Journal of Contextual Behavioral Science 19 (2021) 86–91
Contents lists available at ScienceDirect
Journal of Contextual Behavioral Science
journal homepage: www.elsevier.com/locate/jcbs
Empirical Research
Acceptance and commitment group therapy among Saudi Muslim females
with mental health disorders
Mashael Bahattab a, b, Ahmad N. AlHadi c, d, *
a
Notre Dame de Namur University, Belmont, United States
Psychiatry Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
c
Psychiatry Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
d
SABIC Psychological Health Research and Applications Chair (SPHRAC), Psychiatry Department, College of Medicine, King Saud University Medical City, King Saud
University, Riyadh, Saudi Arabia
b
A R T I C L E I N F O
A B S T R A C T
Keywords:
Acceptance and commitment therapy
Saudi Arabia
Muslim
Depression
Anxiety
Introduction: This study aimed to examine the potential acceptance, feasibility, and clinical impact of Acceptance
and Commitment Therapy (ACT) in a group format for Saudi women who struggle with depression and anxiety
disorders. The findings may help clinicians in Saudi Arabia and other Muslim communities to be aware of ACT as
an emerging therapeutic approach for treating depression and anxiety and related conditions.
Methods: Eight women with depression and anxiety in Riyadh city in the year 2017 were included in the study. A
qualitative design was used for this study to test the possible effectiveness of and receptivity to a group treatment
protocol based on ACT among Muslim Saudi females. The ACT group met for one 1.5-h session per week for 8
consecutive weeks. Thematic analysis techniques were employed. To explore and describe participants’ expe­
riences, the data were analyzed for emerging themes that were then identified and coded.
Results: The results showed preliminary support that ACT could be an effective, well-received therapeutic
approach for Muslim Saudi women as far as decreasing symptoms of depression and anxiety and making an
overall positive change in their attitudes and behavior, as well as increasing self-confidence.
Conclusions: ACT group therapy was well appreciated and viewed as being culturally and religiously acceptable
by the Saudi Muslim female participants. The present results support the notion that ACT is well appreciated as a
potential means of reducing depression and anxiety and can help enhance positive emotions and increase the
psychological well-being of Saudi women.
1. Background
Cognitive behavior therapy (CBT) is considered an effective thera­
peutic method for depression and anxiety disorders. Acceptance and
commitment therapy (ACT) is a new therapeutic form of CBT that, ac­
cording to a growing number of studies, offers remarkable possibilities
and perspectives in understanding and treating depression and anxiety
(Kohtala, 2015; Boone & Myler, n.d.; Folke, Parling, & Melin, 2012;
Rahmani & Rahmani, 2015; Dousti, Mohagheghi, & Jafari, 2015; and
Azadeh, Zahrani, and Besharat, 2016). Individuals who have symptoms
of either depression or anxiety usually struggle because they try to reject
or avoid their unwanted inner experiences. ACT refers to this rejection
as psychological inflexibility and experiential avoidance, which means
the inability to accept distressing thoughts and feelings as they arise
(Arch et al., 2012; Bluett et al., 2014; Hayes, Luoma, Bond, Masuda, &
Lillis, 2006). In contrast to psychological inflexibility, ACT has proposed
a model based on psychological flexibility that consists of six core pro­
cesses: flexible attention to the present moment, chosen values,
committed action, self-as-context, defusion, and acceptance (Luoma,
Hayes, & Walser, 2007).
According to Tanhan (2014) and Yavuz (2016), there are a few
shared characteristics between the fundamental ideas of ACT and Islam,
which may make ACT a fitting choice for helping Muslim clients. The
commonality between the six core processes of ACT and Muslims’ beliefs
and practices will be explained.
Being in the present moment is “the ability to create space to be in
* Corresponding author. SABIC Psychological Health Research and Applications Chair (SPHRAC), Department of Psychiatry, College of Medicine, King Saud
University Medical City, King Saud University, POBox 7805(55), Riyadh, 11472, Saudi Arabia.
