In the Name of God

Quarterly Journal Research on Addiction

Vol. 12, No. 47, Autumn 2018

Licence Holder: Drug Control Headquarters of the Presidency

Managing Director: Mahmoud Minooei, M.A.

Chief Editor: Hassan Ahadi, Ph.D.

Executive Director: Majid Ghorbani, M.A.

Editors: MohammadAli Mohammadifar, Ph.D.

Publisher: Drug Control Headquarters, Research & Education Office

Address: No. 20, Building of Presidential Drug Control Headquarters, after Hoveyzeh Cultural-Entertainment Complex, after Poonak Sq., Ashrafi Esfahani Blv., Tehran Postal Box: 1469915834

Tel/Fax: +98-21-47361730 Fax: +98-21-44411761

Email: [email protected]

The Journal is available at DOAJ, dchq.ir, ISC, magiran.com, SID, Iranmedex, ensani.ir & Noormags.com

Editorial Board

Zarindast, M. R., Ph.D. Professor of Pharmacology, Tehran Medical Sciences University Joghataei, M.T., Ph.D. Professor of Anatomy, Tehran Medical Sciences University Mohseni, T. A. R., Ph.D. Professor of Sociology, Tehran University Navabakhsh, M., Ph.D. Professor of Sociology, Open University-Science and Research Branch Mohammadkhani, P., Ph.D. Professor of Psychology, Welfare and Rehabilitation Sciences University Rezai, R. M., Ph.D. Associate Professor of Management of Treatment Services, Police University Rahimi, M. A., Ph.D. Associate Professor of Psychiatry, Tehran Medical Sciences University

Motavalian, S. A., Ph.D. Associate Professor of Epiodmiology, Tehran Medical Sciences University

Reviewers of This Issue

Ghodrati, M., Ph.D. Assistant Professor of Psycology, Payame Noor University Aghayousefi, A., Ph.D. Assistant Professor of Psycology, Qom Payame Noor University Shirazi, M., Ph.D. Associate Professor of Psycology, Sistan and Baloochestan University Yaghoobi, A., Ph.D. Associate Professor of Psychology, Bu-Ali Sina University Basharpoor, S., Ph.D. Associate Professor of Psycology, Sistan and Baloochestan University Mirhashemi, M., Ph.D. Assistant Professor of Psycology, Roudehen Islamic Azad University Tavakolifard, M., Ph.D. Ph.D. in Addiction Studies Mashaiekh, M., Ph.D. Assistant Professor of Psychology, Karaj Islamic Azad University Hasani, J., Ph.D. Associate Professor of Psycology, Kharazmi University Hosseinchari, M., Ph.D. Associate Professor, Shiraz University Mohammadifar, M.A., Ph.D. Assistant Professor of Semnan University

Instructions for Publishing Papers in Journal of Substance Abuse Addiction Research

- After mentioning the title and author(s), write the abstract as objective, method, results, conclusion, and keywords. - Persian and English abstract of papers should include maximum 150 word and from three to five words should be included for keywords. The English abstract is required to be written exactly in agreement with the Persian version. The exact spelling of the author and co-authors’ names should be written in footnote of the English abstract. - Bibliographical information should be inserted at the end of the paper in alphabetical order as follows: In accordance with APA style, put the English version of an author’s name in the footnote when mentioning it for the first time in the text. If the author has any colleagues (up to five persons), write their last names in the footnote. If the number of authors is higher than five, write the author’s name and then add the term et al. ; the mention of all the authors’ names is obligatory in the reference section. If you are to mention an author and colleagues’ names for the first time, there will be no need to mention the colleagues’ names in the following times; in such cases, use the term et al. - When necessary, write the author’s name and year of publication in parentheses in the text and insert the English equivalent of English terms at the end of that page. Add the name of all the instruments and expressions that are used in the text for the first time to the footnote. As much as possible, avoid using foreign words in the text. - Final acceptance and publication of paper in the journal hinges upon the approval of the editorial board and expert reviewers. - All the articles, to be eligible for publication, should enjoy the observation of the principles and framework for Scientific-Research criteria (introduction, main body of the paper including a theoretical or conceptual framework to explain or describe the variables and their relationships, method (population, sample, sampling method, and instrument), research results and findings, discussion and conclusion, acknowledgement, and reference). - Mention your suggestions in the last paragraph of the paper without inserting the heading of suggestions. - Briefly present the conclusion as the summary of the discussion. - Each paper can contain up to 13 A4 pages, each containing 240 words. - Papers should be necessarily typed in Microsoft Office Word Software with the font of Times New Roman and size of 11 and the related file should be forwarded accompanied by the paper. - The author(s)’ name should be written in full. The author(s)’ affiliation, academic degree, and email address should be mentioned below the author(s)’ names. As well, the corresponding author’s name along with the full address should be written below each article. Meta-analyses and Reviews: - Only an article will be accepted whose author has expertise in the relevant area and refers to his/her own name in the reference section (at least four times). - The general principles of writing such papers are similar to the above- mentioned ones. Notes: 1. The contents published in the journal are not necessarily reflective of Drug Control Headquarters’ ideas. The responsibility of the contents lies with the authors are 2. Quoting the contents of this journal (Research on Addiction) with citing the source is allowed. 3. This journal, hereby, invites all the researchers, professors, and experts to submit their research papers on addiction and narcotic drugs. 4. The journal is allowed to edit, modify, and coordinate scientific terms of papers up to the point that concepts do not get distorted. Babak Vojudi et al

Contents

Title Page The Impact of Family-Based Training on Attitude to Drugs and Irrational Beliefs 11-24 among Female High School Students of Sabzevar with Addicted Parents Bagheri, T., Na'emi, A.

Study of Sociological Functions of the NGOs Active in the Field of Addiction 25-40 Treatment Azad Armaki, T., Sarrami, F.

Jurisprudence Fundamentals of the Prohibition of Drug Use 41-52 Hashemi, H., Mirzaei-Nejad, K.

Inefficiency Analysis of Prevention Programs: Qualitative Research 53-68 Niazi, M., Norouzi, M., Sharifi, E., Khorramian, R.

The Effect of Transcranial Direct Current Stimulation (tDCS) on Drug Use 69-80 Craving and Cognitive Self-Control in Substance Abusers Khosravian, B., Solimani, E.

Addict Women’s Lived Experience in Tehran: Development of an Explanatory 81-98 Model Hajiha, Z., Bahrami Ehsan, H., Rostami, R.

Causal Relationship between Spiritual Intelligence and Addiction Potential 99-114 with the Mediating Role of Meta-Cognitive Beliefs and Academic Hardiness Saberi, Z., Farokhi, N., Namvar, H.

The Effect of Subliminal Presentation of Smoking Pictures on Addiction 115-126 Potential, Addiction Acknowledgement, and Addiction Craving Shabahang, R., Rezaei, S., Bagheri Sheykhangafshe, F.

Prediction of Retaining and Resigning from Addiction Treatment Interventions 127-138 based on Personality Disorders Ghamari Kivi, H., Khoshnoodnia Chomachaei, B.

Prediction of Addiction Potential based on Quality of Work Life and Academic 139-152 Burnout among University Students Esmaeili Moghadam, F., Mashayekh, M., Eslami, S.

Structural Equation Modeling of Sensation Seeking with Addiction Potential 153-164 Mediated by Self-Differentiation and Cognitive Emotion Regulation among Male Addicts under Treatment in Sari Babaei Holari, N., Hasanzadeh, R.

Title Page Comparison of Learning Ability and Memory between Opiate- and 165-176 Methamphetamine-Dependent Patients and Healthy People Akhani, A., Birashk, B., Habibi, M., Ashouri, A.

