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Volumen 22, número 1, 2022

2022, 22, 1

Volume 22, number 1, 2022

Volume 22, number 1
Volumen 22, número 1

March 1, 2022
1 Marzo, 2022				

ISSN: 1577-7057

Research Articles // Artículos de investigación

IJP&PT

Simone Gorinelli
5-19
Psychological Processes in the Social Interaction and
Ana Gallego		Communication Anxiety of University Students: The
Päivi Lappalainen		Role of Self-Compassion and Psychological Flexibility.
Raimo Lappalainen		International Journal of

Palmira Faraci
21-32
Dimensionality and Accuracy of Measurement Based
Giusy D Valenti		
on Item Response Theory in the Fatalism Scale			During the COVID-19 Pandemic in Italy.
		Psychology & Psychological		
Isaías Vicente Lugo González
33-43
Psychometric properties of the Beliefs
Fabiola González Betanzos		
about Medicines Questionnaire (BMQ)
Silvia Susana Robles Montijo		
in Mexican adults with asthma.		
Cynthia Zaira Vega Valero

Laura Inés Ferreira
65-75
Luís Janeiro					

Patrick Okoh Iyeke
77-87
Luís Janeiro					

Treating affect phobias: Therapeutic allianceas a moderator of the emotional experience
effect on outcomes.		

Reducing Social Anxiety among Adolescentsin the Covid-19 Era: Rational Emotive Behavior Therapy
as a Counselling Approach.

Notes and Editorial Information // Avisos e información editorial
Editorial Office     113-114
Editorial Office    115
			

Normas de publicación-Instructions to Authors.		
Cobertura e indexación de IJP&PT. [IJP&PT
Abstracting and Indexing.]

Therapy
International Journal of Psychology & Psychological Therapy			Taiki Shima
45-63
Effect of Adjusting Cultural Backgrounds on the
Natsumi Tsuda		
Impact of Metaphors: A Preliminary Study.
Kazuki Hashiguchi		
Takashi Muto		

EditorFrancisco Javier Molina Cobos
Universidad de Almería, España

Reviewing Editors
			Francisco Ruiz Jiménez

Mónica Hernández López
Universidad de Jaén
EspañaFundación Universitaria Konrad Lorenz
Colombia

Associate Editors
Dermot Barnes-Holmes
Ulster University
UK			
Miguel Ángel Vallejo Pareja
UNED-Madrid
EspañaJ. Francisco Morales

Mauricio Papini

UNED-Madrid
EspañaChristian Texas University
USA

Kelly Wilson
University of Mississipi
USA

Assistant Editors
Francisco Cabello Luque
Adolfo J. Cangas Díaz
Emilio Moreno San Pedro

Universidad de Murcia, España
Universidad de Almería, España
Universidad de Huelva, España

ISSN 1577-7057© 2022 Asociación de Análisis del Comportamiento-MICPSY, Madrid, España

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IJP&PT

International Journal of Psychology & Psyhological Therapy
Comité Editorial / Editorial Comittee

Editor: Francisco Javier Molina Cobos, Universidad de Almería, España
Associate
Editors

Dermot Barnes-Holmes, Ulster University, UK
Francisco Morales, UNED, Madrid, España
Mauricio Papini, Christian Texas University, USA
Miguel Ángel Vallejo Pareja, UNED, Madrid, España
Kelly Wilson, University of Mississipi, USA

Former Editors

Reviewing
Editors
Assistant
Editors

Mónica Hernández López, Universidad de Jaén, España
Francisco Ruiz Jiménez, Fund. Univ. Konrad Lorenz, Colombia
Francisco Cabello Luque, Universidad de Murcia, España
Adolfo J. Cangas Díaz, Universidad de Almería, España
Emilio Moreno San Pedro, Universidad de Huelva, España

Jesús Gil Roales-Nieto, Universidad de Almería, España, (2001-2011)
Santiago Benjumea, Universidad de Sevilla, España, (2012-2016)
Miguel Rodríguez Valverde, Universidad de Jaén, España, (2017)

Consejo Editorial / Editoral Advisory Board
Yolanda Alonso Universidad de Almería, España
Erik Arntzen University of Oslo, Norway
Mª José Báguena Puigcerver Universidad de Valencia, España
Yvonne Barnes-Holmes National University-Maynooth, Ireland
Adrián Barbero Rubio UNED & MICPSY, Madrid, España
William M. Baum University of New Hampshire, USA
Charles Catania University of Maryland Baltimore County, USA
Juan Antonio Cruzado Universidad Complutense, España
Victoria Diez Chamizo Universidad de Barcelona, España
Mª Paula Fernández García Universidad de Oviedo, España
Perry N Fuchs University of Texas at Arlington, USA
Andrés García García Universidad de Sevilla, España
José Jesús Gázquez Linares Universidad de Almería, España
Luis Gómez Jacinto Universidad de Malaga, España
Celso Goyos Universidade de Sao Paulo, BrasilDavid E. Greenway University of Southwestern Louisiana, USA
Patricia Sue Grigson Pennsylvania State College of Medicine, USA
Steven C. Hayes University of Nevada-Reno, USA
Linda Hayes University of Nevada-Reno, USA
Phillip Hineline Temple University, USA
Per Holth University of Oslo, Norway
Robert J. Kohlenberg Univeristy of Washington, Seattle, USA
María Helena Leite Hunzinger Universidade de Sao Paulo, Brasil
Julian C. Leslie University of Ulster at Jordanstown, UK
Juan Carlos López García Universidad de Sevilla, España
Juan Carlos López López Universidad de Almería, España
Fergus Lowe University of Wales, Bangor, UK
Carmen Luciano Universidad de Almería, España
Armando Machado Universidade do Miño, Portugal
Jose Marques Universidade do Porto, Portugal
G. Alan Marlatt University of Washington, Seattle, USA

Ralph R. Miller State University of New York-Binghamton, USA
Rafael Moreno Universidad de Sevilla, España
Edward K. Morris University of Kansas-Lawrence, USA
Lourdes Munduate Universidad de Sevilla, España
Alba Elisabeth Mustaca Universidad de Buenos Aires, Argentina
José I. Navarro Guzmán Universidad de Cádiz, España
Jordi Obiols Universidad Autónoma de Barcelona, España
Sergio M. Pellis University of Lethbridge, Canada
Ricardo Pellón UNED, Madrid, España
Wenceslao Peñate Castro Universidad de La Laguna, España
Víctor Peralta Martín Hospital V. del Camino, Pamplona, España
M. Carmen Pérez Fuentes Universidad de Almería, España
Marino Pérez Álvarez Universidad de Oviedo, España
Juan Preciado City University of New York, USA
Emilio Ribes Iniesta Universidad Veracruzana, México
Josep Roca i Balasch INEF de Barcelona, España
Jesús Rosales Ruiz University of North Texas, USA
Juan Manuel Rosas Santos Universidad de Jaén, España
Jorge Ruiz Sánchez Universidad de Burgos, España
Kurt Saltzinger Hofstra University, USA
Mark R. Serper Hofstra University, USA
Carmen Torres Universidad de Jaén, España
Peter J. Urcuioli Purdue University, USA
Guillermo Vallejo Seco Universidad de Oviedo, España
Julio Varela Barraza Universidad de Guadalajara, México
Juan Pedro Vargas Romero Universidad de Sevilla, España
Carmelo Visdómine Lozano SGIP, Ministerio del Interior, España
Graham F. Wagstaff University of Liverpool
Stephen Worchel University of Hawaii, USA
Edelgard Wulfert New York State University, Albany, USA
Thomas R. Zentall University of Kentucky, USA

