Siqveland,E.,Nygaard,E.,Hussain,A.,Tedeschi,R.G.,&Heir,T.(2015). Posttraumatic growth, depression and posttraumatic stressinrelationtoqualityoflifeintsunami survivors: A longitudinal study. Health and Quality of Life Outcomes, 13(18). doi:10.1186/s12955-014-0202-4 Soltani, E., Hosseini, Z., & Naghizadeh, P. (2018). Relationship between experiential avoidance and cognitive fusion to Social Interaction Anxiety in Students. Shiraz E-Medical Journal, 19(6). doi:10.5812/semj.62496 Tanakaa, M., Wekerle, C., Lou Schmuckc, M., & Paglia-Boak, A. (2011). The linkages among childhood maltreatment, adolescent mental health, and self-compassion in child welfare adolescents. Journal of Child Abuse and Neglect, 35, 887–898. doi:10.1016/j. chiabu.2011.07.003 Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455–471. doi:10.1002/(ISSN) 1573-6598 Twohig, M. P. (2009). The application of acceptance and commitment therapy to obsessive-compulsive disorder. Cognitive and Behavioral Practice, 16(1), 18–28. doi:10.1016/j.cbpra.2008.02.008 Twohig, M. P., Shoenberger, D., & Hayes, S. C. (2007). A preliminary investigation of acceptance and commitment therapy as a treatment for marijuana dependence in adults. Journal of Applied Behavior Analysis, 40(4), 619–632. doi:10.1901/jaba.2007.619-632 Tyndall, I., Waldeck, D., Riva, P., Wesselmann, E. D., & Pancani, L. (2018). Psychological flexibility and ostracism: Experiential avoidance rather than cognitive fusion moderates distress from perceived ostracism over time. Journal of Contextual Behavioral Science, 7, 72–80. doi:10.1016/j.jcbs.2018.02.001 Van der Kooij, I. W., Nieuwendam, J., Bipat, S., Boer, F., Lindauer, R. J., & Graafsma, T. L. (2015). A national study on the prevalence of child abuse and neglect in Suriname. Child Abuse & Neglect, 47, 153–161. doi:10.1016/j.chiabu.2015.03.019 Vettese, L. C., Dyer, C. E., Li, W. L., & Wekerle, C. (2011). Does self-compassion mitigate the association between childhood maltreatment and later emotion regulation difficulties? A preliminary investigation. International Journal of Mental Health and Addiction, 9(5), 480–491. doi:10.1007/s11469-011-9340-7 Vujanovic, A. A., Hart, A. S., Potter, C. M., Berenz, E. C., Niles, B., & Bernstein, A. (2013). Main and interactive effects of distress tolerance and negative affect intensity in relation to PTSD symptoms among trauma-exposed adults. Journal of Psychopathology and Behavioral Assessment, 35(2), 235–243. doi:10.1007/s10862-012-9325-2 Zettle, R. D. (2003). Acceptance and commitment therapy (ACT) vs. systematic desensitiza- tion in treatment of mathematics anxiety. The Psychological Record, 53(2), 197–215. doi:10.1007/BF03395440 12 S. BASHARPOOR ET AL.

Zhou, X., Wu, X., An, Y., & Fu, F. (2014). Longitudinal relationships between post traumatic stress symptoms and sleep problems in adolescent survivors following the Wenchuan earthquake in China. PloS One, 9(8), e104470. doi:10.1371/journal.pone.0104470 Zhou, X., Wu, X., & Zhen, R. (2018). Self-esteem and hope mediate the relations between social support and post-traumatic stress disorder and growth in adolescents following the Ya’an earthquake. Anxiety, Stress & Coping, 31(1), 32–45. doi:10.1080/10615806.2017.1374376