Structural Equations of Emotional Self-Regulation, Behavioral 177-196 Activation/Inhibition Systems by Mediating Thinking Styles in Addicted Patients' Psychological Well-being Alipour, Z., Ahadi, H., Hatami, H., Malihi-al-Zakerini, S.

The Effect of Eight Weeks of Combined Exercise With and Without 197-208 Supplementation of Cinnamon on Hematological and Liver Enzymes AST, ALT, and ALP in Female Amphetamine Addicts Moradi, M., Ali-Akbari Bidokhti, M., Ghofrani, M.

Effectiveness of Behavioral Activation Therapy in Opiate-Dependent 209-220 Patients' Action Resilience and Metacognitive Beliefs Dasht-Bozorgi, Z.

Babak Vojudi et al

First words

Living in the chaotic contemporary world of modernism has been associated with four components of "instability, uncertainty, complexity, and vagueness", and its consequences can be enumerated as changing lifestyle and social values, increasing selfish individualism, incidence of extreme and immediate hedonism, intergenerational breakdown, weakening of traditional values and ethical beliefs, growth of mental disorders, identity crisis, weakness of justice in proper distribution of resources, inefficiency of economic and socio-cultural subsystems, and marginalization and disruption of family function. As a result, the mentioned factors have been considered to be responsible for creating a fragile social environment that results in the prevalence of drug use and addiction in societies. In spite of 109 years of fight against narcotics and psychotropic substances in the international community, it must be acknowledged that this strategic, multifaceted, multi-causal, and systematic threat is the largest third-millennium shock, is a long-term permanent conflict and a new type of slavery in the modern world, and is one of the most important obstacles to sustainable development and human development in societies. On the one hand, it is influenced by the increasing growth of supply and international patterns of production, drug trafficking; on the other hand, it is under the influence of the growing demand and desire for consumption due to the weakness of structures in various dimensions at the community level. In this way, this issue provides the grounds for the massacre of human capital, which should actually help with the headline axis of sustainable development, and leads to the achievement of illegal profits. The Islamic Republic of Iran, as the largest victim of narco-terrorism and flagship in the fight against drug trafficking and terrorism in the international community, considers the issue of addiction and narcotics as the first priority in the country's social p roblems. In this regard, the Islamic Republic of Iran, in spite of the wide and diverse threats, has been able to bring about significant successes in various aspects, as follows: 1. Changing the paradigm of the struggle from the central government to the public participation through socialization and also the effective and continuous intervention of non-governmental organizations and civil society in the field of controlling and monitoring social anomalies, including addiction in such a way that a significant number of NGOs are currently doing continued and effective activities in various aspects of prevention, treatment, strain damage, and social protection of individuals recovered from addiction in the country. In this regard, there is evidence of the taking appropriate measures to control drug use and addiction. 2. Addiction has targeted the heart of sustainable development, namely human capital, including adolescents and youth, workers, educated people, and women. Therefore, in order to promote psychological and social capacities of adolescents and also the family institution, as the main core of society, underpinning measures for the immunization of different strata have been formed in Iran by implementing a national empowerment plan and underlining a significant population of parents and their children.

3. Implementation of the primary prevention curriculum of addiction in Iranian labor and industrial environments, while increasing the level of coverage of workers under the umbrella of empowerment programs, seeks to reduce the incidence of drug use. 4. Streamlining and enhancing effective information interventions, teaching life skills, teaching healthy life patterns, developing alternative activities, developing spirituality and religiosity, strengthening counseling services for female and male schoolchildren as well as female and male university students, while increasing the scope of preventive services, seeks to control the prevalence of drug use among adolescents and young people in Iran. 5. Strengthening the boundaries of addiction knowledge with an emphasis on the local culture in the field of demand reduction with the participation of elites, scholars, and young people in the academic setting, while scientifically developing the process of software struggle, has provided the grounds for the vulnerability of the intelligence system of addiction and narcotics. 6. Increased investment in reducing demand for substances by the government and the private sector has provided a platform for strengthening, su stainability, and continuity of programs in such a way that we can see a change in the pattern of drug use, in particular the dramatic decrease in the consumption of amphetamine-type stimulants (ATS) in Iran. 7. Due to the economic attractiveness of narcotics and its function as a driving force for drug traffickers towards the increasing growth of supply and demand for substances, significant measures have been taken to halt the economic foundations of traffickers by the custodians of the case in such a way that billions of dollars have been damaged to the traffickers' financial system by means of financial supervision, property identification, and seizure and confiscation of finances. 8. Preventing the arrival and transportation of drugs to the heart of cities, with a concentration of about 70% of drug seizures in the eastern borders of Iran, is a significant success in reducing the supply of drugs, which requires stability. 9. Serious attention to women's demand reduction services is one of the other effective measures to strengthen the status of women in programs and consolidate their role in the development process of Iran. 10. Considering the rapid throwing of humanity into a future without proper knowledge of what may happen, there is no policy of confronting it. Therefore, it is important to pay attention to the future of addiction and addiction in the future seems an important issue. In this regard, the IRI's Drug Control Headquarters, while setting priorities, seeks to: - have an all-round struggle with narcotics and psychotropic drugs through supply and demand reduction and consumption management with the aim of reducing 5% addiction each year from 2007 to 2021 and achieving a 25% reduction in addiction by the end of the sixth development plan of the country in 2021. - develop and pass the national plan of comprehensive struggle against narcotics and psychotropic substances and precursors with a social approach, as a roadmap for fighting, containing actions, plans, activities, and executive projects; an d clarify the levels of expectation and announce to all ministries and organizations of the country in order to implement it during the Sixth Development Plan of the country (2017-2021). Despite the above-mentioned items, we need to realize the following: Babak Vojudi et al

A) The need to explore methods in order to achieve innovative and long -term approaches and promote the government and society's level of readiness in facing social harm, especially addiction. B) The need to achieve advanced and effective teaching methods in the field of primary prevention of addiction for different classes of society, such as adolescents, young people, and women for the reduction of the incidence of drug use and addiction. C) The necessity of special interventions in the fields of prevention, treatment, and harm reduction in the effective bottlenecks of addiction prevalence, such as illiterate children, adolescents with personality disorder, marginalized people, children with addicted parents, children of divorced families, and children of prisoners of drug crimes. D) The need for planning to increase access to treatment, rehabilitation, and community-based harm reduction. E) The need to accelerate the development of treatment protocols for users of new psychotropic substances (NPS). F) The need to upgrade the scientific-specialist capabilities of the fighting forces in relation to new psychotropic substances (NPS). G) The need to improve the knowledge of money laundering methods, the illegal proceeds from drug trafficking, and methods of coping with this phenomenon by using the experiences and knowledge of other countries. H) Serious attention to the fight against cybercrime and drug trafficking. I) Efforts to reduce access to drugs at community level. J) The need to pay attention to the improvement of socio-economic, social and economic structures of society in order to prevent the development of social damages. K) The need for efficient and creative human resource training to reduce the demand for substances in the community's target centers. L) The need for developing scientific research in order to measure the effectiveness of programs, recognize opportunities and capacity building in order for the sake of active, effective, and stable competition with the dynamic, intelligent, and active sy stem of narcotics and psychotropic substances. Obviously, the success to reach the above-mentioned points requires a more serious intervention on part of universities and scientific centers around Iran where it is hoped to see widespread mobility by scholars, elites, and scholars of the country to produce organized science in the area of the soft struggle and hardware and drugs and psychotropic substances.

