Effectiveness and Mechanisms of Action of Meta-Inner Humor Therapy (MIHT) in Obsessive Compulsive Disorder: Evidence from Ecological Momentary Assessment and Multilevel Network Modeling
To determine the effectiveness of Meta-Inner Humor Therapy (MIHT) in reducing the momentary intensity of clinical components in the obsessive-compulsive cycle and restructuring the network organization of these components in patients’ daily lives, based on Ecological Momentary Assessment (EMA) data at pre- and post-treatment stages
Design
The present study is a single-group, pre-post intervention clinical trial, conducted using a systematic approach based on established standards for clinical study design. It aims to investigate the impact of Meta-Inner Humor Therapy (MIHT) on the momentary dynamics of the obsessive-compulsive cycle within the daily lives of individuals with OCD. The design is based on a three-phase structure: a 14-day baseline period of Ecological Momentary Assessment (EMA), a five-week program consisting of 10 sessions of MIHT, and a corresponding 14-day EMA period post-treatment. This design enables a detailed analysis of changes at the intra-individual and momentary levels
Settings and conduct
Participants will be recruited between June 20, 2026, and July 21, 2026 using a multi-stage referral and announcement strategy to enhance sample representativeness and reduce self-selection bias, and will receive the intervention at university counseling centers and outpatient clinics in Tehran
Participants/Inclusion and exclusion criteria
Participants will include using the Structured Clinical Interview for DSM-5 Disorders, Clinical Version, administered by trained therapists under the supervision of licensed clinical psychologists.
Intervention groups
Meta-Inner Humor Therapy will be delivered individually in 10 sessions over a 5-week period, implemented according to the standard Meta-Inner Humor protocol.
Main outcome variables
Severity of obsessive-compulsive disorder symptoms
General information
Reason for update
Acronym
IRCT registration information
IRCT registration number:IRCT20130904014564N4
Registration date:2026-05-31, 1405/03/10
Registration timing:prospective
Last update:2026-05-31, 1405/03/10
Update count:0
Registration date
2026-05-31, 1405/03/10
Registrant information
Name
Mehdi Akbari
Name of organization / entity
Kharazmi University
Country
Iran (Islamic Republic of)
Phone
+98 21 6602 1735
Email address
akbari.psy@gmail.com
Recruitment status
Recruitment complete
Funding source
Expected recruitment start date
2026-06-20, 1405/03/30
Expected recruitment end date
2026-07-21, 1405/04/30
Actual recruitment start date
empty
Actual recruitment end date
empty
Trial completion date
empty
Scientific title
Effectiveness and Mechanisms of Action of Meta-Inner Humor Therapy (MIHT) in Obsessive Compulsive Disorder: Evidence from Ecological Momentary Assessment and Multilevel Network Modeling
Public title
Effectiveness Meta-Inner Humor Therapy (MIHT) in Obsessive Compulsive Disorder
Purpose
Treatment
Inclusion/Exclusion criteria
Inclusion criteria:
A primary diagnosis of OCD based on DSM-5
Age between 18 and 70 years
Full proficiency in the Persian language
The ability and willingness to complete smartphone-based EMA prompts multiple times daily throughout the study period
Participants receiving psychiatric medication are eligible provided that their medication regimen has remained stable for at least four weeks prior to the baseline assessment
Exclusion criteria:
Receiving concurrent psychological treatment
Any past or present Bipolar or Schizophrenia disorders
Acute suicidal ideation or recent attempts
Substance use disorder within the past three months
Cluster A or B personality disorders
Physical conditions that could interfere with participation in MIHT exercises (e.g., uncontrolled neurological or cardiovascular diseases)
Age
From 18 years old to 70 years old
Gender
Both
Phase
3
Groups that have been masked
No information
Sample size
Target sample size:
80
Randomization (investigator's opinion)
N/A
Randomization description
Blinding (investigator's opinion)
Not blinded
Blinding description
Placebo
Not used
Assignment
Single
Other design features
Secondary Ids
empty
Ethics committees
1
Ethics committee
Name of ethics committee
Ethics committee of Kharazmi University
Street address
No.43, South Mofateh St, Kharazmi University, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
15719-14911
Approval date
2026-05-13, 1405/02/23
Ethics committee reference number
IR.KHU.REC.1405.024
Health conditions studied
1
Description of health condition studied
Obsessive Compulsive Disorder
ICD-10 code
F42
ICD-10 code description
Obsessive-compulsive disorder
Primary outcomes
1
Description
Obsessive compulsive symptoms
Timepoint
Pre-treatment (baseline) and post-treatment (end of week9)
Method of measurement
Yale Brown Obsessive-Compulsive Scale (Y-BOCS)
Secondary outcomes
1
Description
Momentary severity of the participant’s current obsession, assessed daily via an Ecological Momentary Assessment (EMA) protocol.
