Effectiveness of Narrative Therapy in Groups on Psychological Well-being and Distress of Iranian Women with Addicted Husbands.

BACKGROUND: This paper investigated the effectiveness of narrative therapy in groups on psychological well-being and distress among Iranian women with addicted husbands.
METHODS: The research was an experimental study with pretest-posttest control group design along with follow-ups of one month and three months. The statistical population consisted of all the women with addicted husbands who referred to welfare and social service houses of district 10 in Tehran, Iran. Participants were forty-four persons who had mental health score lower than the mean of statistical society. They were selected using the voluntary sampling method, and were also randomly assigned to two groups, experimental and control. After the early loss, each group included twenty persons and was evaluated by Mental Health Inventory (MHI-28). The experimental group received 10 sessions of the group counseling. Data were analyzed with repeated measure ANOVA and Bonferroni post-hoc test.
FINDINGS: The results showed that psychological well-being of women who received the sessions of group counseling "narrative therapy" was improved significantly rather than those who did not received that (P < 0.001), and psychological distress of them was reduced significantly in comparison to the women who did not participated in the sessions (P < 0.001).
CONCLUSION: Based on these findings, it seems that narrative therapy in groups is effective in the promotion of psychological well-being of women with addicted husbands, and also could be effective in reducing their psychological distress. Therefore, it can be concluded that narrative therapy group interventions improve mental health of women with addicted husbands.

Introduction

Cultural identity has a profound impact on our sense of well-being within our society and on our mental health as well. Our cultural background refers to our ethnicity, but it is also profoundly influenced by social class, religion, migration, geography, gender oppression, racism, and sexual orientation, as well as family dynamics. All these factors influence people's social location in our society, their access to resources, their inclusion in dominant definitions of “belonging”, and the extent to which they will be privileged or oppressed within the larger society. These factors also influence how family members relate to their cultural heritage, to others of their cultural group, and to preserving cultural traditions. Having a sense of belonging, historical continuity, and identity with one's own people is a basic psychological need.1

It is possible to consider two distinct vectors in Iranian culture: nationalist and Islamist. The nationalist aspect of Iranian culture is related to ancient Persian civilization and Zoroastrianism heritage which date 2000-3000 BC, but are still prevalent in different aspects of Iranian society such as calendar, New Year Festivals (Nowrooz) and Persian literature. On the other hand, Islamist and subsequently Shiism aspects are relatively younger and date back to the 7th and 16th centuries, respectively. It has been suggested that besides Persian and Islamist influences, the effects of Western culture on Iranian society should be taken into consideration. In collectivistic societies, private life is invaded by group’s interests, whereas in individualistic societies identity is based on the individuals. Like many other collectivist societies, Iran tends to operate on the basis of personal relationships among individuals, rather than on the basis of impersonal institutions.2

Friedman et al.3 declared that research on psychology and counseling within the family's context is very important. From a system’s perspective, family's central status should be considered as far as any dysfunction or illness of family member influence the other members. Families both affect and are affected by a mentally ill member through a dynamic process impacting patterns of communication, interactional styles, family responsibilities, and family roles as the family adapts to the physical and psychological demands of managing the illness and disorder.4

Addiction is a disorder in self-regulation. Individuals who become dependent on addictive substances cannot regulate their emotions, self-care, self-esteem, and relationships.5 Several women with drug-using husbands eventually got divorced, compared to women with non-drug using husbands. Women who were living with drug-using husbands had more opportunities to use drugs such as heroin.6

Studies have generally shown that higher levels of alcohol and drug use and higher levels of substance-related problems increase risk for partner aggression. With regard to relationship factors among couples with addiction, violent couples are shown to exhibit poorer behaviorally-coded communication strategies versus those who are not violent. These results were consistent with the pattern of findings from clinical samples that suggest that partner discordance in addiction-related behaviors is related to a range of couple-related problems, including partner violence.7 One of the indicators of mental health is psychological well-being. Deci and Ryan8 noticed that psychological well-being is a concept with some combination of positive effectiveness such as happiness and functioning in individual and social life. Other indicator of mental health is psychological distress. In this regard, Drapeau et al.9 indicated that psychological distress, as measured by the Mental Health Inventory (MHI-28), is presented by symptoms of depression, anxiety, and stress which are related to concerns, and is known to arise a lot of severity.