HamidSarrami Director General of the Research and Training Office of Headquarters for Drug Abuse of the Presidency Autumn 2018

Abstract The Impact of Objective: The aim of this study is to investigate the effect of family-based Family-Based training on attitude to drugs and irrational beliefs of female high school Training on Attitude students with addicted parents in Sabzevar in 2016. Method: This to Drugs and research employed a quasi-experimental research design along with pretest- Irrational Beliefs posttest and control group. The statistical among Female High population of this study included female high school students from Sabzevar with School Students of a parent with substance use disorder where 36 ones were selected through Sabzevar with random cluster sampling method and were randomly divided into control and Addicted Parents experimental groups. The experimental group received family-based training program for nine sessions and the control group received no training. The required Bagheri, T. , Na'emi, A. data were collected through Attitude toward Drugs Questionnaire and Irrational Beliefs Scale. Results: The results of covariance analysis showed Bagheri, T. that family-based training had a significant positive effect on attitude to M.A. Student of Educational Management, Department of Educational Sciences, drugs components of female students Islamic Azad University of Sabzevar, with addicted parent (p<0.05); however, Sabzevar Branch, Sabzevar, Iran this educational plan only had a Na'emi, A. significant positive impact on demand for approval, blame proneness, and Assistant Professor, Department of Educational Sciences, Islamic Azad dependency (p<0.05) and there was no University, Sabzevar Branch, Sabzevar, effect on other components of irrational Iran, Email: [email protected] beliefs (p>0.05). Conclusion: Since family-based training produced negative attitudes toward drugs and changes in some components of irrational beliefs among the students, it seems necessary that these training programs should receive the attention of high schools and Research on Addiction universities. Quarterly Journal of Drug Abuse Keywords: family-based training, Presidency of the I. R. of Iran attitude, drugs, addiction, irrational Drug Control Headquarters beliefs Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir/ 12 Research on Addiction Quarterly Journal of Drug Abuse

Introduction In spite of the long history of drug-related disorders, this phenomenon has now become such a serious global problem that affects the social, psychological, economic, personal, family, and political factors (Vossius, Testad, Skjaeveland & Nesvag, 2013), and seriously threatens adolescents' mental health (Kumpfer, 2014). Therefore, the impact of drug abuse disorders on family and its members is worth paying attention. Each family and each member of the family are uniquely affected by the addicted person in the family because of problems, such as non-satisfaction of developmental needs, attachment disorders, economic problems, legal problems, emotional distress, and, sometimes, violence against the addict and, thereby, the risk substance abuse in these families is higher than that in other families (Zimic & Jakic, 2012). Substance abuse disorders arise from the interaction of genetic and environmental factors, such as developmental abnormalities and poor psychosocial status (Haber et al., 2010) and are associated with many cognitive, psychological, and welfare problems (Lombard, Pullen & Swabey, 2017). Substance abuse is referred to as any legal, illegal, sanitary or prescriptive consumption of psychoactive drugs (Gupta, Sarpal, Kumar, Kaur & Arora, 2013), and is initiated under the influence of improper behavioral patterns and negative emotions that originate from the family (Lander, Howsare & Byrne, 2013). Substance abuse not only afflicts the consumers but also imposes a great burden on the family and society (Daley & Marlatt, 2005), disrupts family life, and reduces the family members' vitality and quality of life (Garland, Gaylord, Boettiger & Howard, 2010). Usually, addicted parents do not enjoy appropriate parenting skills. In such families, poor parental supervision, the conflict between parents, the poor quality of parent-child interactions, low intimacy, and unstable discipline are prevalent (Arria, Mericle, Meyers, & Winters, 2012). Children who live with an addicted mother suffer severe psychological trauma and many complicated problems (Lombard, Pullen & Swabey, 2017); and the longer they live with an addicted parent, the more they are likely to suffer from physical illness (malnutrition) and neurodegenerative disorders (Nygaard, Moe, Slinning & Walhovd, 2015). Studies have shown that the probability of addiction in children with addicted parents is 2 to 9 times much more than that in children with healthy families (Kumpfer, 2014). Adolescent substance abuse is also affected by inappropriate family functioning and problems caused by other systems, such as school, peers, and extracurricular activities (Choate, 2015). The factors involved in the onset, continuation, and relapse of substance abuse disorder are diverse and include various personal, familial, and social factors. Pre-addictive backgrounds in addicts (personality traits, family relationships, lifestyle, beliefs, and opinions) are significantly different from those in healthy ones (Heyman, 2011). One of the protective and risk factors of substance abuse is individuals' attitude that is considered as one of the most important factors associated with the consumption and/or non-consumption of Tahereh Bagheri & AliMohammad Na'emi 13 drugs (Cooper, Frone, Russel, & Muder, 2007). Experts perceive attitudes as the beliefs that affect people's thinking, feelings, and behavior (Baron & Byrne, 1977). In other words, attitude refers to the individual's beliefs about the outcome and product of everything s/he intends to do and the value s/he assigns to the obtained outcome (Bagheri, & Bahrami Ehsan, 2013). One of the important and influential factors in the attitude towards addiction is the presence of addicted parents in the family who provide grounds for such an attitude due to their poor child-rearing skills, poor supervision of children's behavior, high conflicts, and unstable discipline (Arria et al., 2012). However, strong family ties, monitoring children's behavior, effective communication, and negotiation about family expectations and positive values are among the important protective factors against addiction. McCuller, Sussman, Dent, & Teran (2001) showed that individuals' intent to substance abuse was influenced by their attitude toward substance abuse at least during the initial period of consumption. Horigian et al. (2016) suggested that parents' substance abuse causes their children to become addicted. Tonato (2008) and Kumpfer (2014) also found that one may take refuge in substance abuse to escape stressful situations (rule breaking, high-risk behaviors, academic failure) and to temporarily relieve these pressures. In the field of psychology, various theories have suggested different causes for addiction. While behavioral theories (Delgadillo et al., 2015) have emphasized the environment and psychodynamics has emphasized conflicts, cognitive theories focus on inefficient thoughts and irrational beliefs. According to cognitive theories, irrational beliefs are often presented automatically, unconsciously, and permanently (Bahremand, Saeidi, & Komasi, 2015); and play an important role in the growth and persistence of substance abuse (Dastjani Farahani, Rahmani, & Tizdast, 2013). Individuals' knowledge and beliefs have a significant effect on the incidence and progression of this disorder and its stages, including symptoms, causes, and behavioral changes (Bahremand et al., 2015). According to Woods (1993; as cited in Fayyaz, & Kiani, 2008), irrational beliefs include one's expectation to receive others' confirmation, excessive expectations of the self, readiness to blame, desperate reaction to failure, emotional irresponsibility, high worries along with anxiety, problem avoidance, dependency, helplessness to change, and perfectionism. The affective level provides one with some clues to understand his/her mistakes at the cognitive level. Therefore, one will hold healthy feelings when s/he has healthy beliefs. Healthy behaviors and healthy feelings are thought to create the right problem- solving approaches (Rovira, 2017). In this regard, various approaches to the prevention and treatment of substance abuse disorder have been proposed (Dolan, Martin, & Rohsenow, 2008). Cognitivism is one of the most important approaches among these ones. In this approach, attempts are made to change positive attitudes and beliefs towards drugs and to strengthen and consolidate the negative attitudes towards drugs. The basic assumption of the cognitive approach is that dysfunctional attitudes are involved in how one interprets and 14 Research on Addiction Quarterly Journal of Drug Abuse evaluates the reality; in addition, that the behavioral responses that derive from specific interpretations contribute to the continuation of substance abuse disorder (Goodarzi, 2001). Based on this approach, individuals' interpretation from specific situations affects their feelings, motivations, and their actions. These interpretations are often shaped by the beliefs that are activated in these situations and result in the desire for consumption. These beliefs are the ones that are activated under certain predicted conditions and are likely to increase substance use (Beck & Emery, 1985; as cited in Ghorbani, Kazemi, & Ghorbani, 2011). Cognitive-affective therapy encourages people to look for the thoughts that appear automatically to observe what they state, and to understand that these ways of thinking have been constructed from irrational beliefs that can be modified (Ellis, 2005). Studies have shown that cognitive therapy can have a positive effect on mitigating the components of irrational beliefs, such as the need for approval and support from others, excessive expectation from the self, reaction to failure, over-concern along with anxiety about the future, and perfectionism (Solberg, Nysether & Steinsb, 2012; Loue, 2008). Faggiano et al. (2010) argue that group training and life skills can be effective in preventing addiction and recovering from it as well as in family functioning and interpersonal relationships. Since addiction is a widespread issue, and only training of an addicted person does not seem adequate; it is necessary to pay attention to the addicted person's family. In other words, instead of using the individual and group methods that focus mainly on the addicted individual(s), a family-based intervention approach that also assigns attention to the members of the addicted family should be used. Research has shown that family-based training programs are superior to individual and group therapy and prevention programs. The research findings reported by Dimitropoulos et al. (2015), Swenne, Parling & Ros (2017), and Rienecke (2017) showed that a family-based intervention program can have a positive effect on reducing eating disorder in adolescent girls. Habibi, Nikbakht Nasrabadi, Shabani Hamedan, & Saleh Moghadam (2016) indicated that family-based training program has a positive effect on improving self-efficacy and self-esteem, and on decreasing relapse rates among addicts. Kumpfer's (2014) findings suggest that it is possible to prevent adolescents' addiction and failure by means of family-based training programs. Na'emi (2015) investigated the effectiveness of family-based training in the mental health and the resiliency of women with addicted husbands and showed that family-based training has a positive effect on increasing the mental health and resiliency rates of women with addicted spouses; therefore, these women's participation in family-based training courses can lead to increased mental health and resiliency in them. Na'emi, & Tajabadi (2017) found that group training had a positive effect on the components of attitudes toward addiction among female students with addicted parents. Due to the importance and status of adolescent girls in the society and their role in sustainable development of the country as well as the growth of addiction Tahereh Bagheri & AliMohammad Na'emi 15 and the lowered age of substance abuse in Iran and the serious risk that threatens female students with addicted parents, it is necessary to study the impact of training interventions. Therefore, the present research attempts to respond to the following question: Is family-based training effective in attitudes towards substance abuse and irrational beliefs among female students with addicted parents in Sabzevar?