International Journal of Psychology & Psychological Therapy
is a four-monthly interdisciplinary publication open to publish
original articles, reviews of one or more area(s), theoretical reviews,
or methodological issues, and series of interest to some of thePsychology areas. The journal is published for the Asociación de
Análisis del Comportamiento (AAC) and MICPSY, and indexed
and/or abstracted in:International Journal of Psychology & Psychological Therapy
es una publicación interdisciplinar cuatrimestral, publicada porla Asociación de Análisis del Comportamiento (AAC), abierta acolaboraciones de carácter empírico y teórico, revisiones, artículos
metodológicos y series temáticas de interés en cualquiera de loscampos de la Psicología. Es publicada por la Asociación de Análisis
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Printed in Spain. All rights reserved.Copyright © 2022 AAC

Effect of Adjusting Cultural Backgrounds on the Impact ofMetaphors: A Preliminary Study
Taiki Shima*, Natsumi Tsuda, Kazuki Hashiguchi, Takashi Muto
Doshisha University, Kyoto, Japan

Abstract
This pilot study investigated the impact of cultural background adjustment on the effect of metaphors,which are used in acceptance and commitment therapy (ACT) as tools for behavioral change. For
adequate function, scholars propose the effectivity of employing examples of metaphors in line withindividual characteristics or cultural contexts. Therefore, this study conducts a preliminary investigationof the effect of metaphors adjusted to reflect cultural context on students from a different culture thanthe one in which the metaphor was created. The increase rates of the tolerance time of a cold-pressor
task time were compared between three groups, namely, (a) adjusted (ACT metaphor adjusted to
the Japanese culture; n= 12); (b) translated (translated ACT metaphor in a textbook; n= 12); and (c)control (without metaphor; n= 11). Analysis revealed that the adjusted group displayed a significant
increase rate compared with the other groups with large effect sizes. Additional analysis using a
reliable change index revealed that although 8.33% of participants showed significant increment in
the translated group, 33.33% in the adjusted group. Those who showed significant increment wereparticipants with high mindfulness traits. Therefore, the result suggested that adjusting the culturalcontext is a factor that can increase the effect of metaphors and mindfulness may moderate the effect.
Key words: metaphor, cultural difference, acceptance, cold-pressor task.
How to cite this paper: Shima T, Tsuda N, Hashiguchi K, & Muto T (2022). Effect of Adjusting
Cultural Backgrounds on the Impact of Metaphors: A Preliminary Study. International Journal of
Psychology & Psychological Therapy, 22, 1, 45-63.
What is already known about the topic?
••

Novelty and SignificanceMetaphors are frequently used in the clinical setting, especially in acceptance and commitment therapy, to alter a client’s
behavior.
Although it was highlighted that optimization of the metaphor’s content to the listener’s context may play an important rolein effectiveness, empirical data supporting this suggestion are lacking.

What this paper adds?
••

Increase rates in pain tolerance time were significantly large by employing culturally adjusted metaphors compared withunadjusted or the nonuse of metaphors.
Considering a listener’s cultural background when selecting or creating metaphors may be useful in the clinical setting.

Many psychotherapeutic models, such as Acceptance and Commitment Therapy(ACT; Hayes, Strosahl, & Wilson, 2012), employ metaphors as a useful tool forbehavioral change (Törneke, 2017; Villatte, Villatte, & Hayes, 2016). Metaphors areused in clinical situations because they validate experiences, promote awareness of
situations or behavioral changes, deliteralize from psychological contents, and increase
the psychological/behavioral flexibility of clients, among others (Foody, Barnes-Holmes,
Barnes-Holmes, Törneke, Luciano, Stewart, & McEnteggart, 2014; Hayes et alia, 2012;
Törneke, 2017). A representative metaphor used in the ACT is quicksand, which can*Correspondence: Taiki Shima, Faculty of Psychology Doshisha University, Japan. E-mail: t.shima1205@
gmail.com. Acknowledgments: Some of this study’s results were presented at the ACT Japan Annual Meetingand the Annual Meeting of the Japanese Psychological Association. We would like to thank Yuma Okada
for his support. This work was supported by JSPS KAKENHI (grant number 17J10709, 19K14461) anda grants-in-aid of the Fukuhara Fund for Applied Psychoeducation Research, Tokyo, Japan. The authors
would like to thank Enago (www.enago.jp) for the English language review.

46

Shima, Tsuda, Hashiguchi, & Muto

implicitly convey the unworkability of one’s attempt to control private experiences. In
this metaphor, for example, employing many coping behaviors in an effort to control
anxiety is compared to struggling in quicksand. If this metaphor functions effectively,
then clients may be likely to recognize the results of their behaviors or to change their
behavior. Because the knowledge of the paradoxical result of struggling in quicksand istransfer into attempts to control their anxiety. In ACT, therapists aim to alter behavior
through the appropriate use or creation of metaphors in a given context (Törneke, 2010;2017).
From the perspective of Relational Frame Theory (RFT; Hayes, Barnes-Holmes,& Roche, 2001), which is the theoretical foundation of ACT, metaphors expected to beof effective use in clinical situations are analyzed as responses that relate two separate
relational networks (Foody et alia, 2014; Stewart & Barnes-Holmes, 2001). For example,
a causal relational network, such as struggling in quicksand–drowning in the quicksand
metaphor, is coordinate with struggling with anxiety (panic). Thus, the function of struggle
as having negative consequences be transferred to the recognition that struggling with
anxiety may lead to panic (Foody et alia, 2014). Therefore, from the perspective of
RFT, metaphor involves four elements, namely, (a) establishing two separate equivalence
relations, (b) deriving a relation between these relations, (c) discriminating a formal
relation via this relation-relation, and (d) a transformation of functions on the basis of
the formal relation discriminated in the third element (Foody et alia, 2014; Stewart &Barnes-Holmes, 2001). Furthermore, from the perspective of recent developments in
RFT, such as the hyperdimensional multilevel (HDML) framework (Barnes-Holmes,
Barnes-Holmes, & McEnteggart, 2020), metaphor is defined as an arbitrarily applicable
relational response at the level of relating relations (Barnes-Holmes, Barnes-Holmes,
Luciano, & McEnteggart, 2017). Relating relations involves training and testing for atleast two sets of separate combinatorially entailed relations (Barnes-Holmes et alia,2020); thus, it is understood to correspond to the abovementioned analysis (Foody etalia, 2014; Stewart & Barnes-Holmes, 2001). In this manner, metaphor derives a new
relation by relating two separate relations, such that the function of the original relational
network had will be transformed. Based on this analysis, the workability or important
aspects of using metaphors in the clinical setting are considered.
Using metaphors have many advantages for clinical practice. For example, theintentional use of metaphors helps clients easily memorize its contents (Martin, Cummings,& Hallberg, 1992), whereas collaborative use reinforces a therapeutic relationship witha client (Angus & Rennie, 1988). Furthermore, new relations derived via metaphors
can offer rules to enact new workable behaviors (Villatte et alia, 2016). A related
experiential analysis about rule-governed behaviors based on HDML demonstrated thatthe level of coherence manipulated through feedback for derived relation will impact
the probability of rule-following when the rule is at a high level of derivation (Harte,
Barnes-Holmes, Barnes-Holmes, & Kissi, 2020). In other words, a new rule derived via
metaphors denotes a high level of derivation in the early stage, and the likelihood of
the occurrence of new behaviors can be increased by enriching feedback to the derived
relational responding at that stage. In this manner, metaphors may play a significant
role in the clinical setting. Therefore, conducting a study to investigate the impact ofthese variables on its effect is necessary.
Three experimental studies were established to investigate variables regarding
metaphors, which are considered to promote psychological flexibility (Criollo, Díaz
Muelle, Ruiz, & García Martín, 2018; Pendrous, Hulbert-Williams, Hochard, & HulbertInternational Journal of Psychology & Psychological Therapy, 22, 1© Copyright 2022 IJP&PT & AAC. Unauthorized reproduction of this article is prohibited.