E-mail addresses: mashaelbahattab@gmail.com (M. Bahattab), alhadi@ksu.edu.sa (A.N. AlHadi).
https://doi.org/10.1016/j.jcbs.2021.01.005
Received 27 September 2020; Received in revised form 9 January 2021; Accepted 17 January 2021
Available online 20 January 2021
2212-1447/© 2021 The Author(s). Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Bahattab and A.N. AlHadi
Journal of Contextual Behavioral Science 19 (2021) 86–91
the here-and-now in an open, receptive, and nonjudgmental mood”
(Hayes, Strosahl, & Wilson, 2012, p. 205). This concept is significant in
Islam, in which it could be practiced in several ways, such as the bodily
attitude prayers. When engaging in the correct way of prayer, Muslims
should be focused on every movement and word they recite while
praying and not focused on their worries and concerns. However, when
it happens that someone gets fused with any aspect of their internal
experience (thoughts, feelings or sensations), Islamic scholars recom­
mend that a Muslim should come back to what they are reciting and
doing without judging themselves (Tanhan, 2014).
The observing-self is “understanding/experiencing the self as a
continuity of consciousness beyond one’s feelings, thoughts, sensations,
experiences, etc.” (Hayes et al., 2012, p. 206). It is one of the other two
aspects of self in ACT; the conceptualized self (or self-as-content) and the
self that is aware of all content (self-as-context) (Hayes et al., 2012). All
the three types of self from the ACT perspective could be seen in Islam as
well; the Holy Qur’an indicates that everyone has a multilevel sense of
self (nafs) (Yavuz, 2016).
Defusion is “making closer contact with verbal events as they really
are, not merely as what they say they are” (Hayes et al., 2012, p. 244).
According to ACT, defusion can be created through metaphors and
experiential activities, while in Islam, defusion can be facilitated
through religious activities such as prayers, stories, and sacred texts to
help the individual to look at thoughts, feelings, sensations as they are,
not as if they were wholly real (Tanhan, 2019).
Acceptance is “the willingness to experience inner states, regardless
of whether they are experienced as pleasant or unpleasant” (Hayes,
2010, p. 206). One of the main concepts in Islam is called sabr. The
purpose and function of sabr is the willingness to accept unwanted inner
or external experiences (Yavuz, 2016). This can be seen through the
word alhamdulillah, one of the most common words that Muslims use in
all conditions regardless of pleasant or unpleasant experience/situations.
This word means taking time/space for that specific experience rather
than running away from it (Tanhan, 2019).
Value is “clarifying what is important to the way one desires to live
life” (Hayes et al., 1999; as cited in Springer, 2012, p. 207). The kinds of
value-based questions in ACT are in line with Islamic principles. Islam
encourages people to think of their actions and goals, as well as what
they want to stand for (Tanhan, 2014).
Committed action “involves flexible moving toward goals that are
consistent with one’s values” (Hayes et al., 1999; as cited in Springer,
2012, p. 207). Similar to ACT, Islam stresses that Muslims should create
their goals according to their values. The Holy Quran emphasizes the
importance of taking actions in almost all verses that mention faith,
which indicates the importance of creating goals according to values and
taking actions from a contextual and mindful perspective. (Tanhan,
2014).
All of the above points to the similarities between ACT and Islamic
principles, which is the main source and guide Saudis refer back to.
Given this, the author thought that ACT would have high probability of
enhancing the mental health in Saudi Arabia in general and specifically
for those with depression and anxiety keeping in mind higher prevalence
among females. In a study that aimed to explore the prevalence of
psychiatric disorders among visitors to faith healers in Saudi Arabia, the
authors found that depression and anxiety disorders were the most
common disorders among the study participants (Alosaimi et al., 2014).
We aimed in this study to identify the applicability and clinical impact of
Acceptance and Commitment Therapy (ACT) in a group format for Saudi
women who struggle with depression and anxiety disorders.
psychiatrists and psychologists working at King Saud University Medical
City.
Individuals interested in participating contacted the researcher via
telephone or e-mail (as indicated on the flyer). An initial intake inter­
view was scheduled to briefly explain the study format to interested
individuals. A consent form was then provided to those who remained
interested in taking part in the study. Once a total of eight individuals
had provided their consent to participate, the start date and time for the
group sessions was sent to the participants. At the end of the study, upon
completion of the research, a debriefing statement was provided to all
participants.
2.2. Design
This study used a qualitative design. Data were gathered through
interviews with eight Saudi females who had a diagnosis of depression
and anxiety. The possible effectiveness of and receptivity to ACT among
Muslim Saudi females were examined using a thematic analysis (Braun
& Clarke, 2006) of all participant narratives drawn from interviews
conducted following their participation in the eight weekly ACT group
therapy sessions. The length of the interviews varied somewhat from one
participant to another; some gave relatively short answers while others
elaborated more. Owing to a scheduling issue, sessions 7 and 8 were held
on the same day during week 8. All interviews were conducted, recor­
ded, and subsequently transcribed by the first author, M. B., who also
did the coding process.