Method Population, sample, and sampling method This research employed a quasi-experimental research design along with pretest- posttest and control group. The statistical population of this study included female high school students from Sabzevar with a parent with substance use disorder in 2016. The entry criteria included participants' willingness to participate in the study and having at least one addicted parent. By addicted parent in this research, we mean the students' parents who had physical and psychological dependence on drugs, stimulants, and hallucinogens. These persons were identified through the school authorities and the interview that the researcher had with them. Ethical considerations, in particular, subjects' consent, voluntary participation, and confidentiality of information were observed and emphasized by researchers. Then, multistage random cluster sampling method was used wherein two schools were randomly selected from girls' schools in Sabzevar. Then, the number of students with addicted parents was identified with the help of school officials where it amounted to 36 students. They were randomly divided into two groups and coding was randomly assigned to an experimental group (n = 18). After the determination of the groups and before the intervention, the two groups were pretested and, then, the experimental group (students with their mothers) received family-based training program for ten 90- minute sessions (one session per week) and the second group was placed on the waiting list to participate in the next round. The family-based training program in this study was an integrated program of cognitive-behavioral methods (Frey, translated by Mohammadi and Farnam, 2005) and life skills training (standard training package by Mohammadkhani and Nouri, 2004). The family-based training program was conducted at the site of one of the schools in 2016 by a female mentor who was an M.A. holder of psychology. The process of each session included reviewing the tasks of the previous session, direct teaching in the form of lectures, group discussions, brainstorming, and wrap-up, which were presented for female students with addicted parents and their mothers. After the end of the training program, both groups took the post-test. The summary of the training structure is as follows: First session: Establishing initial relationship, expressing goals, discussing method of work, and examining how to identify addiction; Second session: Examining how to identify addiction, help-seeking, misconceptions; Third session: Addiction and community, disease and dependence; Fourth session: 16 Research on Addiction Quarterly Journal of Drug Abuse

Appropriate confrontation with addiction and problem-solving skills training; Fifth session: Perfectionism, emotional control, and desire for drug use; Sixth session: Mindfulness, self-expectations, and expectations of others; Seventh session: Empathy training; Eighth session: Response to disappointment and blame, and reliance on others; Ninth session: Accountability training; Tenth session: Decision-making training, replacement of logical beliefs with irrational beliefs, review of feedback, and closing ceremony.

Instruments 1. Attitude toward Drugs Questionnaire: This questionnaire was developed by Delavar, Alizadeh, & Rezaei (2004). It consists of 40 items and three components (effects of drug use: 21 items; consumption or desire to use drugs: 10 items, and the dangers of drug use: 9 items). Each item is scored based on a 5-point Likert scale from strongly agree (5) to strongly disagree (1). The scores range from 40 to 200, which means that the higher one's score on this scale, the higher his/her positive attitude toward substance abuse. The construct validity of this test was obtained equal to 0.938 and retest reliability coefficients were obtained equal to 0.94, 0.85, 0.86, and 0.85 for the total test, the effects of drug use, consumption or desire to use drugs: 10 items, and the dangers of drug use, respectively (Delavar et al., 2004). In this study, Cronbach's alpha coefficient for the whole scale was obtained 0.86 and it was reported equal to 0.79, 0.81, and 0.86 for the above components, respectively. 2. Irrational Believes Test (IBT): This questionnaire was constructed based on Ellis's (1970) theory to evaluate dysfunctional thoughts and it assesses ten questions pertaining to irrational thoughts. It contains 100 questions where each item measures an irrational thought. Examples of statements that are addressed in this questionnaire are: "It is important for me to be approved by others" or "I avoid doing things that I cannot do well." The ten sub-scales of this test include demand for approval, high self-expectation, blame proneness, frustration reactivity, emotional irresponsibility, anxious overconcern, problem avoidance, dependency, helplessness for change, and perfectionism. The retest reliability coefficients of the ten above sub-scales have been obtained from 0.66 to 0.80, and the average reliability value of all sub-scales has been obtained 0.74. Moreover, the validity of the test was confirmed by means of face validity and congruent validity methods where the correlation coefficient of this test with Beck's Depression Test was obtained equal to 0.82 (Alizadeh Sahraei et al., 2010). Cronbach's alpha for this test was obtained equal to 0.82 (Rashidi, Ghodsi, & Shafi Abadi, 2010) and was obtained 0.78 in this study.

