1. Background
Obsessive-compulsive disorder (OCD) is a psychological disorder characterized by a diverse group of symptoms that include intrusive thoughts, obsessive rituals, obsessions, and compulsions (1). Compulsions are repetitive behaviors or mental acts that occur in response to obsessions to reduce distress (2). Obsessions involve intrusive and recurrent thoughts, impulses, or images that are experienced as unwanted and inappropriate, while compulsions involve repetitive behaviors or mental acts that the individual feels compelled to perform in response to the obsessions or according to rigid rules (3).
The OCD is a chronic and treatment-resistant neuropsychological disorder that often develops in childhood and causes significant long-term problems in the individual's life. This disorder involves uncontrollable thoughts that compel the individual to repeat certain actions and cause disruption to daily functioning (4). Individuals with OCD have intrusive thoughts that are also seen in normal individuals (5). There is no qualitative difference between the thoughts of individuals with OCD and healthy (normal) individuals; rather, there is a fundamental difference in the meaning that individuals with OCD assign to their thoughts. In this model, it is assumed that dysfunctional beliefs, which serve as a reference for evaluating obsessive thoughts, are the cause of the transformation of intrusive thoughts into obsessive thoughts (6). Dysfunctional beliefs cause that as the focus and attention on obsessive thoughts increase, efforts to avoid and suppress them become more ineffective. Therefore, dysfunctional beliefs play an important role in the development and maintenance of OCD symptoms and are even said to predict the type and severity of its symptoms (7).
One of the psychological approaches that can have a significant impact on the management and treatment of OCD is reality therapy (RT). The RT emphasizes access to a successful identity that is achieved through successful work and considers the power of choice of the individual as an important factor in his or her mental health. Factors that create a gap between a healthy and unhealthy person include accepting responsibility, living in the present, making conscious and correct choices, being able to control problems, and being aware of real needs. In fact, the main goal of the RT approach is to help people become aware of their needs and monitor appropriate behavior and decision-making (8-10).
In the last decade, the application of RT to the treatment of psychological disorders has attracted the attention of many researchers in the form of various studies. The results obtained from the aforementioned studies can be examined from two theoretical and practical aspects (10). If RT is used to treat OCD, from a theoretical perspective, the findings related to the evaluation of the effectiveness and explanation of it can clarify the mechanisms of the effect of RT intervention on obsessive-compulsive individuals and thereby expand the theoretical scope of scientific findings. From a practical and applied perspective, the findings of the research on the use of RT for OCD can help counselors and clinical psychologists in the treatment of mental patients and provide practical guidance (11, 12).
2. Objectives
The aim of this study was to investigate the effectiveness of RT on obsessive beliefs and cognitive ability in individuals with obsessive beliefs. Based on the principles of cognitive and humanistic psychology, this study seeks to explain the role of RT-based interventions in reducing obsessive symptoms and improving individuals' psycho-emotional functioning.
3. Methods
3.1. Study Design and Intervention Implementation
This study was a quasi-experimental design, pre-test/post-test, with a control group and repeated measures. Based on this method, the selected individuals were randomly divided into an experimental group and a control group. After the members were placed in the experimental and control groups, the RT intervention was applied to the experimental group, while the control group did not receive any intervention. Finally, after the end of the educational intervention for the experimental group, the post-test phase was conducted for both study groups. Among the 18 - 60-year-olds with OCD referring to counseling centers in Tehran in the 2024 - 2025 academic year, 30 individuals (15 experimental and 15 control) were selected using purposive and convenience sampling. The experimental group underwent RT intervention in ten 90-minute sessions, and the control group did not receive any intervention. In order to control for demographic effects, the two study groups were matched in terms of the two variables of age and gender.
When selecting the samples, some criteria including "non-regular participation in educational classes", "failure to complete the required assignments" and "lack of interest in attending educational classes" were considered as exclusion criteria. Meanwhile, "having obsessive beliefs", "informed consent", "age range 18 - 60 years", "not taking chemical or herbal medicines" as well as "not participating in psychological treatment courses" were considered as inclusion criteria for the samples.