2.3. Research protocol
The method of qualitative analysis was Braun and Clarke’s (2006)
Thematic Analysis (TA) process, which involves the following six steps:
1) Familiarizing yourself with your data, 2) Generating initial codes, 3)
Searching for themes, 4) Reviewing themes, 5) Defining and naming
themes, and 6) Producing the report on the aim of the study. Data were
collected and these six steps were utilized to find common themes that
emerged from the responses given by the participants. Themes that
surfaced amongst multiple interviews suggested generalizability, at least
across this sample.
2.4. Confidentiality
The identities of the participants and any revealing information were
kept anonymous by implementing a numeric coding system to store
data. Any personally identifying information was kept confidential. All
the notes from the interviews were secured by a password on a private
laptop. Collected data were used only for research purposes. Ethical
approval was granted from the King Saud University institutional review
board before data collection began. No incentives were offered to
participants.
3. Materials and measures
A list of open-ended questions, presented in Table 1, was asked
following the eight-week intervention. Scheduled individual face-toface interviews took approximately 60 min to complete and explored
participants’ experiences with taking part in the ACT group therapy. All
interviews were recorded and transcribed for analysis.
3.1. Procedure
As noted, the participants were eight Saudi females aged 18–60
years, with a diagnosis of depression or/and anxiety disorders. All the
participants were from Riyadh, Saudi Arabia.
The ACT group therapy consisted of eight weekly meetings. Sessions
were given utilizing a protocol that Matthew S. Boone and Cory Myler
created for a depression and anxiety group (Boone & Myler, n.d.); all the
2. Methods
2.1. Participants
A total of eight Saudi females who had a diagnosis of depression and
anxiety were recruited to participate in the study with the assistance of
87
M. Bahattab and A.N. AlHadi
Journal of Contextual Behavioral Science 19 (2021) 86–91
evaluate the potential acceptance, feasibility, and clinical impact of ACT
group therapy on them.
In terms of clinical supervision, the student was supervised as fol­
lows: first, a Licensed Clinical Psychologist, through VSee (combining
HIPAA video chat, device integration, and health data visualization);
and second, direct clinical supervision conducted by a consultant psy­
chiatrist (second author) who had received fellowship training in psy­
chotherapy and ACT.
Previous research states that ACT is effective among several pop­
ulations who suffer from various mental health disorders (Abbasi et al.,
2015; Azadeh, Zahrani, and Besharat, 2016; Bluett, 2017, p.
2014Molavi, Mikaeili, Rahimi, & Mehri,; Vakili & Gharraee, 2014).
Table 1
Interview questions for participants.
Questions for Participants in English
Questions for Participants in Arabic
• Self-Description:
1. How did it feel to be in ACT
therapy?
• Changes:
2. Have you noticed any specific
changes in yourself after having
participated in the ACT therapy?
For example, are you doing, feeling,
or thinking differently from the
way you did before?
3. What specific ideas, if any, have
you gotten from therapy so far,
including ideas about yourself or
other people? Have any changes
been brought to your attention by
other people?
4. Has anything changed for the
worse since ACT therapy began?
5. Is there anything that you
wanted to change that hasn’t
changed since ACT therapy began?
• Problematic Aspects:
6. Have you found anything about
ACT therapy that has been
hindering, unhelpful, negative or
disappointing for you? These items
may include general aspects and/or
specific events.
7. Were there things in ACT therapy
that were difficult or painful, but
still OK or perhaps helpful? What
were these?
8. Was anything missing from ACT
therapy? What would have made
your therapy more effective or
helpful?
• Religious and cultural aspects:
9. Do you think the six core
processes of ACT therapy are
consistent or inconsistent with
Islamic principles?
10. What is your perspective
regarding the group format of ACT
therapy?