Results From among the 36 female students in this study, 27.8% of them were first graders, 33.3% of them were third graders, and 38.9% of them were fourth Tahereh Bagheri & AliMohammad Na'emi 17 graders. The mean (standard deviation) of their age was 11.6 (1.09) years. The descriptive statistics of the research variables are presented in Table 1. Table 1: Descriptive Statistics of Attitudes toward Drug Use and Irrational Beliefs for each Group Control group Experimental group Variable Pretest Posttest Pretest Posttest Mean SD Mean SD Mean SD Mean SD Effect of drug use 64 2.3 52 17 57 17.4 36.5 6.4 Drug use 18 7 14 6 19 10 11 3 Dangers of drug use 20 9 11 2 18 8 10 1.3 Total attitude 102 29 88 19 94 29 57.50 6 Demand for approval 32.44 5.19 32.5 4.88 31.28 5.31 26.11 3.01 High self-expectation 35.83 3.88 34.78 5.75 31.89 6.95 33.55 5.55 Blame proneness 32.39 5.57 33 4.80 31.44 5.3 26.11 3.3 Frustration reactivity 33.55 4.70 32.17 4.41 32.28 5.4 29.11 4.2 Emotional 31.89 7.30 35.78 5.59 32.67 5.54 33.22 6.77 irresponsibility Anxious overconcern 34.28 5.76 33 6.92 33.28 5.97 32.22 6.63 Problem avoidance 32.33 6.23 32.11 4.81 31.11 7.14 30.78 3.51 Dependency 34.83 6.22 26.22 3.32 35.11 5.32 28.17 4.30 Helplessness for change 32.05 5.52 32.89 3.74 32.78 6.57 32.05 6.58 Perfectionism 31.5 4.68 32.23 3.97 35.28 7.45 33.05 4.83 Total irrational thoughts 324 37 339 32 326 51 321 35

Kolmogorov-Smirnov test was used to ensure the normal distribution of the variables. The results of this test showed the normal distribution of the variables of attitudes towards drug use, irrational beliefs, and its components (p> 0.05). To investigate the homogeneity of variance in the variables, Levene's test was run. The results were indicative of the homogeneity of variances (p> 0.05). In the same way, the results of the homogeneity test of regression slopes pertaining to all variables were not significant (p> 0.05), which indicated the sameness of the relationship between the dependent variable and pretest for both groups. Therefore, multivariate covariance analysis was run and the results showed a significant difference between the two groups in the linear combination of the variables (P <0.001, F=14.602, Wilks's lambda=0.82). To examine the patterns of difference, univariate covariance analysis was used, as presented in Table 2.

18 Research on Addiction Quarterly Journal of Drug Abuse

Table 3: The Results of Univariate Covariance Analysis Representing the Impact of Family-Based Training on Components of Attitude to Drugs and Irrational Beliefs Eta Test Variable Mean Square F Sig. squared power Effect of drug use 1523.40 40.20 0.0005 0.38 1 Drug use 326.80 28.06 0.0005 0.46 0.99 Dangers of drug use 8.099 4.18 0.049 0.11 0.51 Demand for approval 27.85 1.49 0.0005 0.54 0.91 High self-expectation 48.82 1.55 0.22 - 0.23 Blame proneness 4819.2 23.4 0.0005 0.45 0.97 Frustration reactivity 35.03 1.37 0.25 - 0.21 Emotional irresponsibility 16.02 0.41 0.52 - 0.10 Anxious overconcern 1.86 0.04 0.84 - 0.05 Problem avoidance 15.88 0.89 0.35 - 0.15 Dependency 426.80 24.06 0.0005 0.42 0.98 Helplessness for change 25.51 0.74 0.40 - 0.13 Perfectionism 2.95 0.15 0.70 - 0.07 As it has been shown in Table 3, family-based training has been effective in such components as the effect of drug use, drug use, dangers of drug use, demand for approval, blame proneness, and dependency.

Discussion and Conclusion The aim of this study was to investigate the effect of family-based training on attitude toward drug use and irrational beliefs among female high school students of Sabzevar with an addicted parent. The results showed that family- based training has a positive effect on attitude toward drugs and all its components. This result is in line with the results of studies conducted by Heyman (2011), Kumpfer (2014), Swenne et al. (2017), Habibi et al. (2016), Hoorijian et al. (2016), and Na'emi (2015). Substance abuse tendency is a phenomenon that is affected by various factors, including family and cultural factors (Rather, Bashir, Sheikh, Amin, & Zahgeer, 2013). Those children who are in interaction with drug abusers and do not benefit from preventive intervention programs may experience more behavioral and emotional problems and be more at risk of substance abuse (Vilela, Silva, Grandi, & Rocha, 2016). Because family plays an important role in the behavioral health of adolescents, the family-based problems can contribute to the incidence of such trauma as substance abuse, delinquency, sexually transmitted diseases, and HIV. These problems are more severely observed in addicted families. The children of families with addicted parents suffer from depression, high stress, and parental inefficiency. In such a situation, parents spend less time on children and these problems can increase the risk of tendency towards substance abuse in adolescents (Buehler& Gerard, 2013), whereas the selection of appropriate parenting styles by parents can act as a shield that can protect children from behavioral problems, mental disorders, and mistreatment Tahereh Bagheri & AliMohammad Na'emi 19