Timepoint
Four times daily, for 14 days prior to the intervention (baseline) and 14 days following the intervention (follow-up).
Method of measurement
This variable is assessed using a single-item 0–10 numeric rating scale. The item is: “How intense is this obsession right now?” with 0 indicating “not at all” and 10 indicating “very much.”
2
Description
Momentary believability or perceived realism of the current obsession, assessed daily via an Ecological Momentary Assessment (EMA) protocol.
Timepoint
Four times daily, for 14 days prior to the intervention and 14 days following the intervention.
Method of measurement
This variable is measured using a single-item 0–10 numeric rating scale. The item is: “How real or believable does this obsession feel right now?” Higher scores indicate greater believability of the obsession.
3
Description
Momentary urge to perform a compulsion related to the current obsession.
Timepoint
Four times daily, for 14 days prior to the intervention (baseline) and 14 days following the intervention (follow-up).
Method of measurement
This variable is assessed using a single-item 0–10 numeric rating scale. The item is: “Because of this obsession, how strongly do you feel the need to perform a compulsion right now?” Higher scores indicate a stronger compulsive urge.
4
Description
Expected distress when resisting responding to the current obsession.
Timepoint
Four times daily, for 14 days prior to the intervention (baseline) and 14 days following the intervention (follow-up).
Method of measurement
This variable is measured using a single-item 0–10 numeric rating scale. The item is: “If you tried not to respond to this obsession right now, how distressed would you feel?” Higher scores indicate greater distress during resistance.
5
Description
Momentary change in the participant’s urge or perspective toward the obsession following the delivery of a humorous defusion-based audiovisual educational content.
Timepoint
Four times daily, for 14 days prior to the intervention (baseline) and 14 days following the intervention (follow-up).
Method of measurement
How much did this humorous defusion-based audiovisual educational content change your urge or perspective toward this obsession right now on a 0 to 10 numeric scale?” Higher scores indicate a greater change in the individual’s cognitive-emotional experience in relation to the obsession.
Intervention groups
1
Description
Intervention group: Meta-Inner Humor Therapy (MIHT): This treatment is a structured ten-session intervention based on active mindfulness that uses humor as a metacognitive tool to revise the individual’s relationship with thoughts and emotions (Akbari et al., 2026). MIHT unfolds across three therapeutic phases, as described below. Phase 1: awareness and pattern recognition (sessions 1–3): This phase embodies self-criticism, RNT, and cognitive rigidity and begins by framing negative thoughts as a universal human experience. Participants learn to notice typical tone, triggers, and repetitive narratives of negative thoughts without judgment. To make the negative internal voice, or Inner Fool, more recognizable, a simple, gloomy character—such as a Glum-like figure or other culturally familiar example like Eeyore—is used as a metaphor. For example, instead of automatically accepting a thought like “I’m incompetent” or “If I speak, everyone will notice my anxiety,” participants visualize The Inner Fool saying it aloud, exaggerating the certainty and gloom of the thought. By externalizing it in this way, the thought can be clearly recognized as a thought, not an objective fact. This allows clients to give distinct persona to their negative thinking and helps them conceptualize thoughts as mental events rather than objective reality, reducing emotional intensity and fostering cognitive distancing. The exercise turns RNT into something observable, approachable, and open to compassionate engagement. Phase 2: playful reframing (sessions 4–7): In this phase, clients develop an Inner Humorous character—often a familiar, playful figure such as a cartoon or culturally known character—to counter the rigid, gloomy tone of the Inner Fool. Importantly, playful reframing in MIHT does not involve replacing a negative thought with a more rational statement, as in traditional cognitive restructuring. Instead, the intervention invites clients to relate to the thought with humor and lightness, often by exaggerating, personifying, or gently parodying the thought pattern. This approach aims to reduce cognitive fusion and rigidity while maintaining awareness of the emotional experience. The goal is not to argue with negative thoughts but to mock the entire persona of the Inner Fool in a light, non-hostile way. By using humor rather than logic, clients gain cognitive distance from RNT and cultivate a flexible, resilient stance toward distressing thoughts. Instead of responding rationally to statements like “You’re incompetent,” the Inner Humorous playfully exaggerates and teases the Inner Fool, turning its certainty into something predictable and harmless. Playful reframing helps clients observe RNT with curiosity and levity, reducing its power and laying the groundwork for a wiser, more compassionate inner dialogue. For example, if the Inner Fool says, “You’re incompetent,” the Inner Humorous does not respond logically (“No, I am competent because I did X task well”). Phase 3: integration and application (Sessions 8–10): In this phase, clients learn to cultivate two complementary inner capacities, The Inner Nurturer and the Inner Humorous, which together form the balanced voice of the Inner Wise, or the integration of humor and compassion. While the Inner Humorous playfully disrupts RNT, the Inner Nurturer responds to difficult emotions—fear, sadness, or frustration—with warmth, validation, and gentle reassurance. Clients imagine the Inner Nurturer as a caring friend, parent, or compassionate figure who helps regulate emotional distress. Through guided examples, clients practice shifting between these inner voices depending on what the moment requires. Over time, clients learn to alternate or integrate these voices fluidly, enabling them to neutralize negative thoughts, calm emotional intensity, and restore psychological balance. This phase emphasizes flexibility. Sometimes humor is enough, sometimes compassion is needed, and sometimes the integrated Inner Wise leads both. Here is a brief example of the conversion between different mindsets when the client comes up with a thought that begins with the Inner Fool.
