Effectiveness of Positive Thinking Skills Training on the Hope and Quality of Life of Drug-Dependent People.

BACKGROUND: The increase of hope and quality of life (QOL) can play a significant role in improving the mental health of drug addicts. Accordingly, the present study aimed to determine the effectiveness of positive thinking skills training on hope and QOL of drug-dependent people.
METHODS: The present study is a quasi-experimental research with pre- and post-test design with the control group. The study population consisted of all men dependent on drugs who visited addiction treatment centers in Tehran, Iran, in 2016. Thirty subjects were selected using cluster sampling and were randomly assigned to control and experimental groups. The results were analyzed using SPSS.
FINDINGS: The mean scores of pre-test and post-test for hope were 31.67 ± 6.47 and 49.68 ± 10.69, for physical fitness were 17.01 ± 4.21 and 22.84 ± 4.98, for psychological health were 15.36 ± 3.45 and 20.98 ± 3.32, for social relations were 7.80 ± 2.34 and 10.96 ± 2.64, and for environmental health were 20.47 ± 4.36 and 27.50 ± 4.80, respectively, in experimental group (P < 0.050).
CONCLUSION: It is recommended that addiction treatment centers teach positive thinking skills to drug-dependent people in order to increase their hope and QOL.

Introduction

An addiction is one of the fundamental problems at current societies, which destroys millions of lives and spends the great national capitals on costs of fighting, treating addiction and its damages. Today, the problem of addiction has gone beyond the boundaries of healthcare and has become a social crisis and main and disabling concern worldwide. Since drug dependence has inhibitory effects on the growth and prosperity of society, we should see it as a threat and consider it as one of the public health problems around the world.1 Many people approach to use drugs every day and suffer from its physical, psychological, cultural, economic and social consequences. Our country also is a good context for people to approach drug usage because of some cultural reasons, false beliefs and specific geographical position. This devastating problem can influence the family structure, interpersonal relationships and marital relations.2

The family is a safe place to satisfy a variety of physical, intellectual and emotional needs. So it is necessary to know biological, psychological needs and the way to satisfy them.3 In other words, addiction and drug abuse are the results of personality, social and family factors.4 Nowadays in addition to abstain from drug use among drug-addicted people, the consequences of different types of treatment methods and also life quality of drug-addicted people are of high importance. The addiction is related to psychological and physical damages and threatens the health and safety of a person. The drug addiction can threaten the independence and ability of individuals to play their role effectively in a society and on the other hand, can have a significant effect on their level of hope and quality of life (QOL).5

According to World Health Organization (WHO), 1995, the QOL is a measure of individual well-being that is based on individual’s perceptions of different aspects of life including physical health, psychological position, social relationships, personal independence and people’ interaction with prominent aspects of surrounding environment.6 The QOL is one of the most fundamental concepts discussed at positive thinking psychology.7 Researchers have specified many factors that predict the QOL of people. For instance, we can refer to a personal function, personal faith and spirituality, comparing the past and current living conditions and amount of perceived social support by an individual.8 Evidence has shown that drug abuse and consumption of opiate drugs are in line with the lower QOL.9 The results of a research conducted by Diener and Chan10 indicated that positive thinking training is effective in improving the level of QOL among adolescents.

Another factor that could have an effect on the lives of the drug-addicted people is the level of hope. Hope has been defined as the thinking process about personal goals along with the motivation to reach the goals (operational thinking) and methods to reach goals (pathway thinking).11 According to Snyder and Lopez,11 adults with high hope can create more methods to reach their goals and can be motivated effectively to reach the favorable end. In contrast, people with low hope neither have the possibility to find available methods to reach their goals nor they have more motivation to reach what they want. Yalom12 specifies hope as a fundamental element of the treatment process. People usually have vague conditions when they receive treatment and are undecided about the future. When they are at vague conditions and reaching goals is not certain, it is possible to protect their will and targets through relying on the variety of strategies. For example, it is possible to strengthen their will to reach goals by supporting social network or through benchmarking strategies, people had applied in the past, and find new ways to reach their goals.12