Shallcross declared that although traditional forms of therapy, like talk therapy, can be successful in facilitating achievement of improving individual's moods, traditional techniques are not always successful, so there is a need for creative techniques.10

Viv notified that Bruner, who was a psychologist, has argued that we have two different ways of knowing the world: paradigmatic or logico-scientific knowing, which is based on the way in which we organize and communicate experience through stories. According to Bruner, our capacity to narrate develops almost as soon as we acquire language; and from an early age, we are intuitively aware of how to tell stories. While paradigmatic approaches to knowledge, which emphasize conceptual and abstract models of reality, have long had greater status than stories in academic discourse, both are necessary means of making sense of human experience. Our understanding of the world involves interplay between these two modes of thinking.11 Duba et al.12 notified that although there is little research about the effectiveness of narrative therapy in groups, recent studies are doing support for that. In fact, narrative therapy has been displayed useful in the group context. Ricks et al.13 believed that counselors and psychologists in narrative therapy approach in groups are encouraged to use innovative techniques for reframing of individual's narrations. Vromans and Schweitzer14 declared in their research that narrative therapy could be effective on mental health of individuals. That is to say that narrative therapy could reduce symptoms and sings of depression in adults and make their mental health promote. Morgan et al.15 showed in their research about narrative therapy with elderly persons presenting with substance abuse concerns that participating in this group counseling gives a safe place to participants to share painful elements. They learned how to overcome their difficulties. Results from this study indicated how group counseling, "narrative therapy", creates a safe venue for individuals who suffer from problems related to substance abuse. Cloitre et al.16 demonstrated that narrative therapy approach affected mental health of women suffering from post-traumatic stress disorder more than other approaches. In addition, they viewed that this approach could be effective in the promotion of emotions regulation, relationships, and the general functioning of women.

There are differences between men and women about having psychological distress. Deasy et al.17 declared that women report depression, anxiety, and stress more than men. Regarding this factor that women play important roles in the family base, and also women with addicted husbands are exposed to psychological vulnerability more than normal women, considering this group seems essential. In addition, regarding the fact that people with lower mental health made the stories full of problems, necessity of intervention through narrative therapy in groups, and following this, reducing the rate of official and emotional divorce is presented more clearly. Therefore, the present research is the study about effectiveness of narrative therapy in groups on mental health among women with addicted husbands.

Methods

The present study as an experimental one included pretest-posttest control group design as well as follow up; and sampling is done voluntarily. In order to analyze the data, repeated measure ANOVA using SPSS software (version 24, IBM Corporation, Armonk, NY, USA) was applied. The statistical population consisted of all the women with addicted husbands who referred to welfare and social service houses of district 10 in Tehran, Iran. Considering the ethics fundamentals of research for this specific group and in order for them to take part more eagerly, the sampling method was of voluntary type, so that all the women with addicted husbands referring to all the welfare and social service houses of district 10 in Tehran City, all of which residing at the district, were invited to attend the sessions of narrative therapy in groups. Then, those who attended were registered. Before presenting the independent variable (narrative therapy in groups), necessary investigations were conducted in individual sessions by the researcher in order to recognize the appropriate conditions of the research participants (for instance: being interested in participating in the sessions, having the mental health score less than the average of the mental health score of the entire group). From among those who registered, forty-four persons with lower scores who had appropriate conditions and the required motivation for attending the group sessions were selected. Then, they were randomly assigned to the two experimental and control groups. After the initial drop out, each group included 20 persons. For the control group, it was explained that they will not be trained and it was agreed that after the end of sessions, 1-month and 3-months follow-ups and upon the approval of the related authorities of district 10, group consultation in the method of narrative therapy may be applied for them and also for all the persons who had made positive answers to the call and had been registered, in the case of their agreement. Demographic data were collected by applying a self-report questionnaire. The inclusion criteria of persons were: 1) women with addicted husbands, 2) being at least 25-year-old, and 3) being literate.