• ‫ﻭﺹﻑ ﺫﺍﺕﻱ‬:
1. ‫ﻙﯼﻑ ﻙﺍﻥﺕ ﺕﺝﺭﺏﺕﻙ ﻡﻉ ﻉﻝﺍﺝ‬
‫ﺍﻝﺕﻕﺏﻝ ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺝﻡﻉﻱ؟‬
• ‫ﺕﻍﻱﻱﺭﺍﺕ‬:
2. ‫ﻩﻝ ﻝﺍﺡﻅﺕ ﺃﻱ ﺕﻍﻱﺭﺍﺕ ﻑﻱ ﻥﻑﺱﻙ‬
‫ﺏﻉﺩ ﻡﺵﺍﺭﻙﺕﻙ ﻑﻱ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ‬
‫ ﮪﻝ ﮪﻥﺍﻙ ﺃﻱ‬:‫ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺝﻡﻉﻱ؟ ﻡﺙﻝ‬
‫ﺕﻍﻱﻱﺭ ﻑﻱ ﻡﺵﺍﻉﺭﻙ ﺃﻭ ﺃﻑﻙﺍﺭﻙ؟‬
3. ‫ﮪﻝ ﮪﻥﺍﻙ ﺃﻱ ﺃﻑﻙﺍﺭ ﻡﺡﺩﺩﺓ‬
‫ﺍﻙﺕﺱﺏﺕﯼﮪﺍ ﻡﻥ ﺥﻝﺍﻝ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ‬
‫ ﺃﻑﻙﺍﺭ ﻉﻥ ﻥﻑﺱﻙ ﺃﻭ ﻉﻥ‬،‫ﻭﺍﻝﺍﻝﺕﺯﺍﻡ‬
‫ﺃﺵﺥﺍﺹ ﺁﺥﺭﻱﻥ؟ ﻡﺍ ﻩﻱ؟‬
4. ‫ﮪﻝ ﮪﻥﺍﻙ ﺃﻱ ﺕﻍﻱﻱﺭﺍﺕ ﻝﻝﺃﺱﻭﺃ ﻡﻥﺫ‬
‫ﺍﻥﺽﻡﺍﻡﻙ ﻝﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ ﻭﺍﻝﺍﻝﺕﺯﺍﻡ‬
‫ﺍﻝﺝﻡﻉﻱ؟‬
5. ،‫ﮪﻝ ﮪﻥﺍﻙ ﺃﻱ ﺕﻍﻱﻱﺭﺍﺕ ﺃﺭﺩﺕ ﺡﺩﻭﺙﻩﺍ‬
‫ﻭﻝﻙﻥﻩﺍ ﻝﻡ ﺕﺡﺩﺙ ﻡﻥﺫ ﺏﺩﺀ ﻉﻝﺍﺝ‬
‫ﺍﻝﺕﻕﺏﻝ ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺝﻡﻉﻱ؟‬
4. Results
Seven of the eight study participants were included in the ACT group
therapy. One participant who had social anxiety and was afraid of
having panic attacks if she participated received the ACT therapy
intervention individually following the same group protocol.
A brief description of all research participants is provided here, with
numbers to protect participants’ anonymity and confidentiality. All
participants fit the criteria of being Saudi Muslim adults who have
depression or/and anxiety disorders. Also, the participants’ ages were
between 21 and 46 years old. Most of them had bachelor’s degrees,
while two of the participants were medical students.
Through data analysis, the following themes emerged: (1) the par­
ticipants’ perceptions of ACT intervention; (2) ACT in Saudi culture and
Islamic society; and (3) the benefits of ACT in general as well as in terms
of its specific components: acceptance, cognitive defusion, being pre­
sent, observing self, values, committed actions, practicing mindfulness,
and the behavioral effect. All themes were evidenced across the 8 study
participants (Table 2).
6. ‫ﮪﻝ ﻭﺝﺩﺕ ﺵﻱﺉﺍ ﻑﻱ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ‬
‫ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺝﻡﻉﻱ ﻙﺍﻥ ﻝﻩ ﺃﺙﺭ ﺱﻝﺏﻱ‬
‫ﺃﻭ ﻍﻱﺭ ﻡﻑﻱﺩ ﺃﻭ ﻡﺥﻱﺏ ﻝﻝﺁﻡﺍﻝ؟ ﻑﻱ‬
‫ ﺝﻭﺍﻥﺏ‬:‫ﺍﻝﻉﻝﺍﺝ ﺃﻭ ﺃﻥﺵﻁﺓ ﻡﺡﺩﺩﺓ ﻡﺙﺍﻝ‬
‫ ﺃﺡﺩﺍﺙ ﻡﻉﻱﻥﺓ‬،‫ﻉﺍﻡﺓ‬.