Another research showed that high hope results in strengthening self-confidence, high self-efficacy and well-being of people.11,13

Dockray and Steptoe14 found that the components of positive thinking approach are effective in decreasing anxiety and depression and increasing life satisfaction, psychological health, hope and happiness of people. Schueller15 reported in his study that positive thinking psychology is a good device for a good life by focusing on positive emotions, positive properties and positive opportunities. Furthermore, he found out those interventions of positive thinking psychology increase the psychological well-being of people. Since drug-dependent people are unable to find a solution for their problems and gain an approach to improve their QOL and health, implementing psychological interventions is necessary in order to improve the QOL of these people. One of the psychological interventions recently has drawn attention, is positive thinking psychology intervention. This approach has been introduced by Seligman at the late 1990s’ and the beginning of 21st century.16 Unlike other approaches focusing on difficulties and weaknesses, the emphasis at this approach is on increasing positive emotions and improving life meaning. In terms of positive thinking psychology approach, positive emotions and abilities are among the best contexts to prevent psychological injuries. Indeed, psychologists should not focus on stabilizing the problems of people but they should help these people to have a happier, richer and more excellent life. In this regard, this approach aims to explore methods by which people can have more optimistic and pleasant feeling in their life, express their friendship and play a more highlighted role in creating a family, occupational and social environments.17

From Seligman’s point of view, the man has both positive and negative halves and now it is the time to consider positive aspects of thoughts, beliefs, feelings, and behaviors of human being in addition to study pathological aspects and psychological diseases. Meantime, optimism as one of the sub-classes of positive thinking psychology, which is considered among positive characteristics of a human being, has gained a niche in the field of evolutionary psychology, family psychology and psychological health during last decade.16 Our studies indicate that optimism and in general, positive beliefs results in increasing hope, self-efficacy and self-esteem among people.18,19 Therefore, it is appropriate to carry out studies and research in order to recognize these methods from which academic and practical strategies are extracted and apply it as a theory of behavior and psychological health balance along with other similar theories mentioned before.

Hence, this study sought to answer the question of whether training positive thinking skills affect hope and QOL among people dependent on drugs.

Methods

This quasi-experimental research had pre-test and post-test design with the control group. Participants were assigned randomly to two control and experimental groups. The statistical population consists of all men dependent on drugs who visited addiction treatment centers in Tehran, Iran, during 2016. About 30 people were selected using cluster sampling and placed in two control and experimental groups randomly. For this purpose, the city of Tehran was divided into five regions of north, south, east, west and center. One region and one addiction treatment center were randomly selected from a list of all active addiction treatment centers. To this end, the drug-dependent men, who visited addiction treatment centers, answered the questionnaires of hope and QOL in a one month period. After completing the questionnaires, 30 people with the lowest scores were selected and were assigned to control and experimental groups randomly (15 subjects in control group and 15 subjects in the experimental group). The experimental group was received 8 sessions of training each one hour and once a week and control group received no intervention. During the last session, both groups were post-tested. None of the subjects were excluded during 5 months of training and statistical analysis was carried out on 30 people. The obtained data were analyzed using ANOVA method by SPSS software (version 22, IBM Corporation, Armonk, NY, USA). In this study, P less than 0.050 was considered significant.

After treatment sessions for the experimental group, because of interest and respecting ethics, the treatment sessions were held for the control group. Some other ethics respected in this study were as follow: there was no need to have a name of participant on questionnaires. Accordingly, the participants have ensured that participation in this study has no threats to their family, job, and social securities. Before implementing the inventory and intervention, clients were asked whether they would participate in this study.

Before implementing questionnaires, the consents of officials and participants were gained. The questionnaires were distributed and collected by the author so that participants had no concerns about their answers studied by officials of addiction treatment center.

Inclusion criteria for this study were primary and main diagnosis of drug dependence, lack of psychological disorders such as psychosis, delirium, momentum control and organic disorders, being male with age between 20 to 45 years old, no consumption of antipsychotic drugs when included in treatment, living in Tehran and with the family, and minimum education level of guidance school. Exclusion criteria were reluctance to participate in sessions and missing them for more than twice, and use of other psychological treatments throughout the study.