Category
Behavior
Recruitment centers
1
Recruitment center
Name of recruitment center
Academic counseling centers, psychiatric outpatient clinics, and private clinics in Tehran
Full name of responsible person
Dr. Mehdi Solimani
Street address
South Kargar Street, Below the Lashgar, Roozbeh Psychiatric Hospital, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
1333715914
Phone
+98 21 5541 9151
Email
m.akbari@khu.ac.ir
Sponsors / Funding sources
1
Sponsor
Name of organization / entity
Vice-chancellor for Research and Technology, Kharazmi University
Full name of responsible person
Dr. Alireza Harifi
Street address
No.43, South Mofateh St, Kharazmi University, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
15719-14911
Phone
+98 21 8832 9220
Email
m.akbari@khu.ac.ir
Grant name
Grant code / Reference number
Is the source of funding the same sponsor organization/entity?
Yes
Title of funding source
Vice-chancellor for Research and Technology, Kharazmi University
Proportion provided by this source
100
Public or private sector
Public
Domestic or foreign origin
Domestic
Category of foreign source of funding
empty
Country of origin
Type of organization providing the funding
Academic
Person responsible for general inquiries
Contact
Name of organization / entity
Kharazmi University
Full name of responsible person
Mehdi Akbari
Position
Professor
Latest degree
Ph.D.
Other areas of specialty/work
Psychology
Street address
No.43, South Mofateh St, Kharazmi University, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
15719-14911
Phone
+98 21 8832 9220
Email
m.akbari@khu.ac.ir
Person responsible for scientific inquiries
Contact
Name of organization / entity
Kharazmi University
Full name of responsible person
Mehdi Akbari
Position
Professor
Latest degree
Ph.D.
Other areas of specialty/work
Psychology
Street address
No.43, South Mofateh St, Kharazmi University, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
15719-14911
Phone
+98 21 6655 2336
Email
m.akbari@khu.ac.ir
Person responsible for updating data
Contact
Name of organization / entity
Kharazmi University
Full name of responsible person
Mehdi Akbari
Position
Professor
Latest degree
Ph.D.
Other areas of specialty/work
Psychology
Street address
No.43, South Mofateh St, Kharazmi University, Tehran, Iran
City
Tehran
Province
Tehran
Postal code
15719-14911
Phone
+98 21 6655 2336
Email
m.akbari@khu.ac.ir
Sharing plan
Deidentified Individual Participant Data Set (IPD)
Yes - There is a plan to make this available
Study Protocol
Yes - There is a plan to make this available
Statistical Analysis Plan
Yes - There is a plan to make this available
Informed Consent Form
Yes - There is a plan to make this available
Clinical Study Report
Yes - There is a plan to make this available
Analytic Code
Yes - There is a plan to make this available
Data Dictionary
Yes - There is a plan to make this available
Title and more details about the data/document
Information on the main outcome of the research will be shared.
When the data will become available and for how long
Access begins 6 months after results are published.
To whom data/document is available
Data and other scientific documentation can be made available to any person who requests it.
Under which criteria data/document could be used
There are no specific restrictions.
From where data/document is obtainable
To access the data, you can send a message to Dr.Mehdi Akbari's email address: Akbari.psy@gmail.com or m.akbari@khu.ac.ir
What processes are involved for a request to access data/document
One month after the requester sends a message to one of the two emails mentioned in the previous section, individuals can receive the requested information.