3.2. Questionnaires
One of the research tools was the Persian version of the Obsessional Beliefs Questionnaire (OBQ-44), which is one of the most valid questionnaires in the field of obsessional questionnaires and assesses individuals' obsessive beliefs that can disrupt daily functioning. The OBQ-44 covers the main cognitive domains in OCD and has seven components, including feeling responsible for harm and damage, assessing danger and threat, perfectionism, need for certainty, giving importance to thoughts, and controlling thoughts. This questionnaire has 44 questions, and the answer to each question is in the form of a seven-point Likert scale from strongly disagree to strongly agree (13, 14). The validity and reliability of the Persian version of the OBQ-44 were assessed by Shams et al. (15). To calculate the concurrent reliability, the internal consistency reliability was estimated using Cronbach's alpha coefficient (0.92) and the split-half coefficient called the modified correlation (0.94), and the reliability coefficient obtained from the OBQ-44 test-retest method (r = 0.82) was also used to calculate the non-concurrent reliability. Overall, the above data indicated high internal consistency and also indicated the stability of the test scores over a period of 5 to 14 days. To estimate the criterion validity of the questionnaire (OBQ-44), its correlation with two other questionnaires, including Obsessional Compulsive Inventory-Revised (OCI-R) and Maudsley Obsessive-Compulsive Inventory (MOCI), was calculated, which was equal to 0.57 and 0.5, respectively, and was significant. To examine the construct validity of the questionnaire, factor analysis was used. The findings showed that the OBQ-44 is saturated with three factors that have a high correlation with each other, and the high correlation of these three factors indicates the convergence of these factors, which meets the measurement objectives of the OBQ-44 (14).
Another tool used in the present study was the Persian version of the Cognitive Ability Questionnaire (CAQ), which was designed by Nejati (16). The CAQ has 30 questions and seven components (including: Memory, inhibitory control and selective attention, decision-making, planning, sustained attention, social cognition, and cognitive flexibility). The reliability of the CAQ was calculated using the Cronbach's alpha method and the alpha coefficient was 0.834. Thus, the validity of the questionnaire was assessed as very satisfactory. To measure the concurrent validity of the test, the correlation method was used, and a significant correlation was observed for all components (except social cognition) (15).
3.3. Statistical Analysis
SPSS (version 23) software was used for statistical analysis of the data. In this software environment, analysis of variance with repeated measures ANCOVA at a significance level (α = 0.05) were used to analyze the variables and research findings.
4. Results
The findings showed that the total score of the "obsessive beliefs" variable in the pre-test phase for the control and experimental groups was 209.46 ± 16.19 and 207.20 ± 8.91, respectively, and for the "cognitive ability" variable was 47.13 ± 3.88 and 46.53 ± 4.70, respectively. For both variables, no significant difference was observed between the two values obtained (Tables 1 and 2). While after the intervention (post-test phase), the total score for the variable "obsessive beliefs" for the control and experimental groups was 206.00 ± 14.95 and 186.00 ± 8.40, respectively, and for the variable "cognitive ability" was 46.73 ± 3.55 and 61.80 ± 5.04, respectively, which was a significant difference between the two values obtained for both variables (Tables 3 and 4). The findings showed that the effect of RT on all components related to the variables "obsessive beliefs" and "cognitive ability" was significant (P < 0.05, Tables 5 and 6).
Table 1.Descriptive Findings in the Pre-test Phase in the Control and Experimental Groups Regarding the Components of Obsessive Beliefs a
| Components of Obsessive Believes | Study Groups | |
|---|---|---|
| Control Group | Experimental Group (RT Group) | |
| General | 65.87 ± 8.46 | 67.47 ± 5.45 |
| Perfectionism and certainty | 51.20 ± 5.41 | 50.00 ± 4.33 |
| Responsibility and risk and threat assessment | 36.33 ± 3.13 | 35.73 ± 2.74 |
| Importance and control of thoughts | 31.53 ± 2.39 | 31.07 ± 2.05 |
| Complete the work | 24.53 ± 3.25 | 22.93 ± 2.68 |
| Full score of obsessive beliefs | 209.47 ± 16.19 | 207.20 ± 8.91 |
Abbreviation: RT, reality therapy.
a Values are expressed as mean ± standard deviation (SD).
Table 2.Descriptive Findings in the Pre-test Phase in the Control and Experimental Groups Regarding the Components of Cognitive Ability a
| Components of Cognitive Ability | Study Groups | |
|---|---|---|
| Control Group | Experimental Group (RT Group) | |
| Memory | 15.27 ± 2.47 | 16.34 ± 2.03 |
| Inhibitory control and selective attention | 17.87 ± 1.69 | 15.47 ± 2.75 |
| Decision-making | 12.87 ± 2.48 | 12.14 ± 2.19 |
| Planning | 8.137 ± 1.07 | 8.41 ± 1.69 |
| Sustained attention | 8.47 ± 1.51 | 8.14 ± 1.51 |
| Social cognition | 7.207 ± 1.70 | 8.47 ± 0.91 |
| Cognitive flexibility | 10.47 ± 2.17 | 9.407 ± 2.13 |
| Total cognitive ability score | 47.14 ± 3.89 | 46.54 ± 4.70 |
Abbreviation: RT, reality therapy.
a Values are expressed as mean ± standard deviation (SD).