7. ‫ﮪﻝ ﻙﺍﻥ ﻩﻥﺍﻝﻙ ﺃﻱ ﺝﻭﺍﻥﺏ ﻡﺅﻝﻡﺓ ﺃﻭ‬
‫ﺹﻉﺏﺓ ﻑﻱ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ ﻭﺍﻝﺍﻝﺕﺯﺍﻡ‬
‫ ﻝﻙﻥﻩﺍ ﻙﺍﻥﺕ ﻡﻑﻱﺩﺓ ﻥﻭﻉﺍ ﻡﺍ؟‬،‫ﺍﻝﺝﻡﻉﻱ‬
‫ﻡﺍ ﻩﻱ ﺕﻝﻙ ﺍﻝﺝﻭﺍﻥﺏ؟‬
8. ‫ﻡﺍﺫﺍ ﻙﺍﻥ ﻱﻥﻕﺹ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ‬
‫ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺝﻡﻉﻱ ﻝﻱﻙﻭﻥ ﻡﻑﯼﺩﺍ‬
‫ﻭﻑﻉﺍﻝﺍ؟‬
• ‫ﺍﻝﺝﻭﺍﻥﺏ ﺍﻝﺩﻱﻥﻱﺓ ﻭﺍﻝﺙﻕﺍﻑﻱﺓ‬:
9. ‫ﮪﻝ ﺕﻉﺕﻕﺩ ﺃﻥ ﺍﺱﺕﺭﺍﺕﻱﺝﻱﺍﺕ ﻉﻝﺍﺝ‬
‫ﺍﻝﺕﻕﺏﻝ ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺍﻝﺱﺕﺓ‬
‫ﺕﺕﻡﺍﺵﻯ ﻡﻉ ﻡﺏﺍﺩﺉ ﺍﻝﺩﻱﻥ‬
‫ﺍﻝﺇﺱﻝﺍﻡﻱ؟‬
10. ‫ﻡﺍ ﻩﻭ ﺭﺃﻱﻙ ﻑﻱ ﻥﻭﻉ ﻉﻝﺍﺝ ﺍﻝﺕﻕﺏﻝ‬
‫ﻭﺍﻝﺍﻝﺕﺯﺍﻡ ﺏﺵﻙﻝ ﺝﻡﺍﻉﻱ؟‬
4.1. Theme 1: participants’ perceptions of ACT intervention
The effectiveness of the therapy format was received differently. An
advantage of the group format that was highlighted by several of the
participants was the benefit of sharing each other’s experiences and
feelings. Participant 6 noted: “I am not good at expressing my thoughts
and feelings, so the group therapy helped me a lot.” Participant 2 also
added, “hearing the members’ values helped me with clarifying my
values.” Participant 3 thought that in individual therapy format, she
would not have understood that what she has been experiencing is
normal.
Both Participants 5 and 3 emphasized another benefit of being
involved in group therapy, which is gaining a new perspective. How­
ever, Participant 5 shared that she believed the negative side of group
therapy was getting exposed to new fears as a result of listening to the
members’ experiences. Another negative aspect that Participant 5
noticed is that she started doubting herself when the other members said
that they understood the concepts and could apply the techniques. The
same Participant 5, as well as Participant 8, who was in the individual
therapy, indicated that they thought that therapy in an individual
content was translated to Arabic and the sessions led in Arabic, including
the presentation slides and the mindfulness recordings.
The sessions were 1.5 h long and included the following ACT themes:
Session 1: Contact with the present moment; Session 2: Defusion; Session
3: Acceptance/willingness; Session 4: Values; Session 5: Observing self;
Session 6: Committed action; Sessions 7/8: all processes, with a focus on
building greater patterns of committed action in the service of values.
Each group meeting was organized generally as follows: opening
mindfulness exercise, review of LIFE Exercises, assignments from the
previous week, didactic portion with group discussion, experiential ex­
ercise with group discussion, and assignment of LIFE exercises for the
next time. The didactic portion ended in the fifth session and was
reinforced by the readings. More focus on the group “process” and hereand-now discussion occurred in the second half.
The therapist was a female Master’s-level psychology student at
Notre Dame de Namur University. She had completed her one-year
practicum. The student therapist received about 74 h of training on ACT.
There were no expected risks for participants. If they became un­
comfortable in any way, they were free to discontinue their participation
in any group session and/or the study itself. Also, a referral for partic­
ipants was provided should they become distressed at any point in the
study. The referral was a consultant psychiatrist (second author), who
was the direct clinical supervisor at the study site. Upon completion of
the ACT group therapy, each member of the group was interviewed to
Table 2
Participants’ quotes for each theme.