(Kumpfer, Magalhaes, & Xie, 2012). In addition, those who have experienced more difficulties and hardships in childhood are more likely to get involved with substance abuse. In the meantime, those whose parents are addicted and who have more access to drugs find themselves in a more dangerous situation (Benjet, Borges, Medina-Mora, & Mendez, 2013). Another research finding was that family-based training had a positive impact on three components, out of the ten components of irrational beliefs, including demand for approval, blame proneness, and dependency. This finding is not generally consistent with the research findings reported by Dimitropouloset al. (2015), Rienecke (2017), Rovira (2017), and Swenne et al. (2017) where the studies were performed on female adolescents. The reason for this inconsistency cannot be attributed to gender because Rovira's findings (2017) suggest that there is no difference between male and female participants, and the research done by Dimitropouloset et al. (2015) and Swenne et al. (2017) has been conducted on female adolescents. Therefore, it can be attributed to the cultural and social differences as well as the addicted parent's pressure for not participating in this program, and the short duration of the training program; and gender is not involved. In this regard, it can be argued that addicted people hold more dysfunctional attitudes and irrational beliefs than non-addicts (Tonato, 2008). Also, families with an addicted parent do not want their children to receive individual or group intervention on awareness raising and addiction prevention (KelleyD’Lima, Henson, & Cotton, 2014) and, as a result, their children show more resistance and less willingness to participate actively in interventional programs. According to the cognitive theories, dysfunctional thoughts and irrational beliefs influence the way in which one interprets and evaluates the reality. Also, behavioral responses that derive from specific interpretations have an impact on the continuity of substance abuse (Goodarzi, 2001). Ideas such as "I cannot tolerate anxiety" can provoke the idea that "I have to take drugs to soothe myself" in such a way that Ellis (2005) states addicted people's way of thinking can lead to their tendency to repeated drug use. Therefore, students who are supported by their parents and their friends who participate in a family-based training programs reconsider their beliefs about distancing themselves from drug use and holding negative attitudes toward it. Obviously, if the family's awareness of substance abuse and its adverse consequences increases, it can be expected that irrational tendencies to and beliefs about drugs will also be modified in their children, and this is the goal that the family-based training pursues. This is, indeed, the same goal that Piko & Kovács (2010) have also referred to as they suggested that family is one of the most important factors influencing addiction prevention or tendency in children. In this regard, Kumpfer& Hansen (2014) also stated that increased awareness, cognitive skills development, increased attachment and love, improved discipline, communication skills, and reduced risk behaviors (such as addiction, delinquency, academic failure, and unintended pregnancy) can 20 Research on Addiction Quarterly Journal of Drug Abuse contribute to the modification of children's positive beliefs towards narcotic drugs. Generally, family-based training leads to increased mindfulness, accountability, provision of emotional needs, and reduced family disputes; contributes to the tackling of irrational automatic thoughts; creates a ground for modifying positive attitudes toward addiction; and reduces irrational beliefs. Therefore, the mental well-being of children with addicted parents will be improved. This important task is on the shoulder of social institutions, such as educational organizations and welfare institutions to address this social dilemma by means of family-based training. This study was limited to female high school students with addicted parents in Sabzevar. Therefore, it is necessary to exercise caution in generalizing the results to other populations in the long run. It is suggested that the next research examine family-based training on samples of male students along with their parents (especially their fathers), other levels of education, and positive psychological variables (self-compassion, resiliency, hardiness, etc.) to improve the individuals' ability in reducing the rate of addiction. Psychologists, counselors, social workers, and other responsible entities and organizations can also use the findings of this research to counteract the tendency towards addiction. Reference Alizadeh Sahrahi, M., Khosravi, Z., & Besharat, M. (2010). The Relationship of Irrational Beliefs with Positive and Negative Perfectionism in School Students of Nowshahr City, Journal of Psychological Studies, 6 (1), 9-41. Andreas JB, & O’Farrell TJ. (2009). Alcoholics Anonymous attendance following 12- step treatment participation as a link between alcohol-dependent fathers’ treatment involvement and their children’s externalizing problems. 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Haber J, Bucholz KK, Jacob T, Grant JD, Scherrer JF, Sartor CE, & Heath A. (2010). Effect of paternal alcohol and drug dependence on offspring conduct disorder: Gene- environment interplay. Journal of Studies on Alcohol and Drugs, 71(5), 652–663. Habibi, R., Nikbakht Nasrabadi, A., Shabany Hamedan, M., & Saleh Moqadam, A. (2016). The Eff ects of Family-Centered Problem-Solving Education on Relapse Rate, Self Efficacy and Self Esteem among Substance Abusers. Int J High Risk Behav Addict, 5(1), e24421. Heyman, G.M. (2011). Received Wisdom Regarding the Roles of Craving and Dopamine in Addiction A Response to Lewis's Critique of Addiction: A Disorder of Choice. Perspectives on Psychological Science, 6(2), 156–160. Horigian VE, Feaster DJ, Brincks A, Robbins MS, Perez MA, Szapocznik J. (2016). The effects of Brief Strategic Family Therapy (BSFT) on parent substance use and the association between parent and adolescent substance use. Addictive Behaviors, 42, 44-50. Kelley, M.L., D’Lima, G.M., Henson, J. M. & Cotton, C. (2014). Substance-abusing Mothers and Fathers’ Willingness to allow their Children to Receive Mental Health Treatment, Journal of Substance Abuse Treatment, 47(1), 106–111. Kumpfer, K.L. (2014). Family-based interventions for the prevention of substance abuse and other impulsive control disorder in girls. ISRN Addiction. Hindawi publishing. Kumpfer, K.L., Magalhaes, C. & Xie. J. (2012). “Cultural adaptations of evidence-based family interventions to strengthen families and improve children’s developmental outcomes,” European Journal of Developmental Psychology, 9(1), 104–116. Kumpfer, K. L & Hansen, W. (2014). Family-based prevention programs, in Parenting and Teen Drug Use, L. Scheier and W. Hansen, Eds., chapter 8, Oxford Press. Lander, L., Howsare, J. & Byrne, M. (2013). The Impact of Substance Use Disorders on Families and Children: From Theory to Practice. Social Work Public Health, 28(0), 194–205. Lombard S, J-F., Pullen, D. & Swabey, K. (2017). Conceptualizing Trauma for Children of Drug Addicted Mothers: A Developmental Mapping. Journal of Trauma & Treatment, 6(1). Loue S. (2008). The Transformative Power of Metaphor in Therapy. USA: Springer Publishing Company, 1–14. McCuller, W. J., Sussman, S., Dent, C. W & Teran, L. (2001). Concurrent prediction of drug use among high – risk youth. Addictive Behaviors, 26 (1), 137-145 Mohammadkhani, S., & Nouri, R. (2004). Life Skills among School Students. Theoretical and Practical Deputy of Ministry of Education, Tehran: Toloo Danesh Publication. Na'emi, A. (2015). The Effectiveness of Family-based Training in the Mental Health and the Resiliency of Women with Addicted Husbands, Journal of Women in Development and Politics, 13 (1), 41-52. Na'emi, A., & Tajabadi, T. (2017). The Effect of Group Training about Drug Abuse Consequences on Attitude toward Addiction among Female High School Students with Addicted Parents (Case Study), Quarterly Journal of Research on Addiction, 11 (41), 85-101. Nygaard E, Moe V, Slinning K, & Walhovd K.B. (2015). Longitudinal cognitive development of children born to mothers with opioid and poly substance use. The Journal of Pediatric Research, 78, 330-335. Piko, BF. & Kovács E. (2010). Do parents and school matter? Protective factors for adolescent substance use. Addictive behaviors, 35(1), 53-56. Tahereh Bagheri & AliMohammad Na'emi 23

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Abstract Study of Sociological Objective: No significant attention has Functions of the been paid to the sociological dimensions of the functions of nongovernmental NGOs Active in the organizations as a civil institution, and Field of Addiction the present study has investigated this issue. Method: For this purpose, the Treatment qualitative method of Grounded theory was used to conduct deep interviews with the managers of NGOs active at the national level as well as addiction treatment specialists. Results: Following the coding process of the interview results and using Strauss & Azad Armaki, T. , Sarami, F.

Corbin theoretical model, the researcher could present the model and, finally, the organizations under study were Azad Armaki, T. categorized by means of the obtained Department of Sociology, University of model. Conclusion: The results of the Tehran, Alborz Campus, Tehran, Iran analyses showed that assigning the responsibility of social affairs, including Sarami, F. addiction treatment to NGOs have many Ph.D. Student of Sociology, University advantages, such as the deepening of the of Tehran, Alborz Campus, Tehran, Iran recognition of civil institutions in Email: [email protected] relation to social issues, the increase of financial and voluntary support for people in the field of social issues, the increased concern for providing quality services, and the increase of public demand for the conduct of fruitful interventions and public demand from the civil institutions.

Keywords: non-governmental organizations, addiction treatment, sociological functions Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir