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Metaphors and Cultural Backgrounds

47

Williams, 2020; Sierra, Ruiz, Flórez, Riaño Hernández, & Luciano, 2016). Two of thesestudies identified common physical properties as a possible variable (Criollo et alia,
2018; Sierra et alia, 2016) by investigating whether tolerance time using a cold-pressor
task increased when the swamp metaphor was used. The metaphor entailed participants
to imagine crossing a cold and dirty swamp to obtain important things at the opposite
side. At this point, the experience that their hands are dipped in cold water during theexperimental task was relevant to the story of the metaphor. The results demonstrated
that the swamp metaphor increased tolerance time. However, the importance of common
physical properties became subject to debate. Moreover, a replication study conductedby Pendrous et alia (2020) did not support these results. Thus, further investigation isrequired.
Apart from common physical properties, conceptual analyses that examinedvariables promoting the function of metaphors were conducted. For example, scholars
recommended that therapists should select/create metaphors that conform to the cultural
background or characteristics of their clients (Masuda, 2016; Villatte et alia, 2016).
Specifically, modifying the contents of metaphors to reflect the sociocultural context
of clients or to employ the metaphorical language they use is important (Pasillas &Masuda, 2014; Villatte et alia, 2016). From the HDML perspective, metaphors should
be selected or created with high levels of coherence with the relational networks ofclients. Therefore, therapists should pay close attention to the use of metaphors incultures (e.g., eastern, such as Japan) that differ from the one in which metaphors werecreated (e.g., western) because such metaphors may not be coherent with the current
relational network of clients.
The foregoing point is connected with the discussions on the relationship between
the target (an object whose function is altered by the metaphor) and the source (familiar
areas of experience, Törneke, 2010) of a metaphor. In other words, in the functioning
metaphor, an important aspect is that the source should have a more salient stimulus
function or notable property than that of the target (Foody et alia, 2014; Stewart &Barnes-Holmes, 2001; Törneke, 2010; 2017). Thus, to achieve the intended functionof metaphors, therapists should adjust the contents and modify their use of language,
examples, and expressions of metaphors, such that the source is more salient and fit forthe cultural context of the client (Pasillas & Masuda, 2014; Villatte et alia, 2016). The
abovementioned suggestions may correspond to the selection of a metaphor’s content orsource with stronger orienting or evoking properties as proposed in ROEing (relating:various methods to relate stimuli and events; orienting: noting or attending to stimuli or
event; and evoking: evaluating whether noted stimuli or events are appetitive, aversive,or relatively neutral), which is a conceptual analytic unit in recent RFT (Barnes-Holmes
et alia, 2020). However, although scholars suggested adjustments that focus on culturalcontexts to improve the effectiveness of ACT (Hayes, Muto, & Masuda, 2011), empirical
data that suggest whether such adjustments enhance the effect of metaphor are lacking.
Therefore, this study preliminarily investigates whether adjusting the contents ofmetaphors in terms of cultural background improves its effectiveness. This study aims tomanipulate the salience of the stimulus function of the source by adopting the metaphor’s
content to be more familiar with the Japanese experiences. The assumption is that thesalience of the source will increase, and the effects of metaphors will be improved whenusing a metaphor consistent with the Japanese cultural context. Furthermore, this study
intends to provide empirical data to support the point made by Pasillas and Masuda (2014)
and Villatte et alia (2016), that is, a focus on metaphor content is required to achieve
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Shima, Tsuda, Hashiguchi, & Muto

its intended function when using metaphors. This objective is considered consistent withthe proposal regarding the direction of contextual behavioral science research by the
Association for Contextual Behavioral Science Task Force on the Strategies and Tacticsof Contextual Behavioral Science Research (Hayes et alia, 2021; e.g., recommendation
16 or 29). Specifically, this study contributes to the literature on the generalization or
modification of principles or interventions to various contexts.
MethodParticipants
The study recruited 53 undergraduate students (30 females; Mage: 20.67 years).
They were randomly assigned to three groups, which will be described in the next
section. However, this study focuses on cultural context, especially that of Japan. Thus,
the participants should be native Japanese speakers and have lived in Japan longer thanthey did in other countries. Therefore, the results of foreign students (n= 2) were includedin the analysis only when assigned to the control group, which did not implement a
metaphor (one student from Asia was assigned to the control group, whereas the otherwas excluded for an incomplete task). Each participant was paid 3,000 yen (approx.
$27.33). All procedures performed were in accordance with the ethical standards of theinstitutional research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Design and Variables
The independent variable was the content of metaphors in the three groups(adjusted group: a metaphor optimized to the Japanese culture; translated group: atranslated metaphor written in a textbook; control group: no metaphor).
The main dependent variable was pain tolerance. This study used the increased
rate of duration of pain tolerance at post-measurement in relation to pre-measurement(post/pre). Previous studies pointed out that pain tolerance time in a cold-pressor tasksignificantly varies between individuals, whereas tolerance time at pre-measurement may
be controlled by calculating the abovementioned improvement rate (Sierra et alia, 2016).
Following Hayes et alia (1999) and Takahashi, Muto, Tada, and Sugiyama (2002),
the secondary dependent variables were self-reports of discomfort/pain and the perceptionsof other sensations during the cold-pressor task. Evaluations were implemented using
the visual analog scale (VAS), recorded at 10s, 70s, 130s, 190s, 250s, and 300s after
the task started and after it ended. The mean scores of the records were calculated andused for analysis.
Experimental Task
This study employed the cold-pressor task. The participants were required toplace their non-dominant hand in cold water (3.5°C) for as long as possible. However,they were instructed that they were free to remove their hand from the water at any
time. Those who kept their hand in the cold water for more than 300s were stopped
for ethical reasons. A video camera was used to record the performance, where threeevaluators independently measured tolerance time and averaged for analysis.

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Metaphors and Cultural Backgrounds