The exclusion criteria of persons were: 1) not cooperating in the research. 2) not being sure about honest answer to the questions, and 3) being addicted before marriage.

The women did not understand about cleaving to two groups "experimental and control" until doing the treatment protocol completely. In order to control the Hawthorne Effect, attention to the control group was as much as the experimental group as far as the treatment protocol applied for the control group during 2 weeks.

The MHI-28 questionnaire has 28 items which was codified by Veit and Ware,18 and translated and validated in Iran by Besharat.19 This instrument has two subscales; psychological well-being (14 items) and psychological distress (14 items). Answering in Likert scale is from completely agree (5 points) to completely disagree (1 point). The reliability of this instrument in the method of retest for normal subjects in the subscales of psychological well-being and psychological distress was reported 0.89 and 0.87, respectively, and for the subjects with disorders, was reported 0.77 and 0.82, respectively. Internal consistency for normal subjects in subscales of psychological well-being and psychological distress was reported 0.91 and 0.88, respectively, and for the subjects with disorders, 0.85 and 0.89, respectively. The correlation of this instrument with general health questionnaire (GHQ) in the subscales of psychological well-being and psychological distress was -0.85 and 0.86, respectively that indicates the concurrent validity of this instrument.19

According to Dryden,20 number of sessions and the intervals between the sessions are different according to the quality of the subjects brought to the group sessions. Generally, group narrative therapy has fewer sessions than many traditional group consultations. Payne21 declared that there is no fixed contract regarding the duration of group narrative therapy sessions. Techniques and practices applied in narrative therapy in groups shortened the duration of this method rather than many other methods. In fact, group narrative therapy is not short-term, but generally, narrative techniques and works applied in this group method can make the duration of consultation shorter than many other intervention methods. Moreover, there is no hypothesis regarding weekly sessions or any pre-determined interval between sessions.

The general plan of the sessions, excerpted from intervention plan of White et al.,22 was as follows:

First session (introducing the rules): Participants introduced themselves; who they are and what their goals are. The laws related to the group were explained. Regular attendance, having activity in the group, doing weekly duties, and having open communications in the group were considered. Group narrative therapy was explained and the purpose of forming this group was clearly stated. The persons were encouraged to discuss about any question about the approach of group narrative therapy. Group relaxation as well as visualization of self in the best possible status was done. In addition, the persons were encouraged to narrate the troubled story dominating their lives. Finally, homework was assigned for the members, so that they write and expand their life stories.

Second session (checking narrations and starting externalizing): The previous session was reviewed and the homework assigned in the previous session was brought up. The goals, values, the content of intervention, and what is supposed to be done were expressed and explained. A common situation was formed and the clients were directed. The troublesome narratives of the subjects were investigated and the details of what the clients expressed were listened carefully. The session was concluded. In order for the clients to understand their metaphors (beginning of externalization), they were assigned to write their metaphors of the environment, surroundings, and generally, the trouble.

Third session (naming the problem and its metaphor): The problems related to the homework were examined. Then, the program of that session was clearly expressed and the persons' metaphors were investigated. The members rewrote about the first time they got sensitive to their trouble. After investigating the narratives of the members, they were named common problems by giving priority to the clients' words, languages, and their metaphors. The subjects of the session were concluded and practice was assigned for the members to consider their problems separated from themselves and to externalize them.

Fourth session (continuing to do naming the problem and its metaphors and strategies): After investigating the problems related to homework and reviewing the previous session, the problem was metaphorized (giving a tangible name to the problem). It was talked about the ways through which the problem distresses the members, and discussed about the impact of problem on the members. The members were assigned to practice in group and consider the problem as a foreign enemy. Regarding the attitudes to problem, group discussion was formed. Finally, the subjects were concluded and homework was assigned for the members to find and write the tricks of the problem causing that impact on them.