This scale was prepared by Snyder in 1991 and includes 12 questions with eight options. The subject will be scored 8, 7, 6, 5, 4, 3, 2, and 1, respectively for totally agree, highly agree, agree, slightly agree, slightly disagree, disagree, highly disagree and totally disagree. Therefore, the hope score is 8 to 64 eventually. Here, 8 is considered as the lowest score (less hope) and 64 as the highest score (high hope). In this scale, the questions 3, 5, 7 and 11 were trick questions and in this regards, they receive no score. The validity and reliability of this test were defined by Snyder and Lopez.11 Cronbach’s alpha was obtained between 0.14 and 0.84 and the reliability of retest during a 10-week period was obtained 0.80. According to Kermani et al.,20 the psychometric properties of the questionnaire were acceptable.21 In the present study, the reliability of this scale was obtained 0.73 using Cronbach's alpha method.

This scale was prepared by WHO in collaboration with 15 international centers in 1989 and has 26 items examining the QOL of a person in terms of various aspects in a Likert scale of 1 to 5. Two questions are about the person’s overall feeling of his own QOL and rest of questions measure the feeling and behavior of a person during last two weeks in the fields of physical health (7 questions), psychological (6 questions), social relations (3 questions) and social environment (8 questions).22 After completing the required calculations for each domain, the score between 4-20 for each domain is obtained separately, where 4 shows the worst and 20 reflects the best-targeted domain. The score of each item is between 1 (rarely, never, highly-dissatisfied) and 5 (very much, always, highly-satisfied). It should be noted that questions 3, 4 and 25 were scored reversely. The reported results for the reliability of the QOL questionnaire were measured by the group developed the WHO-QOL scale (1998). In this regard, 4802 people from 15 countries, 4104 from 13 countries and 2369 from 5 countries were evaluated. Cronbach's alpha was reported 0.66 to 0.84 for four subscales and the whole scale, which indicates a good internal consistency.23

Also, in a study conducted by van Esch et al.24 on women with cancer, the reliability of the WHO-QOL questionnaire re-test was 0.70. In addition, the reliability of WHO-QOL was studied by Rahimi25 and Cronbach’s alpha coefficient was reported 0.88 for the whole scale, 0.70 for physical health, 0.77 for mental health, 0.65 for social relationship and 0.77 for the quality of the neighborhood. In a research conducted by van Esch et al.,24 concurrent validity was obtained for subscales of physical health as 0.86, mental health as 0.91, social relation as 0.89 and neighborhood as 0.14. Reliability of QOL questionnaire was obtained 0.79 for the whole scale, 0.68 for physical health, 0.78 for mental health, 0.61 for social relations and 0.70 for neighborhood by Cronbach’s alpha coefficient. In the present study, Cronbach's alpha coefficient was calculated as 0.74 for the whole scale, 0.63 for physical health, 0.74 for mental health, 0.65 for social relations and 0.68 for the neighborhood. Table 1 refers to the content of teaching skills training sessions.

Table 1

The content of training sessions for positive thinking skills

Session	Brief description of each session
First	Explaining how to do something, why people are selected, familiarity with the concept of positive thinking, familiarity with the group and its governing regulations
Second	Familiarity with how to form thinking and attitude
Third	Familiarity with negative thoughts and its adjustment methods, positive thinking and its impact on health and longevity of people
Fourth	Training how to be positive by challenging negative thoughts, changing mental images, using constructive language and revision of beliefs
Fifth	Training how to be positive through institutionalization the strategies of positive thinking in life, continue to practice positive thoughts, opportunities for positive thinking through coping problems that we cannot resolve them.
Sixth	Trying to live positive through creating a positive relationship, health as a prerequisite for being positive, establishing good relations with people and loving them dearly
Seventh	Being positive through training thinking stop method, relaxation and a change of attitudes including requirements, harness and defiance
Eighth	Entering laughter into the life, creating self-confidence and creating good habit of doing exercise

Results

Table 2 describes the basic and demographic characteristics of the studied samples. Table 3 data indicate that positive thinking skills training in post-test were significantly different from the pre-test and this shows the effect of the intervention. After controlling the effect of pre-test there was a significant difference between hope and QOL in both experimental and at the post-test stage can be associated with positive thinking skills effectiveness for these variables. Statistical test results showed that hope (P = 0.024) and QOL (P = 0.001) have been significant.