49

Instruments and Measures
The following measures were used to investigate intergroup homogeneity:
Acceptance and Action Questionnaire-II (AAQ-II; Bond, Hayes, Baer, Carpenter, Guenole,
Orcutt, Waltz, & Zettle, 2011; Japanese version by Shima, Yanagihara, Kawai, &Kumano, 2013). The AAQ-II is a seven-item, seven-point Likert-type scale thatmeasures psychological flexibility. Previous research conducted by Shima et alia (2013)
demonstrated that the Japanese version of the AAQ-II contained adequate psychometricproperties with a one-factor structure. In the current study, Cronbach’s alpha was .88(95% CI [.82 to .93]).
Cognitive Fusion Questionnaire (CFQ; Gillanders et alia, 2014; Japanese version by Shima,
Kawai, Yanagihara, & Kumano, 2016): The CFQ is a seven-item, seven-point Likert-type
scale that measures cognitive fusion. Shima et alia (2016) provided evidence that theJapanese version of the CFQ has adequate psychometric properties with a one-factor
structure. In this study, Cronbach’s alpha was .91 (95% CI [.88 to .95]).
Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, &Toney, 2006; Japanese version by Sugiura, Sato, Ito, & Murakami, 2012): The FFMQ
is a 39-item, 5-point Likert-type scale that measures mindfulness. Sugiura et alia
(2012) mentioned that the Japanese version of the FFMQ has adequate psychometricproperties with a five-factor structure that is the same as the original version. In thisstudy, Cronbach’s alpha was .85 (95% CI [.80 to .91]).
We used the following measures to conduct manipulation checks for the metaphors aimed
to confirm the appropriateness of the experimental operation and participants’ comprehensionof the core ideas of the metaphors. As these measures were designed to confirm manipulation
checks for metaphors, the employed items in the control group differed from those of the othergroups that included metaphor intervention. In addition, a manipulation check was conducted tocompare the adjusted and translated groups:
Comprehension test. To confirm the comprehension of the participants regarding the contents,
tests were implemented after the intervention. The percentage of correct responses iscalculated and used for analysis.
Subjective evaluation about intervention. When the significant effect is detected in the main
outcome, it is required to identify which element of the intervention contributed to thechange. Therefore, to confirm the effect of the difference in intervention between theadjusted and translated groups, the participants were asked to complete the following
items using VAS. 1) “the perspicuity of the exercises” (from 0= not at all to 100=very easy to understand) to confirm whether the adjustment of a metaphor’s material
enables perspicuity of the metaphor itself, 2) “similarity to one’s experiences andcontents of exercises” (from 0= not similar at all to 100= very similar) to confirm
whether the similarity between the participant’s experience and the contents of metaphorsdiffered between each group, 3) “familiarity of the exercise contents with the Japanesepeople” (from 0= not familiar at all to 100= very familiar) to confirm the difference offamiliarity of the metaphor’s contents for Japanese people between the two groups, and4) “usefulness of the exercises to daily life” (from 0= not useful at all to 100= very
useful) to identify the existence of a difference in anticipated usefulness between eachpair of metaphors. In the control group, similar items that changed the word “exercise”
to “lecture” were used to control the experimental time and procedure.

Experimental protocols
The interventions were carried out individually. The contents for each group,with reference to Hayes et alia (1999) and Takahashi et alia (2002), were as follows.
Adjusted Group. ACT-related psychoeducation and intervention, which contained metaphors andexercises, were implemented. This group was informed that (a) intentionally removing negative
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Shima, Tsuda, Hashiguchi, & Muto
thoughts and feelings is impossible, and (b) thoughts and feelings do not cause behavior. Regarding
element (a), the short- and long-term effects of experiential avoidance were described, and athought-suppression task was conducted for one min (Part A). For element (b), the Joe the Bum
metaphor (Hayes et alia, 2012, p. 279), which was partially modified to fit the Japanese culturalcontext, was implemented to facilitate participants’ understanding of the concept (Part B). The
metaphor describes a situation where a bum named Joe comes to a housewarming party. It aims
to convey the problem of trying to make him leave the party (experiential avoidance) and that
accepting him and working on whatever one should and wants to do (not being dominated bythoughts and feelings) is possible. The Japanese people rarely hold home parties; thus, imagining
the metaphor’s scenario is difficult. For this reason, the situation was changed to a welcome ora drinking party at a club or a part-time job, and the character was modified to a peer whom theparticipants disliked. The objective was to increase the ease of imagery (i.e., the salience of thesource of the metaphor) by incorporating scenarios likely experienced by the Japanese. In addition,
an exercise based on the metaphor, namely, the modified version of “Soldiers in the Parade” (i.e.,
Leaves on a Stream and Watching the Mind Train; Hayes et alia, 2012, p. 255) was conducted toenrich the image of acceptance. The participants were instructed to imagine a situation in which
they have a bird’s eye view of the welcoming party. Then, they were encouraged to imagine theemerging private events as their peers were moving around and to let them be. The participants
performed this exercise for three min.
The materials of the metaphor in Part B were modified in the adjusted group. The script used inPart B was as follows (the remainder of the script is described in the Appendix).
Imagine you are at a welcome or drinking party at your club or part-time job. Can you imagine
you are talking with participants? You can move freely between seats and interact with various
participants. You are having fun chatting with your friends and eating delicious food. You arehaving a great time, but then a peer you do not like arrives. This peer is a horrible person who
can be bossy, talk badly about others, and treat others unfairly. Although this peer does notalways do so, it worsens when you confront them about their behavior. This peer is fickle, andoccasionally, he misbehaves. However, you cannot help but feel bad when he appears. Can you
imagine that peer? It makes you feel somewhat unpleasant. Now, how will you deal with thesituation when he appears? Let’s imagine two ways of interacting with him.
One way of coping with this situation is to attempt to ignore or silence him or evacuate toanother area. Imagine this peer interrupts when you are enjoying chatting with friends. You
could try to turn him away in various ways because he is troublesome. Alternatively, you might
become frustrated and say “Stop!” or try to avoid him by running off to your senior. However,the peer is persistent and meddling with you repeatedly. In addition, he is condescending andstarts talking badly about you to others. Even if you try to avoid him, you find yourself worrying
about where he is and what he is doing; therefore, you cannot chat with your friends, nor taste
the scrumptious spread on offer, nor enjoy the party. If you try to avoid him or fight, your peer
will become increasingly repulsive, and you will waste your energy. It is similar to the “pinkelephant” that we just experienced. Can you imagine a situation like this?
Now, the other option is to dare to do nothing. As this peer is fickle, he might or might not beannoying. Although he becomes more annoying when you try to avoid or fight him, he might
wander off and go to other people if you let him go. Therefore, can you continue to chat withyour friends when the peer interrupts you? This peer is fickle, and he disappears and returns.
Can you actually maintain a psychological distance with him while being here, instead of trying
to kick him out? Can you imagine being able to actually stay here, instead of interrupting a chatwith a friend because of your bad feelings?
You may indeed feel unpleasant because of the annoying peer. However, if you fight or avoid
him, you will waste a large amount of effort and will be unable to enjoy the moment or the food.
You can still let your peer be free even if you do not like him. Imagine a situation where you
allow the peer to be free, in order to save your energy, and do what is important to you, suchas chatting with your friends. The peer might still misbehave, disappear, or return. You may feel
unpleasant when he returns; however, you can also enjoy the party. It is like accepting the peer,
can you imagine this?
Now, this may seem abrupt, but imagine that the peer is an experience of unpleasant feelings,
sensations, and thoughts. Can you do the activities you need and want to do while maintaining areasonable distance from those experiences? Do you see that you can perform the same reaction
as you did with the peer I previously mentioned? The peer and those experiences are the samein that they are uncontrollable. Furthermore, they are similar in that they cannot physically limit