26 Research on Addiction Quarterly Journal of Drug Abuse

Introduction According to a recent report distributed by the United Nations Office on Drugs and Crime (UNODC(, the population of drug users is about 255 million people of the world population; they are at the age of 15 to 64 years old, and has consumed at least one type of substance once a year in 2015. Moreover, according to the results of the report provided by the Study Center for Disease Tolerance Assessment in 2015, about 17 million years of healthy life of the addicts’ life have been wasted away due to the physical and psychological disorders caused by drug use (World Drug Report, 2017). The statistics released by the United Nations Office on Drugs and Crime in 2010 indicate that 41% of the world's opium is consumed in Iran (World Health Organization, 2010). While, the process of drug use has changed as compared to the past; on the one hand, the average age of drug users decreased as compared to the previous years, and on the other hand, the consumption pattern is changing from the smoking use of opium to the injection consumption of heroin (Razzaghi, Rahimi Movaghar, & Madani, 2003). The statistics of the 8,000 high-risk addicts reported by the Drug Control Headquarters in 2011, as well as the mortality rates among addicts in the metropolis of Tehran, show that Tehran is the most polluted city in the country in terms of narcotics. In 2010, it had the highest mortality rates due to drug use among other provinces, with 1068 deaths (Roshan Pajuh, et al., 2015). Based on the latest results of the epidemiology in the general population of the country (15-64 years old) in 2013, the rate of drug use prevalence in the country has been 5.4 % (equivalent to 2,802,800 continuous drug users and also 1,600,000 for-fun drug users), which 156,000 people has been female drug users. The average age for the onset of substance use is 24.1 years for males and 26.2 years for females and the total average is 24.3 years. According to the results of this study, it was observed that the prevalence of drug consumption in 5.4% of the population at the age of 15-64 years is 2,802,800 people, in such a way that the pattern of drug use in these individuals is as follows: opium (53.8%), cannabis, flower, marijuana, and grass (11.9%), glass and heroin (7%). The trend of the consumption pattern indicates that the consumption of flower, marijuana, and grass has increased in the country (Roshan Pajuh, 2015). Furthermore, according to the calculations, the total costs for drug use in 2004 has been 15 million dollars (Hashemi, & Mokhtarian, 2010). According to the reports and statistics published annually by the international assemblies, drug consumption is increasing throughout the world; although the manner of drug use and the type of substances are changing due to various reasons. To this end, the administrators of controlling drug supply and demand from different countries gather several times a year in order to hold conferences and meetings; they attempt to solve this problem by sharing their experiences and policies in this field. International policies in the area of demand reduction included different approaches from the past to the present: using the legislative Taghi Azad Armaki & Fatemeh Sarami 27 tools commensurate with each country’s consumption, giving importance to the field of treatment, preventing or mitigating harm. In 1961, according to the Convention on Narcotics, the majority of countries of the world were obligated to implement drug prohibition laws, with varying degrees of legal stringency in accordance with their own society (Felbab-Brown, 2009). Furthermore, with the passage of time and conducting research on the impact issues, the use of scientific approaches was at the head of the prevention activities. One of the important approaches in the area of prevention was the secondary prevention with the aim of controlling and preventing further consumption and taking other high-risk behaviors caused by drug use. Thus, the need for harm reduction and treatment programs along with preventive programs were considered as interdependent to each other and the addicts’ treatment was identified as one of the major components of the demand reduction strategy. In addition, helping people to reduce drug use, improving the health condition, reducing crime and increasing social function, especially in the developed countries, are all the inseparable parts of the treatment process. Considering that treatment is a long- term process and recurrence is one of the most common stages in this process; however, a wealth of evidence suggests that treatment is a successful strategy in reducing drug use and other social issues associated with it. Moreover, the treatment process and therapeutic methods have progressed dramatically throughout the world over the past two decades (World Drug Report, 2000). In Iran, the national supply and demand reduction policies were also announced in 2006 and are still used as the agenda for the administrators in this field. These policies are written based on several basic principles: 1. A comprehensive and decisive fight against all illegal activities and actions related to substances and psychotropic drugs and their precursors, such as cultivation, production, import, export, storage, and supply of drugs; 2. Strengthening, development, equipping, and comprehensive use of informational, military, disciplinary, and judicial facilities to identify, prosecute, and destroy the networks and to deal with the main domestic and international factors related to narcotics and psychotropic drugs and their precursors; 3- Strengthening, equipping, and developing units and mechanization of the control systems, focusing the information in order to control the borders and entrances of the country, preventing illegal activities related to substances and psychotropic drugs and their precursors, and strengthening the specialized structure for fighting against narcotics in the police force and other relevant organizations; 4. Adopting preventive actions against the threats and harms caused by narcotics and psychotropic drugs by utilizing the governmental and nongovernmental facilities; 5. Criminalizing the use of substances and psychotropic drugs and their precursors except for the scientific, medical, industrial, and the approved programs for treatment and harm reduction. 6. Establishing and developing public facilities for the detection, treatment, rehabilitation, and taking comprehensive actions; 7. Preventing the change of 28 Research on Addiction Quarterly Journal of Drug Abuse drug use pattern from low-risk substances to high-risk substances; 8. Adopting the necessary measures for social support after the treatment of addicts to the substances and psychotropic drugs. Prior to recognizing the entry of non-governmental organizations into the area of drug control management, the administrators of this field included the governmental organizations, such as the Drug Control Headquarters as a policy- maker and coordinator institution and also as a supervisor on the performance of other public organizations active in this field (including 12 governmental members: President, Attorney General of the country, Minister of the Interior, Minister of Information, Minister of Health, Minister of Education, Head of Islamic Republic of Iran Broadcaster, Police Commanders, Head of the Islamic Revolution Court, Head of the Prison Organization, Head of Niruyeh Moghavemat Basij, Minister of Culture and Islamic Guidance) and the Welfare Organization. In spite of the efforts made in the area of demand reduction, and especially in the area of treatment by the governmental organizations and spending large budgets, this problem has not significantly reduced as it was expected by the society. There are several reasons for criticizing the activities of government in this field: Lack of relationship among different treatment patterns and the conceptual or attitude differences among them, which in turn can be an opportunity to improve the services quality, has sometimes stopped service provision in this area; it requires special attention. A brief survey from a large number of experts showed that lack or poor organizing of the treatment social models on the one hand, and the mere medical attitude towards addiction treatment and neglecting the psychological-social treatments on the other hand are considered as the weaknesses of the treatments domain (Roshan Pajuh, et al., 2015). Polarization of views in the area of addiction treatment services and the elimination-based attitudes toward some programs, such as harm reduction programs, are major threats for the treatment programs. In addition, despite the significant expansion of treatment services and harm reduction, a comprehensive assessment of the treatment outcomes has not been carried out due to the dispersion and the extent of the activities of the governmental organization (Saberi Zafarghandi, Roshan Pajuh, Mirkazemi, & Bolhari, 2013). Although the article 15 of the law of fighting against drug, enacted in 2011, paid attention to the treatment and allowed drug addicts to go to the treatment centers, in Article 16 of the same law, in the case of the obvious commitment and recurrence of the disease, the punishment approach has been considered. This could have a negative impact on the referral and treatment in the primary health care system due to the individuals’ concern to register their characteristics or to be punished in the case of recurrence. Moreover, the health services belonging to the governmental sector do not have the required quality (Roshan Pajuh et al., 2013). Furthermore, social support, treatment, rehabilitation, and harm reduction of addiction in Iran have different administrators and resources, Taghi Azad Armaki & Fatemeh Sarami 29 and there is no effective coordination between the relevant organizations. This will lead to waste effort and capitals. Today, the presence of the non-governmental organizations along with the governmental organizations in the area of reducing demand at the international level has become one of the significant issues; inasmuch as the importance of the role of these organizations is considered as a missing link of the effectiveness of the government preventive and therapeutic activities (National Committee for Addiction Treatment, 2011). Features such as lack of dependency to the bureaucratic structure and the public resources of the government and being voluntary or democratic distinguish these organizations from the governmental organizations. The future of the world will be dominated by the nongovernmental organizations. Accordingly, each country will determine the probability of its power survival through the expansion of the NGO organizations (Rahimi et al., 2011). NGOs have existed throughout the world for centuries and in different forms, and the peak of their flourishing and emergence has been since the 1980s (Lewis, 2003). An attempt to move from the mass democracy to the organized democracy has led to proposing the civil society perspective against a mass society. Civil society in its new meaning refers to the area of social relationships that is free from political power and includes a set of institutions, organizations, and private and civil (non-private) entities. These institutions play the mediating role between the political and social power, and their most important feature is that they are public (Masoudnia, 2005). In Iran, we have witnessed a formal and serious presence of volunteers, the non-governmental organizations, and the community-based organizations for more than two decades; they are actively involved in the area of fighting against the problem of drug addiction, preventing, and treating it. According to article 44 of the Constitution, the role of non-governmental organizations in the social development of the country is of particular importance; moreover, in paragraph 9 of the macro policies pertaining to drug control, enacted in 2007 by the Expediency Discernment Council of the System entitled as "Adopting the necessary measures for the serious presence and participation of people and families in the areas of prevention, reduction of harm, and treatment of addicts" and the use of NGOs in Article 15 of the drug control law, adopted in 2010, there are the legal status according to which the nongovernmental organizations can work in drug control affairs. In addition, in paragraph z of Article 97 of the Law of the Fourth Plan of Development, emphasis has been placed on strengthening the role of people and non-governmental organizations in preventing and fighting against addiction. More than 80% of the programs pertaining to the harm reduction and treatment in the area of narcotics in Iran are carried out by the NGOs; and among 2271 nongovernmental organizations, about 37% of them are active in preventive activities, 56% are active in treatment, and 7% are active in reducing harm (Roshan Pajuh et al., 2015). 30 Research on Addiction Quarterly Journal of Drug Abuse