Table 3.Descriptive Findings in the Post-test Phase in the Control and Experimental Groups Regarding the Components of Obsessive Beliefs a
| Components of Obsessive Beliefs | Study Groups | |
|---|---|---|
| Control Group | Experimental Group (RT Group) | |
| General | 64.67 ± 8.01 | 59.67 ± 4.81 |
| Perfectionism and certainty | 50.74 ± 4.12 | 45.81 ± 3.73 |
| Responsibility and risk and threat assessment | 35.53 ± 2.87 | 32.40 ± 2.13 |
| Importance and control of thoughts | 31.20 ± 3.17 | 28.40 ± 2.55 |
| Complete the work | 23.87 ± 2.06 | 19.73 ± 1.79 |
| Full score of obsessive beliefs | 206.00 ± 14.95 | 186.00 ± 8.40 |
Abbreviation: RT, reality therapy.
a Values are expressed as mean ± standard deviation (SD).
Table 4.Descriptive Findings in the Post-test Phase in the Control and Experimental Groups Regarding the Components of Cognitive Ability a
| Components of Cognitive Ability | Study Groups | |
|---|---|---|
| Control Group | Experimental Group (RT Group) | |
| Memory | 14.87 ± 2.097 | 19.41 ± 2.36 |
| Inhibitory control and selective attention | 17.41 ± 1.51 | 18.81 ± 2.76 |
| Decision-making | 13.20 ± 1.82 | 15.60 ± 2.26 |
| Planning | 8.20 ± 1.01 | 12.06 ± 1.94 |
| Sustained attention | 8.47 ± 1.40 | 11.13 ± 1.77 |
| Social cognition | 6.27 ± 1.71 | 11.27 ± 1.39 |
| Cognitive flexibility | 10.60 ± 1.50 | 11.73 ± 1.98 |
| Total cognitive ability score | 46.73 ± 3.55 | 61.80 ± 5.04 |
Abbreviation: RT, reality therapy.
a Values are expressed as mean ± standard deviation (SD).
Table 5.Covariance Analysis of the Obsessive Beliefs Variable in the Two Phases of Pre-test and Post-test in the Experimental Group (Recipient of Reality Therapy Intervention)
| Variables; Sources of Variance | Sum of Squares | DF | Mean of Squares | F | P | Effect Size |
|---|---|---|---|---|---|---|
| General | 27.326 | 0.001 | 0.33 | |||
| Intervention effect | 43.584 | 1 | 43.584 | |||
| Error | 43.064 | 27 | 1.595 | |||
| Total | 124934.000 | 30 | - | |||
| Perfectionism and certainty | 0.98 | 0.001 | 0.51 | |||
| Intervention effect | 118.649 | 1 | 118.649 | |||
| Error | 32.587 | 27 | 1.207 | |||
| Total | 70504.000 | 30 | - | |||
| Responsibility and risk and threat assessment | 14.417 | 0.001 | 0.34 | |||
| Intervention effect | 53.680 | 1 | 53.680 | |||
| Error | 47.177 | 27 | 1.747 | |||
| Total | 34865.000 | 30 | - | |||
| Importance and control of thoughts | 8.58 | 0.007 | 0.24 | |||
| Intervention effect | 38.593 | 1 | 38.593 | |||
| Error | 60.971 | 27 | 2.258 | |||
| Total | 26932.000 | 30 | - | |||
| Complete the work | 16.81 | 0.001 | 0.38 | |||
| Intervention effect | 74.266 | 1 | 74.266 | |||
| Error | 31.593 | 27 | 1.170 | |||
| Total | 14490.000 | 30 | - | |||
| Full score of obsessive beliefs | 108.66 | 0.001 | 0.62 | |||
| Intervention effect | 2405.041 | 1 | 2405.041 | |||
| Error | 315.801 | 27 | 11.696 | |||
| Total | 1159598.000 | 30 | - |
Abbreviation: DF, degree of freedom.
