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Introduction
Nursing is one of the professions in which making mistakes can cause irreparable damage to patients and their families. Because nurses suffer much stress depending on their work type and experiences [1], it can cause burnout and other mental disorders in them [2, 3] and even affects their commitment to their job and duties [4]. Therefore, paying attention to the tiniest professional issues and not ignoring them may affect this group’s behavioral and personality styles and turn them into perfectionists [2]. Since perfectionism and mental rumination are the decisive factors in elucidating and predicting social anxiety [5], social anxiety disorder (SAD) has been recognized as the most prevalent psychiatric disorder. SAD is placed in the third rank after depression and alcohol abuse and has severe negative effects on patients’ mental, individual, and social health [6]. SAD is a persistent and significant fear of negative estimation in social and functional situations [7]. Often, social anxiety suggestively weakens social functioning and can lead to impaired social skills [6]. Avoiding social relationships [8] can result from this disorder [6]. Numerous approaches to psychotherapy, such as psychoanalysis, behavior therapy, cognitive therapy, etc. are effective in treating social anxiety; however, various studies showed higher effectiveness of cognitive-behavioral treatments compared to other approaches, and much scientific evidence supports it [9]. However, therapists have seen many clients who, despite being highly motivated and working hard to recover, could not overcome the disturbing thoughts and feelings and achieve the necessary success. Sometimes, despite the treatment’s success, after a few months, they lost their motivation and felt that, in the long run, there were no significant changes in their feelings about their lives [10]. Therefore, there is a need to use more effective therapies to change the function of cognitions and emotions. One of the third wave therapies developed in the context of cognitive-behavioral therapy is ACT. This treatment helps people to accept what is beyond their personal control and to commit to an action which enriches life. In fact, ACT seeks to change the potential functions of unwanted thoughts and feelings by correcting the psychological context in which they are experienced [11].
Along with ACT, another treatment method (psychodrama) was applied to treat the disorder of social anxiety, which was directly associated with the disorder of people because of its display nature [12]. It is a therapy method based on experiences that makes individuals apply a controlled curative role for solving personal and social complications and finding possible explanations by actions rather than words [13]. Actually, through the reconstruction of reality and playing a role, psychodrama helps individuals to assess their attitudes and thoroughly comprehend their positions in life [11].
In acceptance-commitment therapy, individuals with SAD should be encouraged to actively confront their frightening mental experiences along with changing behaviors and creating a goal and motivation to commit to a more social lifestyle [8]. Using psychodrama techniques helps a person to achieve what should be accepted and to avoid denial and avoidance. Considering the effective empirical background of both therapeutic approaches in reducing social anxiety symptoms and the lack of research on combining both interventions to reduce nurses’ anxiety, by conducting the present study, we assessed the effect of group therapy on nurses’ SAD using both ACT with psychodrama.