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our behavior. Can you imagine a situation where you can accept these unpleasant experiences
and behave freely despite them? Even if you have those thoughts, sensations, and feelings, you
can still behave differently.
Translated Group. For this group, the intervention content was the same as that for the adjusted
group except for element (b). The conducted metaphor and exercise were based on the translated
version. In other words, the participants were instructed to visualize a home party, and thecharacter’s name was Joe.
The script used in the translated group (that differed from the adjusted group), was as follows.
The script employed in this study was based on Hayes et alia (2012).
Imagine that you have purchased a new house and have invited all of your neighbors over to ahousewarming party. Everyone in the whole neighborhood is invited. You even placed a sign at
the supermarket. Therefore, all of the neighbors arrive, the party’s going great, and along comes
Joe, who lives behind the supermarket in the trash dumpster. He’s stinky and smelly and you
think, “God, why did he show up!” He is a terrible person because he swears and complains toothers. Although he does not always do so, it worsens when you confront him about it. Can you
imagine that person? Well, you did say on the sign “Everyone’s Welcome.” Can you see that it’s
possible for you to welcome him and really, fully do that without liking that he’s there? Let’s
imagine two options of interacting with him.
One option is that although you said everyone was welcome, in reality, he’s not welcome. But assoon as you do that, the party changes. Now you have to be at the front of the house, guarding
the door so he can’t return. Alternatively, if you say “OK, you’re welcome” but you don’t reallymean it –you only mean that he’s welcome as long as he stays in the kitchen and doesn’t mingle
with the other guests– then you’re going to have to be constantly ensuring he follows these rules
and your entire experience will be consumed with this. The more you monitor Joe, the worse
he swears. Meanwhile, life continues, the party’s going on, and you’re off guarding Joe. It’s justnot life-enhancing. It’s not much like a party. It’s a lot of work and not fun whatsoever! It is awaste of effort and similar to the “pink elephant” that we just experienced. Can you imagine asituation like this?
However, choosing the second option, you can welcome him although you don’t respect him.
You can dare to do nothing. As Joe is fickle, he might or might not be annoying. Although hebecomes more annoying when you attempt to monitor him, he might wander around aimlessly if
you let him go. You don’t have to like him. You don’t have to like the way he smells, nor his
lifestyle, nor his clothing. You might be embarrassed about the way he’s dipping into the punchor the finger sandwiches. Your opinion of him and your evaluation of him are absolutely distinct
from your willingness to have him as a guest in your home. You can do what is important foryou, such as having fun chatting with others or having delicious meals, even when he walks
around the party venue. Of course, you may have unpleasant experiences when Joe is withinsight; however, you can use the effort required to monitor or turn him away toward something
more important. Imagine that you continue to do what is important for you while leaving him
free to do as he pleases. It is like accepting Joe. Can you imagine it?
Now, this might seem abrupt, but what if all the feelings, memories, and thoughts that you don’t
like and that appear were just undesirable people at your door? The question is: What position
would you take with them? Are they welcome? Can you choose to welcome them in although
you don’t like the fact they have arrived? If not, what’s the party going to be like? Joe and theseexperiences are the same in that they are uncontrollable. Furthermore, they are similar in thatthey cannot physically limit our behavior. Can you imagine a situation wherein you can accept
these unpleasant experiences and behave freely despite them? Even if you have those thoughts,
sensations, and feelings, you can still behave differently.
Control Group. The participants were given a lecture with reference to Takahashi et alia (2002). An
explanation of the basics of the sensation mechanism, an experiment on the two-point threshold,and an introduction to cognitive behavioral therapy techniques for pain were conducted. Regarding
cognitive behavioral techniques, no exercise or training was conducted. The script employed inthis group is described in the Appendix.

As previously stated, only element (b) differed between the adjusted and translatedgroups, whereas the salience of the metaphor was manipulated based on cultural differences.
In addition, exercises were provided following the metaphors to train the participants inthe strategies that they will engage in at the second cold-pressor task. In other words,
the exercises were employed to promote the participants’ understanding of metaphors.
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Shima, Tsuda, Hashiguchi, & Muto

Procedure
The research ethics committee of the institution approved the procedure of thestudy. Informed written consent was obtained from all participants. This experiment
was conducted individually by one experimenter, which follows a pre-designed plot. A
tablet was employed to complete the questionnaires. The participants were instructedto call the experimenter after filling out the questionnaire. The entire session lasted
approximately 45 min.
Figure 1 depicts the flow of the experiment. After confirming that the participants
were in good physical condition, informed consent was obtained, and the questionnaires
were given (Phase 1). The cold-pressor task was then explained and performed. The
participants were asked to record their discomfort, pain, and other sensations perceived
during and after the task using VAS (Phase 2). Subsequently, an intervention lasting
approximately 15-25 min was implemented, after which they responded to items regarding
the manipulation checks for the metaphors and undertook a comprehension test (Phase3). They were then invited to perform the cold-pressor task again, and each measurement
was recorded using the same procedure in pre-measurement (Phase 4).
Phase 1
・Informed Consent
・Questionnaire application
Phase 2・Cold-Pressor Task (pre)・Self-report
Phase 3Adjusted group

Translated group

Control groupJapanese version
metaphor
implementation

Translated version
metaphor
implementation

Psychoeducation
implementation

Phase 4・Cold-Pressor Task (post)
・Self-report

Figure 1. Overview of the Experimental Procedure.

Data Analysis
All analyses included data in which all two tolerance times of the cold-pressor task
were less than 300s. Prior to analysis, the increase rate was logarithmically transformedby groups because it ensuring normality was considered difficult due to the small sample
size. Ten percent of the participants in each group (two participants with the highest andthe lowest increase rates) were excluded based on the analytical procedure of Sierra etalia (2016). Data from the remaining participants were analyzed.
To confirm intergroup homogeneity, one-way analyses of variance (ANOVA) with
the AAQ-II, CFQ, and FFMQ as the dependent variables were conducted. To conduct the
manipulation checks for the metaphors, a t-test comparison was conducted between theadjusted and translated groups using the comprehension tests and subjective evaluation
about interventions.
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Metaphors and Cultural Backgrounds

53

Furthermore, referring to Sierra et alia (2016), one-way ANOVA was conductedon the increase rate of tolerance time. The mean tolerance times and standard deviations
for the pre and post tests were calculated to describe the actual change in tolerance timein each group. For secondary dependent variables, two-way ANOVAs were performedin the self-report measurement of discomfort, pain, and other sensations perceived
during the task.
In addition, the reliable change index (RCI; Jacobson & Truax, 1991) was
calculated for additional analysis. The RCI is used to assess whether a change in aparticular indicator in an individual is statistically significant. It is expressed by theformula RCI= (posttest-pretest) / √2 (s√1-rxx)2. In this formula, s represents the standard
deviation at the pretest, and rxx represents the test-retest reliability. If the RCI value isgreater than 1.96, the change in the individual is considered a greater change than themeasurement error. Therefore, by calculating the RCI, it is possible to detect clinicalchanges. In this study, the reliability coefficient required to calculate RCI was obtainedusing a two-time measurement of the control group. Then, the participants that displayed
significant increase rates in pain tolerance time in the adjusted and translated groups wereidentified. Using the RCI, it is possible to describe changes in individuals that would
be discarded in an analysis of group difference. If common characteristics are extracted
from individuals who show significant changes, this may result in the identification of
the moderating or mediating variables that make the applied intervention work. Thisfocus on individual change might also result in Process-Based Therapy (Hayes, Hofmann,
Stanton, Carpenter, Sanford, Curtiss, & Ciarroch, 2019; Hofmann & Hayes, 2019).
In this study, as a supplementary analysis, the scores of process measures (AAQ-II,
CFQ, and FFMQ) were compared using t-tests between those whose RCI values weresignificant and not for each questionnaire to explore possible moderating variables. The
investigation related to the RCI was conducted only using the data of the adjusted andtranslated groups because the reliability coefficient was calculated from the measurementsof the control group.
Results
The data from one participant who was unable to complete the task and 11
participants who could tolerate cold-pressor tasks greater than 300s were excluded.
The remaining data from 41 participants were subjected to logistic transformation.
Subsequently, referring to Sierra et alia (2016), two participants with the highest andlowest increase rates in each group, or a total of six participants, were excluded. Finally,
35 participants (23 females, Mage= 20.74±0.92 years; adjusted group: n= 12, translatedgroup: n= 12, and control group: n= 11) were subjected to series of analyses.
One-way ANOVAs revealed no differences between the three groups in the
AAQ-II (F[2, 32]=.00, p=.99, η2= 0.00), CFQ (F[2, 32]= 0.37, p= .69, η2= 0.02), and FFMQ
(F[2, 32]= 0.32, p= .73, η2= 0.02). Accordingly, these groups were deemed equivalent at
pre-test with respect to these variables. Descriptive statistics of each questionnaire areindicated in Table 1.
Table 1. Descriptive Data and Condition Difference for Each Questionnaire.
Adjusted (n= 12)
Translated (n= 12)
Control (n= 11)
M
SD
M
SD
Mean
SD
AAQ-II
23.83
5.80
23.83
8.07
23.64
7.42
CFQ
22.92
7.68
26.08
10.26
25.36
10.17
FFMQ
117.33
11.09
117.2512.05
121.91
20.70
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Shima, Tsuda, Hashiguchi, & Muto