Fifth session (beginning of the problem intrusion on persons and their communication, and beginning of the influential questions): Firstly, the previous session was reviewed and the problems of the homework were investigated. Then, regarding the members' cognition of the problem, group discussion was formed. The members were informed about the fact that how the problem declares itself to the members, overcomes them, and impacts on them through the family members, the people around them, and their surrounding environment. How the problem can dominate persons through dreams, beliefs, values, etc. was explained. Group practice was formed in order for tackling the problem as a foreign enemy and recognizing the techniques used by the problem for impacting on the persons. The subjects were concluded and the members were asked to collect their favorite subjects, memories, photos, etc., related to the subject of the sessions, as homework.

Sixth session (completing the intrusion of the problem on persons and their communication and using the deconstruction technique): After reviewing the previous session and investigating the problems of homework, the progress of the members was evaluated and the persons made their feedbacks about the sessions. Goals and wishes of the problem regarding the lives of persons were explained and expanded, and the assistants of the problem and their confederates were discussed in group with the goal of empowering the problem. Roles were played in the group and sentence completion practice was done by the persons. The persons were assigned to complete their incomplete sentences.

Seventh session (the intrusion of persons on the problem and their abilities as well as writing to the problem): Firstly, the problems of homework were investigated. Then, techniques for confronting the problem were discussed in the group. The abilities and positive attributes of the persons were presented in the form of group practice. Group discussion about focusing on the peoples' goals, and their assistants for overcoming the problem was formed, and the group practice of role playing technique was applied. Finally, the persons were assigned to write a letter to the problem and to mention their pros and cons in that letter.

Eighth session (unique consequences): The problems of homework were investigated. It was focused on unique consequences by asking questions such as: Has the problem ever tried to overcome you but you have not let it? What was your feeling? In what environment were you? What were you doing? Explain the details, etc. The feelings of persons were considered and investigated. The persons discussed in group about the fact that a person is in no way the problem and the problem is the problem, and in fact, it is the person who has problem. Group relaxation as well as visualization of the self in the best possible status was done. The persons were assigned to rewrite the narrative of their lives from the past to the present as homework.

Ninth session (rewriting the narration of life): After reviewing and investigating the problems of homework, group discussion was formed about the self, surroundings, relations, attitudes, behaviors, etc. in the situations wherein the persons were able to overcome their problems. Theoretical and practical parts of life narratives were explained as well as how to do the new narrative theoretically and practically. We were able to make new narratives for any happening, and from among different narratives we could attain the best one. Group relaxation and visualization of the self in the best possible way was formed. The members were assigned to rewrite the narrative of their lives from the present to the future and to give a new title to their life narrative.

Tenth session (summarizing and evaluating): Firstly, homework as well as all the sessions was reviewed and feedback of the members about the sessions and their viewpoints about the group were presented. Then, the persons talked about their feelings. Group discussion was formed about what they had learned from the group and generally any change having been occurred as a result of taking part in this group. The members mentioned their evidence about changes as a result of taking part in these sessions. Group discussion was formed about the reaction of the members when confronting other problems in their lives and they were asked to present their criticisms regarding the group, the process of the sessions, etc. Finally, a memorial was presented to the group members.

The members were asked to attend within one week after this session so as to take part in the posttest. In order for conducting the posttest for the control group, they were informed that they must be present at the time of conducting the posttest. According to the design of the present research, it was agreed that the experimental and control groups should attend for reimplementation of the questionnaires in one-month and three-month duration.

Results

Findings related to demographic characteristics of women are provided in table 1. The findings show that the groups "experimental and control" have not significant differences in domains such as age, education, number of children, the duration of living with their husbands, having a job for themselves and their husbands.