Table 6.Covariance Analysis of the Cognitive Ability Variable in the Two Phases of Pre-test and Post-test in the Experimental Group (Recipient of Reality Therapy Intervention)
| Variables; Sources of Variance | Sum of Squares | DF | Mean of Squares | F | P | Effect Size |
|---|---|---|---|---|---|---|
| Memory | 91.62 | 0.001 | 0.57 | |||
| Intervention effect | 82.499 | 1 | 82.499 | |||
| Error | 24.596 | 27 | 0.911 | |||
| Total | 8975.000 | 30 | - | |||
| Inhibitory control and selective attention | 45.47 | 0.001 | 0.42 | |||
| Intervention effect | 85.832 | 1 | 85.832 | |||
| Error | 50.962 | 27 | 1.887 | |||
| Total | 8522.000 | 30 | - | |||
| Decision-making | 36.41 | 0.001 | 0.37 | |||
| Intervention effect | 52.648 | 1 | 52.648 | |||
| Error | 39.039 | 27 | 1.446 | |||
| Total | 4845.000 | 30 | - | |||
| Planning | 25.66 | 0.001 | 0.28 | |||
| Intervention effect | 18.422 | 1 | 18.422 | |||
| Error | 19.383 | 27 | 0.718 | |||
| Total | 2106.000 | 30 | - | |||
| Sustained attention | 40.78 | 0.001 | 0.402 | |||
| Intervention effect | 26.537 | 1 | 26.537 | |||
| Error | 17.567 | 27 | 0.651 | |||
| Total | 2131.000 | 30 | ||||
| Social cognition | 121.79 | 0.001 | 0.51 | |||
| Intervention effect | 86.931 | 1 | 86.931 | |||
| Error | 19.271 | 27 | 0.714 | |||
| Total | 2561.000 | 30 | - | |||
| Cognitive flexibility | 39.38 | 0.001 | 0.31 | |||
| Intervention effect | 25.718 | 1 | 25.718 | |||
| Error | 17.631 | 27 | 0.653 | |||
| Total | 3837.000 | 30 | - | |||
| Total cognitive ability score | 352.00 | 0.001 | 0.62 | |||
| Intervention effect | 1815.425 | 1 | 1815.425 | |||
| Error | 123.782 | 27 | 4.585 | |||
| Total | 90582.000 | 30 | - |
Abbreviation: DF, degree of freedom.
5. Discussion
The findings of the present study showed that RT has a significant effect on individuals' obsessive beliefs. Obsessive beliefs are rooted in distorted cognitive patterns that include exaggerated responsibility, excessive concern about risks, and perfectionism (6, 7). The RT, by emphasizing realistic responsibility, conscious choices, and acceptance of limitations, reconstructs these distorted patterns (16, 17). From a cognitive perspective, RT causes the individual to focus on practical and manageable choices instead of focusing on irrational and uncontrollable thoughts, which leads to a decrease in the intensity of obsessive beliefs (18). In explaining this finding, it can be said that OCD is a type of cognitive processing disorder in which a person experiences thoughts, images, and impulses that are intrusive and intrusive, causing discomfort and the individual finds them meaningless and alien to him/her (4, 6, 7, 12). In this regard, it is important to understand the information processing processes that are involved in the development and maintenance of OCD. This will, on the one hand, lead to a better understanding of OCD and a more accurate and realistic picture of this disorder, and on the other hand, it is a fundamental step in creating effective intervention techniques in the treatment of OCD (19, 20).
Obsessive-compulsive individuals suffer from chronic anxiety due to perfectionism and excessive control over the environment. The RT helps the individual to shift the source of control from the outside (e.g., obsessive rules, fear of contamination) to the inside by strengthening the sense of internal control (21, 22). Research evidence shows that therapeutic approaches based on increasing internal control reduce the severity of obsessive symptoms, reduce anxiety, and ultimately lead to a decrease in the need for obsessive beliefs and actions (23, 24).
Research using neuroimaging techniques has shown that OCD is associated with abnormalities in specific brain circuits involved in motivation, habit, response control, and decision-making. The main circuit implicated in OCD is the Cortico-Striatal-Thalamic-Cortical (CSTC) circuit. This circuit includes the orbitofrontal cortex (OFC), which is involved in error processing and consequences of actions; the basal ganglia, particularly the striatum, which is involved in habit formation and movement control; and the thalamus, which relays sensory information to the cerebral cortex. In people with OCD, there appears to be excessive activity in this circuit; for example, the OFC may be overactive and continuously send “danger” or “defect” signals, even in the absence of actual threat. This overactivity can lead to an inability to stop obsessive thoughts and compulsive behaviors because the brain cannot properly process the “all is well” signal (25). In contrast, cognitive control and decision-making training in RT can activate executive control regions (such as the dorsolateral prefrontal cortex), which are associated with reduced activity in the obsessive-compulsive circuit. Interventions that increase cognitive inhibition also reduce obsessive rumination (26). The RT activates this same pathway by increasing self-regulation.