Materials and Methods
In this randomized trial study with a pre-test-post-test design, four groups (1 intervention group and 3 control groups) participated in 2017. The statistical population comprised nurses with a Master’s degree from Torbat Heydarieh University of Medical Sciences. The SAD of the participants was assessed by a self-reporting questionnaire of social anxiety developed by Connor et al. A psychologist diagnosed 48 participants with SAD according to DSM-V criteria. After that, they were randomly divided into 4 groups (12 nurses in each group): One intervention group or combined psychotherapy group (who received therapy based on psychodrama along with treatment based on acceptance-commitment) and three control groups (who received psychodrama therapy, ACT, and no therapy). The reason behind selecting the groups with the same number of members was that in short-term interpersonal group treatments, according to the possible resources and training requirements, the required number of members in each group should be 6 to 12 people, of whom one or two are leaders.
The samples were divided randomly into one intervention group and 3 control ones through permutation blocks (4 blocks). The intervention group was considered with 4 blocks of code 1, and the control group with 4 blocks of code 2. In each of the blocks, two codes 1 and two codes 2 were considered without any repetition. The blocks were selected at random, and after being applied, each one was canceled. Then, the following block was re-chosen at random. Each block regulated individuals’ entry arrangement into intervention or control groups. For example, block 1221 referred to the arrangement by which the first and fourth people were gone into the intervention group, and the second and third people were enrolled in the group control. The inclusion criteria were SAD diagnosis based on DSM-V diagnostic criteria, having no mental disorder, an optimum level of psychological and physical status based on clinical interviews, and satisfaction with attending meetings. However, using anti-anxiety medicines and not attending more than one therapy meeting were considered the exclusion criteria.
ACT group therapy for the first control group was undertaken by one therapist specialized in ACT therapy, and group therapy based on psychodrama for the second control group was undertaken by one psychodrama therapist. In the intervention group, the sessions were held with a combination of treatments and were chaired and conducted by both therapists. Questionnaire 1 was accomplished by 78 nurses referring to the counseling center through the interviews with the center’s psychologist, 48 of whom had social anxiety and were divided randomly into 4 groups (n=12 in each group).
 The group of intervention was provided by a psychotherapy combination (ACT as well as psychodrama therapy) (Table 1) in 12 sessions; each meeting lasted 90 min (two sessions every week) according to the protocol for the SAD [14-16], determined and developed by the researcher. The first and second control groups were provided with ACT (Table 2) and therapy based on psychodrama, respectively, in 10 sessions (Table 3), while the third one was provided with no treatment. A pre- (before the treatment started) and a post-test (after the treatment completion) were considered to be done so that questionnaires were filled in all groups, and an independent evaluator led the pre-test and post-test assessment. The third group of control, which was not provided with any therapy during the research, received ACT psychotherapy after the end of the study. It is notable that throughout the investigation, one participant from the group of intervention and one from the ACT group did not continue their therapy sessions due to interference with the sessions during their work hours.

The therapy sessions in the intervention group are provided in Table 1.
Its purposes were clarified to the participants before they started the research. The study information confidentiality was ensured for all nurses, along with observing all ethical issues. Nurses were free to leave the study whenever they wanted. At the end of the study, the education provided to the groups of intervention was given to the group of control too. The data collection in the research was performed through the social anxiety questionnaire designed by Connor et al. in 2000. This 17-item self-reporting questionnaire was developed to evaluate a broad collection of SAD symptoms in three categories: Experiencing panic in social positions (6 items), avoiding social relationships (7 items), and experiencing mental stress in social positions (4 items). Then, the participants were asked to estimate symptoms in the previous week as follows: Any symptom (score=0), low (score=1), some degree (score=3), high (score=4), and very high (score=5) [2]. The total questionnaire score ranges between 0 and 68. The great validity and reliability were defined for this tool so that its reliability was obtained from 0.78 to 0.89 by the retest method in groups diagnosed with SAD. Also, using the Cronbach α method, the coefficient of internal consistency of this questionnaire was at 0.94 in a normal group and at 0.89, 0.91, and 0.80 in the categories of panic, avoidance, and mental embarrassment, respectively [16]. SPSS software, version 20 was applied to analyze the information. The Mean±SD were used to describe quantitative variables, and the frequency and percentage to describe qualitative ones. Data were analyzed by analyses of variance and covariance at a 95% confidence level.


3. Results
In the research, 48 nurses with social anxiety were divided into 4 groups of no treatment, psychodrama, ACT, and therapy based on the combination of the two methods. The Mean±SD age in the psychodrama group was 30.5±6.34 years, in the ACT group, 30.75±5.83 years, in the combined therapies group, 29.50±19.58 years and in the no therapy group, 31.5±6.16 years. The groups had the same number of participants, and their sex (P=0.18) and education level were similar too (P=0.39). Individuals’ demographic data by the groups of the research are presented in Table 4. 

The findings exhibited a substantial diminution in the total score of the SAD and its dimensions in all three groups in such a way that the Mean±SD social anxiety score in the psychodrama group was 63.75±11.37 before the intervention and 50.08±7.75 after the study period. However, the Mean±SD social anxiety score was 60.21±10.71 before the intervention and 43.66±7.05 after the study in the ACT group. In the combined therapy group, before applying intervention and after that, the Mean±SD social anxiety scores were found to be 61.75±11.49 and 34.75±8.19, respectively. A noteworthy difference (P=0.86, Table 1) could not be diagnosed in the mean anxiety score in the group of control. However, the score difference, indicating the decrease in social anxiety, was expressively greater in the intervention group of combined therapy compared to the considered control groups (P<0.001) (Table 5).