Table 2 displays the t-test results for each measurement between the adjusted
and translated groups and scores of the control group as supplementary information.
Analysis revealed that the adjusted group scored significantly higher than the translatedgroup only in the item “familiarity of the exercise contents with the Japanese people.”
The other items’ scores are not different.
Table 2. Descriptive Data and Condition Differences between the Adjusted and Translated Groups for Each Index for
Manipulation Checks.
AdjustedTranslatedtdfpd
95% CI(n= 12)(n= 12)74.83
67.50
Perspicuity of the exercises
0.88
22
.39
0.36
-0.45 to 1.17
(21.48)(19.11)
Similarity to one’s experiences and
61.58
56.50
0.41
16.36
.69
0.17
-0.63 to 0.97
contents of exercises(38.26)(19.51)
Familiarity of the exercise contents with
the Japanese people
The usefulness of the exercises to daily
life
Comprehension test

Perspicuity of the lecture
Similarity to one’s experiences andcontents of lecture
Familiarity of the lecture contents with theJapanese people
The usefulness of the lecture to daily life
Comprehension test

71.00
(24.58)83.58(13.98)77.08(16.71)42.17(19.87)70.08(18.62)
89.58(11.72)Control(n= 11)
86.82(10.14)64.27(21.15)64.55(23.33)77.18(12.28)59.09(11.31)

3.16

22

<.01

1.29

0.41 to 2.17

2.01

22

.06

0.82

-0.01 to 1.65

-2.12

22

.05

-0.87

-1.70 to -0.03

Figure 2 illustrates the increase rate for each participant by groups. One-way
ANOVA revealed that between-group difference was significant (F[2, 32]= 5.93, p <.01, η2=0.27). Moreover, the result of multiple comparisons indicated that although the adjusted
group displayed significantly large increase rates than did the other groups (translated:
3

3

2.5

2

Change from pretest to posttest

Change from pretest to posttest

2,5

2

1.5
1,5

1
1

0.5
0,5

0

0

TranslatedGroup
1 2 3 Adjusted
4 5 6 7 Group
8 9 10 11 12 13 14 15 16
17 18 19 20Group21 22 23 24 25 26 27 28Control
29 30 31 32
33 34 35 36
Control
Translated
Adjusted

Figure 2. Differential Pain Tolerance for Each Experimental Condition (Each bar represents thelogistic transformed change score from pretest to posttest of one participant).
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Metaphors and Cultural Backgrounds

55t[32]= 2.57, p= .02, d= 0.99; control: t[32]= 3.26, p <.01, d= 1.18), no difference was
detected between the translated and control groups (t[32]= 0.75, p= .46, d= 0.42).
Furthermore, post-hoc power analysis revealed that (1-β)= .72. The mean scores andstandard deviations for each group are indicated in Table 3.
Table 3. Descriptive Data and Condition Difference for
Cold-Pressor Task Tolerance Time.
Pre
Post
Group
Mean
SD
Mean
SD
Adjusted (n= 12)
48.13 27.81 82.16
59.66
Translated (n= 12)38.73 27.53 43.96
36.05
Control (n= 11)
39.12 19.06 39.58
22.84

Two-way ANOVAs performed on the secondary outcomes also revealed that
although the main effect of time in the other sensations was significant, there wereno significant interactions for all indicators (Table 4). Therefore, there were no groupdifferences in the self-report measurements.
The test-retest reliability, which was calculated using a two-time measurementof the control group indicated ICC (A, 1)= .87 (.58 to .96). The calculation of RCI for
each participant of both groups revealed that four out of 12 participants in the adjusted
group (33.33%) showed a significant change (RCI >1.96) compared with one out of 12
participants in the translated group (8.33%).
As supplementary analyses, t-tests between participants who showed significant
RCI value (n= 5) and not significant (n= 19) for each questionnaire were conducted.
The significant difference was indicated only in FFMQ (RCI >1.96= 128.00±9.92,
RCI <1.96= 114.79±10.18, t[22]= 2.59, p= .02; AAQ-II: RCI >1.96= 21.80±8.17, RCI<1.96= 24.37±6.64, t[22]= -0.74, p= .47; CFQ: RCI >1.96= 20.40±5.90, RCI <1.96=
25.58±9.49, t[22]= -1.15, p= .26). Those who showed significant changes in the adjusted
group were in the first, third, fourth, and seventh place out of 12 participants. Within
the translated group, participants showing significant change had the highest score. Allof these participants showed greater scores than the standardized mean scores (113.19)
reported in Sugiura et alia (2012).
Discussion
This study aimed to investigate the effects of metaphors with a consideration of
the cultural context. We used a metaphor for promoting acceptance and compared theincrease rates of tolerance time in the cold-pressor task among three groups, namely,
the adjusted group, which used a metaphor tailored to the Japanese cultural context;
the translated group, which used a translated metaphor created in a cultural backgroundother than Japan; and the control group.
The results demonstrated that the metaphor used in the adjusted group addressed
contents that are generally familiar to the Japanese experience compared with thetranslated metaphor because the score for the item “familiarity of the exercise contents
with the Japanese people” was higher than that of the translated group. This metaphor
was intended to increase the salience of the source of the metaphor by incorporatinga scenario that the Japanese are likely to experience, which functioned as intended.
Furthermore, no differences were found between both groups except for the index;
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Shima, Tsuda, Hashiguchi, & Muto

Table 4. Descriptive Data and Group Difference for Each Self-Report Measure.
Other
UnpleasantnessPainsensations
A
65.50 (26.47)
78.25 (17.46)
38.17 (27.02)
PreT
66.08 (15.67)
72.75 (14.86)
27.75 (18.12)
C
71.36 (15.94)
78.73 (17.27)
19.64 (21.05)
A
57.25 (20.91)
72.58 (12.74
46.67 (20.64)
PostT
62.92 (15.26)
70.67 (9.94)
34.00 (18.33)
C
65.73 (16.14)
75.27 (14.07)
27.82 (13.41)
F (2, 32)
0.51
0.49
3.01
Group
p
.61
.62
.06
F (1, 32)
4.19
3.25
7.49
Time
p
.05
.08
.01
F (2, 32)
0.29
0.26
0.06
Interaction
p
.75
.77
.94

Notes: A: Adjusted Group; C: Control Group; T: Translated Group.