The research findings also showed that RT has a significant effect on the cognitive ability of people with obsessive beliefs. This finding can be explained from several theoretical, psychological, neurological and clinical perspectives. Glaser's RT, by focusing on responsible choice, autonomy and goal setting in life, activates the prefrontal areas of the brain (especially the dorsolateral prefrontal cortex). These areas are responsible for executive functions such as cognitive control, working memory and response inhibition, which usually have poor performance in people with obsessive beliefs (27). In fact, obsessive beliefs cause the mind to chronically engage with irrational and repetitive thoughts that consume cognitive resources and occupy working memory space. The RT intervention helps reduce cognitive load by replacing ineffective thoughts with meaningful and realistic goals, thereby increasing working memory capacity and conscious decision-making (28, 29). In RT sessions, the therapist challenges the person’s current thoughts and beliefs by helping them identify core psychological needs, such as belonging, power, freedom, and fun. This process is a form of cognitive restructuring that is consistent with the cognitive-behavioral therapy paradigm (8-12). Recent studies have also shown that cognitive restructuring can modulate hyperactive activity in the medial prefrontal cortex and reduce obsessive thoughts (30). Another explanation is that RT reduces cognitive involvement with obsessions. One of the central problems in OCD is excessive preoccupation with the content of obsessive thoughts. This reduces cognitive resources and impairs the ability to focus, selective attention, and problem-solving (8-11). The RT recalibrates the attentional system by shifting the person’s focus from obsessive thoughts to internal goals and real needs (8, 9). From a neurological perspective, this shift in attentional focus may be associated with activation of the central control network and inhibition of the default mode network; A network that is activated during intellectual conflicts and rumination (31).
The neurological explanation for this effect is that RT enhances cognitive flexibility. Cognitive flexibility is a key component of healthy cognitive function that allows an individual to explore different perspectives, try new strategies, and avoid rigid obsessive behaviors. The RT helps improve this cognitive skill by teaching alternative choices. From a neurological perspective, this process is associated with increased connectivity between the prefrontal cortex and basal ganglia, which are involved in regulating flexible responses (32, 33).
Previous studies have shown that RT is also effective in treating other mental disorders and reduces obsessive beliefs. Ebnosharieh and Aghili (34) reported that group RT training based on Glasser's choice theory improved the general health of divorced women and reduced their obsessive beliefs (35). The findings of the study by Rezaee and Babakhani showed that online training in RT concepts increased and improved cognitive emotion regulation and reduced maternal anxiety in students during the COVID-19 quarantine period (36). In addition, Eslamy et al. found that group RT reduced negligent behaviors and increased student responsibility (37). Abdi Dehkordi et al. reported that group RT can be used as a suitable method to improve the psychological and academic status of gifted students (38). The results of the study by Vafaei-Jahan showed that RT significantly reduced anxiety in people who believe in the superstition of the sore eye (39). In this regard, Farzan Azar and Mehrabi showed that RT can be effective in improving the psychological state of infertile women (40). Also, the results of the study by Hoseini Almadani showed that RT has a significant effect on improving social competence and quality of life of drug addicts (41). Based on the findings of the study by Azimi et al., it was determined that RT has a positive and significant effect on the psychological flexibility of the elderly (42).
5.1. Conclusions
The findings of this study indicate that RT, as an approach based on individual choice and responsibility, can be effective in modifying dysfunctional beliefs, especially obsessive beliefs and cognitive abilities. The findings of the present study, while confirming the effectiveness of RT in the treatment of OCDs, can be a basis for designing clinical interventions and training therapists in the field of cognitive psychology.
5.2. Limitations
The limitations of the present study included reduced external validity and low confidence in the generalizability of the results to other parts of the population due to the controlled conditions of the study, the selection of samples only from Tehran as the statistical population, the lack of follow-up of the results, the limited time of the training course, and the lack of full cooperation during the training course. The use of a self-report questionnaire as the only tool to measure personality variables of public health, which are complex and multi-causal, is another limitation of this study. The variables of this study were measured with self-report questionnaires, and these tools may not be accurate enough due to the influence of response bias, the tendency to present social desirability, or the lack of understanding of individuals about themselves.