4. Discussion 
Our research determined the impact of the combination of ACT with psychodrama therapy on participants with SAD. This research showed the effectiveness of the psychological interventions applied in all three groups of ACT, psychodrama, and their combination in declining the symptoms of SAD. However, the combination of ACT and psychodrama reduced the symptoms more.
The study by Witlox et al. showed that blended ACT was an appreciated alternative treatment to CBT for anxiety in the later years of one’s life [16]. Yabandeh et al. investigated the impacts of the two approaches of ACT and therapy based on cognition-behavior elements on SAD and showed a significant reduction in social anxiety by ACT compared to the one found on cognition-behavior elements. However, a remarkable difference could not be detected between the two treatment methods. The researchers suggested that the significant impacts of the two approaches might be because of their common elements, like coping with stressful notions rather than overcoming or limiting them [17]. Rickardsson et al. showed that the technique of psychodrama had a significant effect on the reduction of the chronic mental problem of patients since this therapy approach by confirming the subconscious played an important role in patients’ sentimental discharge and their relief [15]. Witlox et al. demonstrated intervention based on an ACT for anxious cancer survivors; as reported by clinical social workers in cancer care clinics, accelerating psychological retrieval and energy levels and reduction in overlooked medical engagements could be detected. A stronger and broader effectiveness was seen for more anxious and avoidant participants. This finding demonstrates more benefits for cancer survivors with more marked psychological symptoms [16].
Pour Rezaian showed the impacts of psychodrama therapy on SAD and suggested the reason behind the impacts of psychodrama was the capacities of this therapy method. It can help patients reduce stress by recreating anxious positions through exercise and innovative emotional methods [11].
Comparing the effectiveness of these two approaches with each other, the results showed that although both therapeutic methodologies were influential in diminishing the SAD symptoms (in comparison with the control group) and led to a reduction in its symptoms, their decline was more when the components of psychodrama were used along with ACT.
In psychotherapy techniques, people face situations in which they are afraid. They see it and show others what they fear. As a result, the source of fear becomes obvious and apparent so that they can calmly watch the situation they fear, and this confrontation with the source of fear in a safe place makes them more courageous and reduces their social anxiety in various social situations. The ACT approach also provides a context in which the individuals become aware of inflexible and automatic responses to their experiences and realizes their responses to anxiety are inefficient and exacerbate problems. Given that the goal of ACT is the elimination of experiential avoidance and enhancement in psychological resilience through contact with the present, committed behaviors, and a life based on values, the exposure traces are clear in all of these solutions. Therefore, this can be another reason combining these two therapeutic approaches can increase the effectiveness of treatment.
According to the results, the combination of psychoactive components with ACT psychotherapy is a promising treatment for SAD, but there is a need for more controlled research in this area. Like other studies, the present study has some limitations, including the short period of conducting the treatment protocol and the lack of follow-up during a few months after the treatment sessions. So, this treatment protocol is suggested to be done for a longer time and with a longer follow-up to examine all dimensions of the combination of these two treatments. Also, considering the spatial limitation in sampling and limiting the statistical population to nurses who were educated and employed people, generalizing the results of this study to other populations of society should be done with caution. In the current study, for the first time, the researchers designed a new protocol for treatment according to the two conventional methods of psychotherapy to investigate their effects, which was an innovation in the guidelines of treatment for the disorder of social anxiety [18, 19, 20].

5. Conclusion
Considering the social anxiety prevalence in society, especially among nurses, and the complications caused by it for the progress of people and society, taking this disorder into account and finding a more successful approach to treating it seems necessary. Although separately using psychodrama therapy and ACT has been displayed to have an important impact on SAD symptoms, the use of the two approaches together intensifies their powerful impacts even more. So, individuals participating in psychological health, like psychotherapists, are recommended to apply this protocol to treat the disorder of social anxiety of clients, their life quality, and social interactions.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Torbat Heydarieh University of Medical Sciences (Code: IR.THUMS.REC.1397.019), (Registration No.: IRCT20181009041282N3).

Funding
This research was supported by the research project, funded by Torbat Heydarieh University of Medical Sciences. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors appreciate the participation of all nurses and colleagues at Torbat Heydarieh University of Medical Sciences.



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