thus, the quality of the other metaphor, which was used for the adjusted group, can beconsidered equal to that in the translated group.
Interpreting this study based on the HDML perspective (Barnes-Holmes etalia, 2020), the manipulation of the content might reinforce the orienting or evoking
functions of the metaphor by setting the source that has a high level of coherence withthe currently existing relational network of participants. However, this study overlooked
the measurement of each dimension or function of the relational network. Therefore,
experiments that can capture the change in each property of relational networks or its
impact are required. For example, if a change in coherence level could be captured, thendescribing the relationship between employing sources with high levels of coherencewith currently existing relational networks and recalling the metaphor are probable. By
doing so, the results could lead to a workable procedure for creating tailored metaphorsfrom the perspective of the HDML framework.
In terms of the increase rates of pain tolerance time in the cold-pressor task, theadjusted group exhibited significantly large change rates compared with those of theother groups with large effect sizes between the adjusted and other groups. Furthermore,
the results of the additional analysis using RCI indicated that 8.33% and 33.33% of
the participants showed a significant increase in pain tolerance time in the translatedgroup and the adjusted group, respectively. Considering the preliminary nature of thisstudy, that is a small sample size, we infer that the results warrant further investigation
regarding the consideration of the cultural context in the use of metaphors.
No significant interactions were found in the secondary dependent variables suchas self-report of discomfort, pain, or other sensations perceived during the task for eachgroup. These results were consistent with those of previous studies (e.g., Criollo et alia,
2018; Hayes et alia, 1999; Sierra et alia, 2016; Takahashi et alia, 2002). To the best of
our knowledge, the results of the current study may be one of the important findings
given the application of ACT to culturally diverse targets.
However, although a significant difference was noted in the increase rate for pain
tolerance time between the groups, a significant change in RCI was observed only in 1/3of the participants in the adjusted group, which, thus, requires further investigation. These
results suggest that only a few participants yielded strong reactions to the adjustment of
the metaphor employed in this study (see Figure 2). In other words, although the metaphor
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Metaphors and Cultural Backgrounds

57

employed in the adjusted group may produce strong changes in reaction compared withthose of the translated version, the extent to which the effect may have been influenced
is limited. Based on the supplementary analyses regarding RCI, it is suggested that if
a client shows a high FFMQ score or high mindfulness trait, it might be more likely
to produce clinical change by introducing metaphors adjusted to their cultural context.
However, this result was derived from a supplementary analysis and only indicates apossible candidate for a moderating variable for the effect of metaphors. Therefore, amore detailed study with a larger number of participants is required. The other possible
reason for these results is that although the content of the metaphor may be applicableto many participants, it might lack optimization for an individual’s experience. Out of
the questions for manipulation checks for the metaphors, the adjusted group displayed ahigh score for the item “familiarity of the exercise contents with the Japanese people”
compared with those of the translated group, as previously mentioned. However, nodifference was observed in the item for “similarity to one’s experiences and contentsof exercises.” For participants who had difficulty imagining the content of the metaphor
because they had a little experience similar to the content used in the metaphor, it wasdifficult to say that the salience of the source in the metaphor was high. From the
HDML perspective, for those participants, the source of the metaphor may not have ahigh level of coherence with the existing networks, which is insufficient for changing
the orienting or evoking functions. The scores on the manipulation checks items also
showed room for improvement in the metaphor or exercise (Table 2), that is, a broad
range of cultural factors should be employed to render the metaphor more effective
for a wide range of listeners. In clinical settings, therapists are required to adjust or
create metaphors to optimize their use for the individual. However, in a group format
or self-help setting, doing so under diverse situations is difficult. Therefore, studies thatinvestigate and intend to develop effective interventions by adjusting the cultural context
of the contents of the intervention, similar to the design of this study, are considered tocontribute to and necessary for the development of standardized programs.
The results of this pilot study suggest that considering the client’s culturalcontext when using metaphors may be effective. However, this study is positioned as
preliminary because of its nature. In line with the important role of a preliminary study
in suggesting future directions, we discuss related limitations and directions. First,
the number of participants was small and limited to healthy undergraduate students.
Therefore, experiments with a sufficient number of participants with other attributes
are required to investigate the generalizability of the results across populations. Second,
further investigation using various tasks is necessary because the study examined theeffect of cultural consideration using one experimental task (i.e., cold-pressor). To
further expand the generalizability of the current results, further studies should employ
alternative tasks that are similar to the cold-pressor task (e.g., paced auditory serial
addition task; Lejuez, Kahler, & Brown, 2003) or the other tasks, such as problem
solving or reaction time tasks. Similarly, experiments using other forms of metaphor
may be valuable. Third, further studies that examine the relationship between various
types of variables that may impact the effect of metaphors and behavioral change are
required. In this study, no common physical property (e.g., Criollo et alia, 2018; Ruiz &Luciano, 2015; Sierra et alia, 2016) was noted between the task and employed metaphor.
As previously mentioned, although the replication study conducted by Pendrous et alia
(2020) failed to support the previous findings and required further research, common
physical property may be a promising variable that impacts the effect of metaphors.
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Shima, Tsuda, Hashiguchi, & Muto

Thus, future scholars should determine the moderation effect of cultural contexts with
the incorporation of this factor. For instance, as supplementary analysis suggested
that mindfulness could be a possible moderating variable, it also requires further
investigation. Fourth, investigation under different experimental settings is required
because the current setting was insufficient as an analog for the clinical setting. For
example, the link between a client’s values and related behavior was incorporated into
the metaphor in the clinical setting but not in the current study. Thus, devising a settingthat better resembles the clinical environment may be necessary. Lastly, studies that use
psychological measures apart from the AAQ-II as an index of psychological flexibility
are needed because the questionnaire faced several critiques or issues (e.g., Gámez,Chmielewski, Kotov, Ruggero, & Watson, 2011; Ong, Pierce, Woods, Twohig, & Levin,2019; Rochefort, Baldwin, & Chmielewski, 2018; Tyndall, Waldeck, Pancani, Whelan,
Roche, & Dawson, 2019; Wolgast, 2014). Therefore, a re-examination that uses othermeasurement tools, such as the multidimensional experiential avoidance questionnaire(Gámez et alia, 2011) when focusing on experiential avoidance and the comprehensive
assessment of ACT processes (Francis, Dawson, & Golijani-Moghaddam, 2016) or themultidimensional psychological flexibility inventory (Rolffs, Rogge, & Wilson, 2018)
when focusing on general psychological flexibility, is recommended.
Despite the abovementioned issues, this preliminary study suggests that considering
the cultural background of listeners may be useful when selecting or creating metaphors.
We hope that future research will lead to the elaboration of the use of metaphors to
explain cultural differences.