Table 1

Demographic findings related to the groups of experimental and control

Variable		Control group	Experimental group
Age (year)	25	1	1
	More than 25	19	19
Age (year) (mean ± SD)	-	38.75 ± 6.02	37.45 ± 5.50
Education	Completed secondary school	10	7
	Diploma	9	12
	Above diploma	1	1
Husbands' education	Completed secondary school	11	8
	Diploma	7	9
	Above diploma	2	3
Number of children	1	7	4
	More than 1	13	16
Duration of living with husband (year)	2	2	1
	More than 2	18	19
Job	With job	15	16
	Without job	5	4
Husbands' job	with job	12	13
	Without job	8	7
Religion	Islam	20	20

SD: Standard deviation

Descriptive findings of pretest, posttest, one month and three months follow-ups and the signification of within and between group effects are provided in table 2. According to the table, the posttest mean of experimental group has a significant difference with pretest mean of that, but the posttest mean of control group has not a significant difference with pretest mean of this group. In addition, there is no significant difference about two follow-ups with posttest in the experimental group. These findings declared that group counseling "narrative therapy" has been effective significantly on psychological well-being and distress, and also its effect has been durable.

Table 2

Summary of descriptive findings about subscales of mental health inventory (MHI) and the signification of within and between group effects

Scale	Tests	Experimental group	Control group	P
		Mean ± SD	Mean ± SD
Psychological well-being	Pretest	30.85 ± 3.09	30.25 ± 3.05	< 0.001
	Posttest	39.60 ± 4.36	28.90 ± 2.84
	Follow-up "1"	41.85 ± 2.58	28.80 ± 2.78
	Follow-up "2"	41.70 ± 2.38	28.90 ± 2.93
Psychological distress	Pretest	54.75 ± 5.06	52.95 ± 4.31	0.004
	Posttest	46.55 ± 3.91	53.05 ± 4.50
	Follow-up "1"	46.55 ± 4.33	51.10 ± 4.48
	Follow-up "2"	48.15 ± 3.32	53.70 ± 4.85

SD: Standard deviation

For doing assumptions of repeated measure ANOVA, Shapiro-Wilk test for normality of data, Levene's test for homogeneity of variances, Box's M test for equality of covariance-matrices of dependent variables among the groups, and Mauchly's test for sphericity of data and showing equality of error covariance among dependent variables in the groups were employed.

About psychological well-being, findings of Shapiro-Wilk test (0.96) with signification (P = 0.160), Levene's test (f = 0.14, P = 0.700), Box's M test (20.30) with signification (α < 0.05 = 0.001), and Mauchly's test (0.79) with signification (P = 0.120) were found.

Findings of repeated measure ANOVA about psychological well-being and distress show that interaction of two variables "time and group" is significant. Because index "F" obtained of interaction of these two variables is significant for psychological well-being (147.30) with signification of (P < 0.001, P = 0.001), interaction of two variables "time and group" is significant. It means that independent variable has been effective on dependent variable. In the other words, narrative therapy in groups has been effective significantly on mental health of women with addicted husbands.

Findings of Bonferroni post-hoc test show that mean difference of pretest-posttest for the psychological well-being variable (P < 0.001) and for the psychological distress variable (P < 0.001) is significant, but that of posttest-follow-up "1" for each variable (P = 0.090, P = 0.730, respectively) and posttest-follow-up "2" for each variable (P = 0.190, P = 0.110, respectively) is not significant. It means that narrative therapy in groups has affected on the variables and its effects approach is durable on mental health of women with addicted husbands.

Discussion

Because women play important roles in the family and women with addicted husbands are exposed to psychological vulnerability more than normal women, it seems that considering this group is essential. Many of them have to take responsibility of financial issues and patronage of family in addition to the home affairs and children upbringing. This fact creates unfavorable consequences such as: severe conflicts, emotional separation, divorce, and dissolution. Therefore, doing consultative interventions for the women could be so effective. The present research is done in order to investigate the effects of narrative therapy in groups on psychological well-being and distress among women with addicted husbands.