Table 2

Basic characteristics

Group	Age (year) (mean)	Education level			Marital status
		Middle School	Diploma	Associate degree	Bachelor	Single	Married
Experimental	32.57	4	5	3	3	4	11
Control	32.67	5	3	4	3	5	10

Table 3

Mean and standard deviation (SD) scores of hope and quality of life (QOL) components for both groups of experimental and control

Variables	Experimental group		Control group
	Pre-test	Post-test	Pre-test	Post-test
Hope (mean ± SD)	31.67 ± 6.47	49.68 ± 10.69	32.78 ± 6.71	31.27 ± 6.34
Physical health (mean ± SD)	17.01 ± 4.21	22.84 ± 4.98	17.47 ± 4.57	16.95 ± 4.35
Psychological health (mean ± SD)	15.36 ± 3.45	20.98 ± 3.32	15.39 ± 3.12	16.78 ± 3.46
Social relations (mean ± SD)	7.80 ± 2.34	10.96 ± 2.64	7.25 ± 2.11	7.36 ± 2.78
Environmental health (mean ± SD)	20.47 ± 4.36	27.50 ± 4.80	21.12 ± 4.36	20.67 ± 4.20

SD: Standard deviation

Overall, the findings show that training positive thinking skills influences hope and quality of life (QOL) of people dependent on drugs.

Discussion

This study aimed to investigate the effect of training positive thinking skills on hope and QOL of drug-dependent people. The results showed that training these skills leads to increase the hope. Accordingly, the results indicated that training leads to increase the QOL of the people dependent on drugs. While studying the research background, it was specified that the results of this study are consistent with the results of studies by Nikmanesh and Zandvakil,26 Saeedi et al.,27 Dargahi et al.,28 Layous et al.,29 Sergeant and Mongrain,30 Sadeghi et al.,31 Porzoor et al.32 and Schueller.15

While explaining the results, it can be noted that QOL is a comprehensive, complicated and multilateral concept that depends on physical and social conditions of an individual in addition to his mental perception. Therefore, it seems that it is required to have a long-term and multi-lateral intervention in order to improve QOL. Not only should it focus on a psychological aspect of a patient, but also the physical, social and environmental aspects should be considered. Positive thinking skills training is accomplished by making changes in various fields such as positive thinking about self, others, and life as well as being aware of the effect of positive thought on health and longevity of people, revision of beliefs, changing mental images, positive and constructive relationship with others, knowing how to stop thinking and also relaxation training.33

According to these fields and based on positive thinking and also cognitive behavioral theories, the dependence on drugs, like other behaviors, consists of a series of acquired behaviors which are learned through imitating models as a result of knowing the consequences of drug, like reducing anxiety and depression, pain relief and enhancing the ability of socialization. In this regard, the main goal of treatment is to identify important consequences and teach effective methods to authorities and addicted person for dominating them in order to disrupt relations with drugs. In this treatment method, the emphasis is on the managing methods of negative mood, defiance and controlling anger.32

The effectiveness of this treatment in the present study based on various aspects of QOL of addicted people such as physical, psychological, social relations and environmental situations aspects are consistent with those findings that have shown the effect of cognitive behavioral treatments on the QOL of people dependent on opioid substances.34 Also in this regard, a research showed that not only positive psychotherapy creates positive resources, but also it can create a mutual effect on negative symptoms of addicted people and can be also as a barrier for their re-occurrence.35