88
Example of each theme
The participants’ quotes
Theme 1: Participants’
Perceptions of ACT
Intervention
Theme 2: ACT in Saudi Culture
and Islamic Society
Theme 3: Benefits of ACT
Participant 6: “There are things that I regret not
doing even though I want so badly to do them.”
Participant 4: “I am sure that ACT strongly
supports the Islamic principles.”
Participant 5: “I thought there was no solution
for what I am going through, but ACT made me
realize that there are still techniques that I
haven’t tried before and could help me to cope.”
M. Bahattab and A.N. AlHadi
Journal of Contextual Behavioral Science 19 (2021) 86–91
format is more helpful because they can focus on themselves.
Another aspect about which the participants had different percep­
tions was the protocol. Most of the participants had the same opinion in
terms of the insufficient length of time of the sessions as well as the
number of sessions. Another element that was pointed out was the lack
of visual aids in the presentation. Most of the participants agreed that
the sessions that included PowerPoint presentations and more photos
were more attractive to them and helped them comprehend the content.
Participant 2 thought that the protocol could have been enriched even
more through the presentation of details of case studies that actually
benefitted from ACT.
An additional component of the protocol that the participants
highlighted was the experiential exercises during sessions. Participant 4
reported: “In the session that you gave me a paper to write down my
painful thoughts and feelings, I began to cry when I saw them in front of
me on the paper. I saw the suffering that was causing me inner pain.”
Participants also shared their experiences when they were asked to
imagine themselves in their 80s and to think about a few value-based
questions that were provided to them.
The last component that the participants discussed regarding the
protocol was the at-home assignments. The assignments were various
readings, mindfulness exercises, and some paperwork. Participant 7
reported that the assigned book in the protocol helped to further clarify
the points that were hard to understand during the sessions. Also,
Participant 4 stated that having a reading assignment at home helped
her to strongly grasp the content in the session, which made her feel
comfortable.
learned to first understand my feelings which helped me to accept
them.”
Cognitive Defusion. Participants had various perceptions of the
cognitive defusion strategies. Participant 3 thought that the strategies
were helpful in terms of distinguishing between what is fact and what is
an opinion that she has about herself or that other people have about
her, and then evaluating whether or not it is beneficial to consider this
opinion. Also, Participant 1 reported, “I liked the idea that our thoughts
are different than ourselves.”
Being Present. Participants stated that when they constantly remind
themselves to bring their awareness to the present moment, they feel
more relaxed, which helped them appreciate even the small things in
their lives. Participant 5 thought that ACT helps to take the most of life
by being present in the moment, “so that we do not miss it and have
regrets later.”
Observing Self. The observing-self component of ACT was repeat­
edly mentioned in the participants’ feedback about their experience.
Participant 2 thought that learning about the observing-self part of her
was a significant discovery. Participant 3 stated that knowing about the
observing-self helped her avoid engaging with her unhelpful thoughts.
Most of the participants mentioned how the weather metaphor reso­
nated with them. Participant 7 reported: “I realized that there is an
original me, regardless of how I feel.”
Values. The participants thought that ACT helped them clarify their
values, which were not present for some of them. Participant 5 stated
that she didn’t tend to pay attention to what she values because she was
not aware of the importance of having her values as a guide for what she
should or should not do. Participant 2 reported that clarifying her values
helped her better regulate her emotions. She explained: “Now when I am
sad, I sit with my sad feelings for a moment and then I try to remind
myself of my goals and where I want to be in 10 years.”
Committed Actions. Participant 3 stated that maintaining a dis­
tance between herself and her thoughts gave her space to think about
whether or not the thoughts were useful in terms of moving toward her
values. Participant 2 agreed that understanding the nature of feelings
helped her allow them to be, and at the same time think of the next step
to move toward her goals as well as where she wants to be in 10 years.
Participant 6 also said: “I learned that I cannot change people around
me, but I can change myself.”
Practicing Mindfulness. The other component of ACT that most of
the participants appreciated was the mindfulness exercises. Participant 7
stated that practicing mindfulness helped her regain her selfempowerment and made her calmer, more relaxed, and active when
she got up in the morning. Participants commented on how mindfulness
helped them with their sleep problems. Participant 7 said, “I started
listening to Sound Cloud recordings before I went to bed, and I noticed
that the thoughts that used to come to my mind, even those coming on a
day of trouble, became much less; now I can fall asleep in an hour and a
half at maximum.” Participant 5 and another participant did express a
negative aspect of practicing mindfulness. Participant 5 reported: “Some
of the mindfulness exercises caused me panic attacks. Facing my
thoughts was what made me panicked.”