One of the results of the research shows that the psychological well-being's score of the women who participated in group counseling is increased significantly in comparison to the women who did not participated in the group. In the other words, the group counseling could improve psychological well-being of the women, and its effects maintained in the follow-ups (one month and three months). Studies have examined distal risk factors for partner violence, including individual and couple-based characteristics among those seeking treatment for alcohol or drug addiction. In addition, according to Payne,21 who acclaimed that personal narratives of individuals are presented in group counseling to understand how they play roles in various social and personal positions, and their relationships with themselves and others, this finding is explained obviously.

Other finding shows that the score of psychological distress among the women who received the sessions of the group counseling is reduced significantly rather than those who did not receive that. In the other words, this group counseling could be effective on psychological distress of the women, and also its effects maintained during the follow-ups of "1 and 3 months". On the one hand, psychological distress is presented by symptoms of depression, anxiety, and stress; on the other hand, Morgan et al.15 declared that the use of group counseling "narrative therapy" with individuals with substance abuse concerns creates suitable conditions without any prejudgment in which the participants obtain a good status to share painful and upset feelings in the life. Results indicated that learning of the participants about overcoming their problems and having better feeling is increased, this finding is presented clearly. Furthermore, one way to develop one’s own theoretical approach is to consider questions of how people change; what motivates people to behave, think, and feel in the ways that they do; and how someone grows and develops. These elements are foundational and must be considered when developing a theoretical orientation. In addition, one’s view of human nature will influence which type of theoretical orientation the counselor decides on and subsequently selects23 that group narrative therapy approach focusing on the elements.

Generally, the findings of the present research show that narrative therapy in groups affects the mental health of women with addicted husbands. A woman with a drug-using husband has to overcome not only her own addiction but the impact of her husband’s addiction as well;6 these women challenge more with familial situations. If the counselor believes that one’s internal state (e.g., thoughts) leads to the clients’ emotional distress, then the counselor will select a theory that specifically focuses on the role of changing thoughts in order to increase mental health and well-being. If one believes that the clients’ narratives or stories have impact on their mental health, then the counselor will more likely select a theory that focuses on the stories that clients create. The techniques used with this theory will focus on how the stories one creates can actually be modified if the client is taught how to reconstruct the story line.23 In this regard, Hibel and Polanco24 represented that a fundamental element to success in the narrative therapy approach is listening to the clients’ stories instead of to symptoms and/or information needed to gain insight. They suggested that group members and group facilitators listen carefully for how clients view themselves in the process of group counseling. Therefore, focus should be on the clients’ intentions and goals as opposed to focus on causes that have influenced the clients’ behaviors and challenges.

It could be said that non-assistance of/access to the other family members in the sessions of group counseling is a limitation of this research. It is offered that this research would do more with cooperation of all of the family members, especially husbands. The paper suggests further investigation of narrative therapy in groups in regard to mental health of women with addicted husbands in the other cultural and social contexts, and demographic variables.

Conclusion

The results of this research showed that narrative therapy in groups is effective in increasing mental health of women with addicted husbands. Although the women in Iran had to tolerate husband’s addiction, and challenge more with their familial situations, several women with addicted husbands got divorced. This research demonstrated that narrative therapy approach affected mental health of women with addicted husbands, and its effects were significant during the time.

In the Iranian society, any malfunction of men in the family influences the other members. Women with addicted husbands in this country have a more important role in controlling life affairs than normal women. They have to take responsibility of financial issues; hence, they confront with many life problems and make the stories full of problems. It seems that in the collectivist religious society of Iran, what is fundamental to the psychological interpretation is recognizing the problems and the ways of penetration of them as a factor which plays many important roles in the life, and thinking of the women as tolerating the bad situation where their husbands are usually without job or have jobs that do not make enough income; so that the women are forced to provide life incomes. The techniques of narrative therapy in groups focus on what the life problems are and how the women create the stories in their life and how they can modify these stories for penetrating them and having a better life.