Schueller15 reported in his research that positive psychology is a good measure to have a good life by focusing on positive emotions, positive characteristics and positive opportunities. He also found out positive psychological interventions can increase the QOL. Bolier et al.36 found that positive psychological interventions are effective in improving the physical and psychological well-being of people and additionally can help to reduce the symptoms of depression. Reviewing the results showed that training positive psychology provides a new method for cognitive processing and adjusting emotions, which in turn decreases the psychological and interpersonal problems. The fundamental element of positive psychotherapy intervention includes training clients to guide their attention to positive emotions and creating positive resources. In other words, increasing positive emotions leads to more compatible methods to respond to difficult situations. At last, this will lead to increase the QOL and decrease the negative symptoms of emotions.

In another explanation for the effectiveness of positive thinking skills training on hope among drug-dependent people, it can be noted that training these skills in order to strengthen and improve the positive relationship with self, others, and the world will lead people to know themselves better, recognize their positive experiences and find out the role of these positive experiences in increasing and enhancing the respects to themselves. Paying attention to positive points and previous good experiences would increase the possibility to have more positive perceptions about self and others. This leads people to be more responsible about their values and reach the more comprehensive understanding of themselves.27 All these would cause an increased hope among people. Accordingly, if people justify and interpret events logically and based on all tools, this will lead to face with life events in a right way and as a result, experience more peace in their life. Therefore, their hope and QOL are high. Generally, patients were more aware of their thoughts and feelings during training sessions and developed more positive beliefs, revising and rethinking the negative thoughts and replacing them with positive thoughts has been increased among them, which eventually resulted in increased hope in drug-dependent men. Moreover, they considered exploring strengths and facilitating positive attitudes toward self and others, logical and realistic interpretation of events, paying attention to blessings and living positive, which ultimately lead to increase hope among them.

Positive thinking training helps drug-dependent men to acquire more hope through identifying strengths and their capabilities. On this basis, they have a more optimistic outlook for the future of their own. Seeing bright future can increase the tolerance power for problems in these people and double their efforts to reach their goals. Explaining good and positive experiences and getting feedback from other members of the group are among the strongest stages of positive thinking method in recognizing the reliable abilities. A part of the cognitive ability is due to the attention of people to the development of the intellectual structures of a person and specific roles that as a result of such structure should play in social affairs. Paying attention to the strengths, and nice and sweet experiences of the past would increase the possibility of more positive personal perceptions about self. This enables the people to assume greater responsibility for their validity and values and achieve better and more complete self-understanding. In this regard, Taylor et al.37 stated that if the normal human perception comes along with a positive sense of self and of personal control and an optimistic perspective, even false about future, not only helps to control tides in life, but also in dealing with very stressful and life-threatening incidents such as death of a spouse, addiction and divorce. Seligman38 also believes learning how to push the route of our thoughts to the optimistic forecasts after every defeat would give us a permanent skill so that we can deal with disappointments. It also helps us to have better health. This skill is effective in problem-solving, overcoming despair, healing diseases, psychological and physical health. Seligman38 believes that optimism can be learned. The level of optimism can deeply change what is going to happen. He considers optimism as a tool to help a person to reach his pre-determined goals. When an acquired optimism comes along with a refined commitment to the public, widespread depression, despair and absurdity all come to us.

Limitations of this study include the implementation of this research only on men with substance abuse; therefore, care should be considered while generalizing it to other samples (other age groups and women). Collecting information based on self-report scale shows that these reports can be false due to defenses without any knowledge, prejudices while responding or motivational factors, and insufficiency of quasi-experimental research to control all intervening variables. It is, therefore possible that subjects were influenced by conditions that were out of control of the researcher.

Conclusion

The research findings showed that holding workshops to train positive thinking skills can increase the hope and QOL of drug-dependent people. Accordingly and based on these results, it can be concluded that training positive thinking can be helpful in order to improve the positive relationship with self, others, and life and also increase the hope. Similarly, training positive thinking and optimism skills encourages individuals to recognize good and positive experiences and their roles in increasing and improving the QOL for themselves and others. They also learned to take a proactive place in the world and shape their lives in person.