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Received, August 11, 2021
Final Acceptance, January 31, 2022

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Appendix
Part AHow do you usually cope with when you experience pain? Generally speaking, when
we become aware of unpleasant feelings, thoughts, or other experiences, we attempt toeliminate them. This is very natural for us, and therefore, it might be automatic. These
coping strategies are common for us, and you may use them on a regular basis. However,recent research indicates that these common and sensible coping strategies might notalways work. For now, I will introduce you to several new ways of responding to unpleasant experiences (Show the handout).
First, I would like to explain the following two points. In this handout, the points
regarding the relationship between our thoughts or feelings and the actions we actuallytake were described. The first is that it is impossible to remove “bad” thoughts or feelings.
And the second is that thoughts or feelings are not the cause of our behavior.
Now, let’s look at the first point that it is impossible to remove “bad” thoughts or
feelings. Our common coping strategy is to actively try to remove thoughts, feelings, orsensations evaluated as “bad.” This can sometimes work temporarily; therefore, it is often
performed repeatedly. Have you ever had experiences where you have felt temporarily
refreshed by distraction when you felt unpleasant? However, does this coping always
work? How about in the long term? In fact, recent research has shown that this coping
strategy is often counterproductive and problematic in the long run.
Can you stand up, please? Since you woke up today, have you thought about “thepink elephant?” I bet you haven’t. Now, I will ask you not to think about the pink elephantfor one minute. Don’t think about any images. Never think about the “pink elephant,” andwalk around in this room while you are not thinking about it. Please try to never think
about it and walk as long as possible. If you think about it, stop walking and stay in thatplace [60 seconds].
How was it? It’s impossible, isn’t it? In fact, it is a very difficult task to intentionally
try to eliminate thoughts, feelings, or sensations. I think you have experienced that thisstrategy often prevents you from doing what you want or should do. Many studies haveshown that sometimes we can suppress unpleasant experiences; however, in many cases,
they quickly return or do so more intensely.
Part B
Now, let’s look at the second point, that thoughts or feelings are not the cause of
our behavior. Typically, we think of thoughts, feelings, or sensations as a cause of our
behavior; for example, missing class because of feeling bad or using medicine becauseof having an itch. That’s the general and common sense feeling. However, this common
sense is not always true. Therefore, let’s perform a little exercise.
Migrate to a different script for each group. See Methods section.
Let’s think about how we can actually deal with it. After this, I would like to ask
you to retry the cold-pressor task again. In preparation for the task, you will be practicing
how to respond to pain and its related thoughts or feelings, using the example of the party
previously mentioned. Imagine that you are looking down on the scene of the party fromthe second floor. You can see the participants chatting and eating delicious meals. Youmight even see yourself in that scene. As you imagine it, various thoughts, feelings, ormemories of the past event will surface. I would like you to imagine them as the peer/
Joe is doing bad things and then let it go. It is important not to try to eliminate or avoid
thinking about them because doing so would result in a “pink elephant.” Therefore, I
would like to ask you to try to have an attitude of continuing to observe the situation. For
example, when the thoughts such as “I want to quit” or “I’m tired” arise, imagine that thehttps://www. ijpsy. com

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peer/Joe is shouting that and maintain an attitude of observation. When you notice thatyou are no longer looking down on the party, return to that image and resume the exercise.
Have you figured out how to do this? (Three minutes to exercise and moving to Phase 4)
Control group
Do you know how the senses are generated? I would like to provide a brief explanationof the mechanisms and functions of the senses.
First, there are three main types of senses: somatic senses, visceral senses, andspecial senses. The so-called five senses are categorized as somatic and special senses.
As you know, the five senses are sight, hearing, taste, smell, and touch. These senses are
generated by external stimuli. The organs that receive these stimuli are called sensory
organs. Organisms, including humans, have a variety of sensory organs, each of which
can receive only a certain type and range of stimuli. For instance, the human eye canonly receive visible light with a short wavelength of 360-400nm and a long wavelengthof 760-830nm. The optimal stimulus that can be received by a certain sensory organ iscalled the adequate stimulus, and the range of intensity that can be received is called
the threshold. Since each sensory organ can only receive a specific stimulus, organisms
have various sensory organs. For instance, the photoreceptor cells that produce vision
receive light, and the hair cells of the organ of Corti that produce hearing receive sound.
In this case, light is the adequate stimulus for the visual nervous system, and sound is thestimulus for the auditory nervous system. However, visual sensations may be produced
when neural activity somewhere in the visual nervous system occurs, even in the absenceof an adequate stimulus. For instance, when hitting the head or placing pressure on theeyes, the visual nerves are pushed and become active, and something like a light may befelt. Have you ever experienced something like this? The stimuli that cause this kind of
sensation are called inadequate stimuli.
Subsequently, the stimuli received by the sensory organs are transmitted to the brain,
and they are used as information for the organism to respond to the outside world. Throughthe received stimuli, organisms become aware of the world outside of themselves.
Sensations are also an important research topic in the field of psychology. For a longtime, there has been a study called psychophysics. Our sensory nervous system responds
to physical stimuli. If the amount of physical stimulation from the outside world is small,sensation may not occur, however, if the amount is large, it occurs. Thus, to measure thecorresponding psychophysical quantity such as whether we see light or not by operating thephysical quantity of stimuli (such as intensity of light or sound) is called psychophysicalmeasurement. By adjusting the amount of stimulus, we can find the value at the absolute
threshold of the sensation. Therefore, the absolute threshold is the lowest stimulus intensity
required to produce a certain sensation. In contrast, the minimum difference we can findbetween two stimuli is called the discrimination threshold. The visual acuity test that we
perform when we acquire glasses or contact lenses is also measuring a kind of threshold,in this case, the minimum readable range.
Now, we are going to investigate which part of our body can easily discriminate
between two points using this caliper (Give participant a caliper). Try touching various
parts of your body to find out which parts can discriminate between two points and whichparts cannot (Experimenter should wait for a while). Next, try changing the size of thetwo points and see how many millimeters you can discriminate between the two points(Experimenter should wait for a while).
I think you found that there is a difference between the parts that are easily
discriminated against and those that are not. In general, it is thought that this depends onthe density of receptors that receive the stimulus and the size of the area in charge of thecortical sensory cortex. Therefore, the two-points discrimination threshold on the dorsum isInternational Journal of Psychology & Psychological Therapy, 22, 1© Copyright 2022 IJP&PT & AAC. Unauthorized reproduction of this article is prohibited.

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60-70mm, while it is said to be 3-5mm for the fingers. The density of touch or pressure spot
on the body surface is inversely proportional to the size of the two-points discriminationthreshold. This is higher on the fingertips and lips, and lower on the upper arms, lower
legs, and back. Therefore, the threshold of the tactile pressure is lower in the former andhigher in the latter. This means that fingertips and lips are more sensitive to touch.
Now, move on to the next section. When you placed your hand in the cold watera short while ago, I think you felt pain. There is extensive research on pain in the fieldof clinical psychology. For instance, intervention methods for chronic pain have beendeveloped. However, today I would like to discuss cognitive behavioral therapy. In CBT,the focus is how the patient understands, thinks about, and behaves in response to painfulstimuli. The idea is to support patients to consider what their thoughts about pain mean, tosort out what motivational or emotional problems and physical change they experience,and to help them learn how to cope in their daily lives. I would now like to briefly explain
the described method (Show the handout).
Cognitive restructuring is a method of correcting the thought process that leads tonegative perceptions of pain in a different, more positive, and realistic way. A concrete
example is to think positively when pain occurs such as “I can handle it.”
Visual imagery is a method of imagining a calming scene such as a natural landscapewith closed eyes.
Distraction is a method of directing attention to stimuli other than pain in order toreduce the focus on the pain. Examples include watching TV or reading a book.
In progressive muscle relaxation, patients relax a specific muscle group by using
the mechanism of muscle contraction and relaxation. The patients sit comfortably andapply force to a body part such as the shoulders, arms, or legs for five seconds, then relax
it repeatedly.
Pain education is designed to educate and deepen the understanding of pain. It is
often conducted in hospitals because a specialist provides a lecture.
Pleasurable activity planning involves making plans for enjoyable activities such as
making travel plans or weekend plans.
Activity pacing involves planning pacing activities that take activity time into
account. It attempts to control pain by setting the activity time to a shorter duration than
the time when the pain begins.
Finally, modeling is learning (by observation) the efforts of others who are in pain.
The methods include listening to people who have been able to endure their pain throughexercise.
Now that I have briefly explained pain control, are there any coping strategies thatyou use regularly? (Moving to the Phase 4).

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