Behavioral Effects. The participants discussed several changes they
noticed throughout the eight weeks. Participant 7 reported that ACT
helped her with her weight issue; she lost a few kilograms, which had
always been one of her goals. Participant 4 shared that even though she
realized that her situation was tough and made her cry, she is now much
calmer because she is more willing to accept her feelings.
Finally, Participants 3, 7, and 2 indicated that the quality of their
sleep had clearly improved.
4.2. Theme 2: ACT in saudi culture and Islamic society
All the participants reported feeling that ACT was in line with Saudi
society as well as Islamic principles. They also mentioned that there
were several scripts in the Quran and Hadith (the major source of
guidance for Muslims apart from the Quran) that support the ACT core
processes. Participant 5 noted that, “in this group therapy, we were
given therapeutic strategies and concepts that we have already practiced
and believed.” Participant 1 reported that acceptance is a significant
concept in Islam, but that ACT presented it in a different form.
4.3. Theme 3: benefits of ACT
Participants indicated that they noticed several benefits of being
involved in ACT group therapy in general and as a result of each
component of ACT in particular. Participant 5 thought that ACT teaches
important life skills even for those who do not struggle with mental
health disorders. Participant 2 shared her experience with ACT: “I feel
like my brain has enlarged learning about all of this.” Participant 7
thought this experience made her feel more confident. She also said, “I
felt like I needed someone to save me, and I was actually saved.”
Acceptance. The participants reported that the concept of accep­
tance was a bit of a challenge for them because they were used to
rejecting and escaping from their pain in different ways. Participant 7
reported, “I could not accept the idea of accepting my pain. I thought
acceptance was just a philosophical word, but I have realized later that it
is true, and it is in my hands to choose to accept.”
The participants indicated that they had a strong belief that, for them
to live meaningful lives, they should first get rid of their painful thoughts
and feelings. They also stated that what significantly helped them accept
their unwanted thoughts was their awareness of the nature of thoughts
and the fact that they come and go. Also, most of the participants
expressed their appreciation of the fact that pain is normal, which made
it easy for them to hold their pain while simultaneously moving forward.
Participant 4 reported, “I believe that when I accept my feeling, I gain
more self-confidence.” Participant 2 stated that acceptance gave her a
new perspective, which helped her to deal with her overreacting issue.
She also added: “Therapists used to tell me to be positive, but with ACT I
5. Discussion
Participants reported positive results—both personal and inter­
personal—from their work in the ACT group therapy. These perceived
benefits indicated that ACT was associated with a positive change in
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M. Bahattab and A.N. AlHadi
Journal of Contextual Behavioral Science 19 (2021) 86–91
anxiety and depression symptoms, in addition to the positive changes in
diet, sleep, psychological flexibility, emotion regulation skills, valuebased living, and mindfulness. The results of this study regarding the
effectiveness of ACT group therapy among Muslim women in Saudi
Arabia are aligned with the findings reported in studies conducted
among non-Muslim societies, including the work of Folke et al. (2012),
Kohtala (2009), and Dousti et al. (2015). Also, these findings are in line
with studies carried out among members of Iranian Muslim society,
including studies by (2014)Molavi, Mikaeili, Rahimi, & Mehri, Rahmani
and Rahmani (2015), and Azadeh, Zahrani, and Besharat (2016).
As evidenced by the data acquired from interviews with the Saudi
Muslim female participants, the group format was reported as being
highly effective and powerful in terms of the validation and support
provided as a result of sharing and listening among the group members.
Regarding the links between ACT and the Muslim Saudi society, the
participants implied that ACT supports Islamic values and that it actu­
ally helped them become the Muslims they wanted to be. In particular,
they mentioned the concept of acceptance and its importance, as well as
benefits that are emphasized by many scripts in both the Quran and
Hadith.
Another factor worth mentioning about this group therapy process is
that the presented metaphors were received in a very positive way.
According to Dwairy (2009), one of his Muslim-Arab clients achieved a
significant change in his belief system, self-esteem, happiness, re­
lationships, and satisfaction with himself and with God using metaphor
therapy based on the client’s own culture and religion. Even though the
metaphors based on culture and religion was proven to be effective, the
therapist used only the metaphors that were provided in the protocol
without any adaptation. However, since both the participants and the
therapist share the same faith background, mentioning the religious
aspect from time to time was inevitable but not a focus.
Also, the participants commented on the protocol that was used for
the intervention. They appreciated the presentation slides, especially
those that had more pictures. The results of this study encouraged
having ACT-based therapy that consists of eight sessions. Though some
participants stated that eight sessions were not enough, they indicated
how valuable and helpful the intervention was for them. This finding is
supported by studies in the literature review, which indicated that
providing eight sessions or fewer, such as six or four, was still signifi­
cantly helpful (Folke et al., 2012; Kohtala, 2009; Dousti et al., 2015;
Shaker, Rahimi, & Zare, 2016; Abbasi et al., 2014).
The participants also found that the experiential exercises, as well as
the group discussions, were helpful and shared that the assignments had
enriched and deepened their understanding. They specifically appreci­
ated the reading and mindfulness exercises. Participants reported on
how mindfulness exercises improved their sleep and emotional regula­
tion skills and led to positive changes in terms of a greater appreciation
for life. A similar outcome in terms of the effectiveness of the mindful­
ness exercises was reported in a study of mindfulness-based stress
reduction among Emirati Muslim women (Thomas, Raynor, and Bakker,
2016).
The participants also said that ACT gave them a great deal of
awareness and a new perspective in terms of the nature of their thoughts
and feelings. They claimed that this awareness helped them move for­
ward depending on their values. Also, their responses indicated that
awareness of their thoughts and feelings seemed to have improved the
overall quality of their lives, which is aligned with the findings reported
in the study of the Quality of Life Improvements after Acceptance and
Commitment Therapy in Nonresponders to Cognitive Behavioral Ther­
apy for Primary Insomnia (Hertenstein et al., 2014). Participants
thought that the ACT core processes gave them the necessary life skills
and increased their value-based living.
Participants did report several challenges associated with the first
process of the group therapy. The fact that they would experience a
group therapy format was an anxiety-provoking for some of them. In
addition, for two participants, the mindfulness exercises seemed to be a
trigger for their panic attacks. Another challenge that the participants
experienced was with the concept of acceptance. Some of the partici­
pants found it difficult to deal with their painful thoughts and feelings
with openness and without judgment.
More studies are needed to better understand how the six core pro­
cesses match the beliefs of Islam. Also, considering the small sample,
more studies with more participants are required. A suggestion that was
also proposed by Tanhan (2014) is that because ACT uses several met­
aphors, it would be helpful to conduct future studies about metaphors
from Islam that might be used within the ACT perspective.
6. Conclusions
Despite the relatively small sample size, the ACT group therapy was
well appreciated and viewed as being culturally and religiously
acceptable by the Saudi Muslim female participants. Also, the present
results support the idea that ACT is well appreciated as a potential
means of reducing depression and anxiety among Saudi women. Addi­
tionally, the results lend preliminary support to the notion that ACT can
help enhance positive emotions and increase the psychological wellbeing of Saudi women.
This research topic was specifically chosen because the researcher
has strong connections to the studied population and wants to bring
mental health services to this group. The themes discovered here help to
achieve the desired goal of exploring a new therapeutic approach that
could assist people with mental disorders in Saudi Arabia and that they
would accept as a culturally appropriate approach.
Ethics approval and consent to participate
Approved by the ethical committee of The College of Medicine at
King Saud University, Riyadh, Kingdom of Saudi Arabia. Informed
consent was preceding the survey questions containing the aim of the
study and the participant’s right to withdraw at any time without any
obligations towards the study team.
Consent for publication
Not applicable.
Availability of data and materials
Data related to this study are presented in the results section. Raw
data can be obtained from the corresponding author upon reasonable
request.
Funding
The Funding of this research was obtained by the SABIC Psycho­
logical Health Research and Applications Chair, Department of Psychi­
atry, College of Medicine, Deanship of Post Graduate Teaching, King
Saud University. The funding body has no role in the design of the study
and collection, analysis, and interpretation of data nor in writing the
manuscript.
Author’s contributions
All authors contribute equally to study design, data collection, data
analysis and manuscript writing. All authors read and approved the final
manuscript.
Declaration of competing interest
The authors declare that they have no competing interests.
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Journal of Contextual Behavioral Science 19 (2021) 86–91
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