Although addiction is considered as a social problem in our country, there is still no general consensus on "drug addiction" as a crime or illness, and the responsible authorities have different approaches to it. In fact, considering the addict as a patient or criminalizing him/her makes the subject personal subject. While, the social issue of addiction will not be resolved by the person’s betterment, and the problem of addiction should be addressed in a more progressive approach. In other words, where drug addiction has become a social issue, all groups and organizations of the society must be involved in dealing with it (Sedigh Sarvestani, 2006). Accordingly, today, it is necessary to pay attention to new approaches in the area of fighting against narcotics. Among the features of this new approach is an approach that is based on different approaches from the past, and requires a change from the prescriptive perspective to the participatory and community-based perspective, from the dependency to the existing resources to the social capacity building and searching support, from focusing on government-oriented solutions to the evidence-based problem- solving methods; the emphasis on the civil society initiatives, as well as the emphasis on collective collaboration, social cooperation, and accountability are among the main features of this new approach. Therefore, the main issue of the present study is to identify the role and presence of the nongovernmental organizations and civil institutions in the field of management and demand reduction of drugs as much as possible; assuming that the presence of the public sphere, as Habermas mentions, reduces the fragility of the collision between the private and governmental domain and increases the social flexibility. From Habermas's point of view, the public sphere is a part of civil society, and although the government monitors the institutions of the public sphere, including circles and associations through the law, the main function of the public sphere is to limit the power of the government and create a kind of stability and moderation (Azad Ermaki, 2011). Theories of Civil Society: At the end of the twentieth century, for some reasons, the idea of civil society was taken into consideration more than the decline of communism and the rise of capitalism. Looking back over the last 100 years, the political leaders found that there was a catastrophic mistake in the modern organization of the society. At that time, the advocates of civil society argued- this argument is still common- that the governments that have grown too much have not been able to solve the domestic and global issues. Governments are elitist and bureaucratic, and are heavily under the influence of powerful pressure groups. Therefore, the governments are part of the problem rather than a solution for it (Viterna, Clough, & Clarke, 2015). One of the most popular views of the civil society is considering it as a public sphere; today, we often recognize this view as Habermas and its human aspect is more prominent as comparison to other perspectives. According to this view, a public sphere is similar to a civil center. Each center where people can talk freely, honestly, and hopefully with order about the issues affecting the society Taghi Azad Armaki & Fatemeh Sarami 31

(Geisler, 2006). Jürgen Habermas defined the "public sphere" as a space where people contemplate about their shared relationships. An internalized space where people discuss about issues of civil and social life (Habermas, 1989). Unlike the institutions which are under the foreign domination or have the internal power relations, the public sphere informs about the principles of democratic participation and supervision (Holab, 1996). Moreover, Azad Ermaki in his book "Iranian Hangout and Modernity", has explored the public domain in the Iranian society through hangouts and civil associations and communities. In this book, the concept of hangout is against the concept of mighty power and is sociologically referred to the concourse of a group of people who, in the absence of any official and bureaucratic rules and regulations, act to hold meetings on the margin of the official life of society. Hangouts, as a specific form of community, have a special structure, and this new status is a structure that gives identity to the hangout. The type of the relationship between the individuals, the degree and severity of the relationships, leadership and management, goals, the discourses within the hangouts, the culture and value system governing the relationships, the type of the relationship with other social groups, the outcome and function of the hangouts and ... represent the structure of the hangout (Azad Ermaki, 2011). Despite all these theories, no independent field of study was developed for voluntary and non-profit studies. However, since the issues of the nongovernmental sector are attributed to the social sciences, studies in this area began to emerge. For sociologists, the fundamental discussion about the role of nongovernmental organizations in developed and developing countries was more based on the analysis of public supervision, in which the nongovernmental organizations provide the welfare and social services more effectively and efficiently than the governments. As a result, communication and cooperation between the governments and these organizations in the provision of welfare services became a dominant issue in countries such as the United States, Germany, France, and the United Kingdom (Anheier, & Salamon, 2006). The NGOs and the phenomenon of addiction: Although the fight against narcotics has been accepted as an essential issue in all countries of the world, and has been more or less accompanied with success, according to the developmental level of countries (developed or in under-development), different policies and strategies have been used in terms of fighting against drug abuse in the areas such as controlling drug supply and demand, prevention, treatment, research, and so on. In the last two decades, a relatively coherent approach has been developed to provide the health for community members in general, and to succeed in the fight against narcotics in particular; according to this approach, it is believed that the health or illness and discomfort of the society members is fundamentally considered as a social issue. The only way to make a significant change in the quantity or quality of health and illness in society is through the society itself. The most striking attempt in highlighting this approach is done by 32 Research on Addiction Quarterly Journal of Drug Abuse the World Health Organization in the “Ottawa Charter”, according to which health promotion can be achieved by empowering the society members to control and manipulate their health-related factors (Keshavarz Mohammadi, Zarei, & Parsinia, 2013). The socialization process of fighting against narcotics in this way is summarized in such a way that the beneficiary groups describe the subject through the discussion in different contexts of their lives and their place of residence; enumerate its various aspects in such a way that is related to their place of residence; identify the most problematic families; and, more important of all, suggest the solution, and actively participate in all processes of fighting against drugs including planning the program, enacting the program and, finally, implementing and evaluating the program (Piran, 2000).

Method Population, sample, and sampling method The research method used in the present study for collecting data and analyzing them is the qualitative method of grounded theory; it allows the researcher to develop a new theoretical model instead of using the predefined theories, in the cases where it is not possible to compile the hypothesis. This new theory is not based on the researcher's personal opinion, and is actually based on the data collected from the real environment in the real situations. The instruments for data collection include the qualitative in-depth interviews with two groups of respondents used in the interviews. The first group are the leaders of the non- governmental organizations and the second group are the experts in the area of treatment and the NGOs; the information was collected through the in-depth interviews. The well-known model that was introduced by Strauss and Corbin as a systematic GTM, was in fact a way for conducting the process of qualitative analysis. According to him and his colleague Corbin, in this model, it is essential that the data be coded in several steps, and finally the result should be uniformly arranged and represented in the framework of a predetermined model (Farasatkhah, 2016).

Central phenomenon (the main category)

Specific contexts

Strategies Effects

Intermediary and Consequences Consequences and Causal Causal contributors intervening factors

Paradigm Pattern Diagram in Strauss and Corbin's Systematic Approach (1998) Taghi Azad Armaki & Fatemeh Sarami 33

The time of data collection lasted from January to March 2017 due to the time-consuming process of making the required coordination to complete the questionnaire by the clients, as well as the interview with the managers of the organizations and experts in this area. The average duration of conducting the interviews was 45 minutes to one hour. The sampling method for the qualitative interviews was as follows: According to the statistics provided by the Welfare Organization and the Drug Control Headquarters, the total number of the registered medical centers in Tehran province was 184 centers; they were classified into three levels. The first level is the non-governmental organizations that has received the activity license from the Ministry of Interior and are work at the national level. The second level is related to the nongovernmental organizations that receive their activity license from the governor-general and work at the provincial level. The third level is related to the non-governmental organizations that are licensed by the governor’s office and work at the city level. Non-governmental organizations involved in this study include the non-governmental organizations that are active at the first level and are working in the areas of treatment and harm reduction. According to a list provided to the researcher by the Drug Control Headquarters and Welfare Organization, the total number of non-governmental organizations active at the first level was 12, of which 9 centers were active and the others were closed or suspended for some reason. Therefore, the qualitative interviews pertaining to the managers of the NCOs active at the first level include 9 centers. In addition, the second group of the respondents of the present study include a group of experts in the field of addiction and especially in the treatment domain. To this end, according to the researcher’s request from the administrators in the area, including the managers of the non-governmental and private organizations, the managers of the Welfare Organization's departments of Fighting against Drug and the Drug Control Headquarters, a list of experts in the field was provided to the researcher. This method is in fact a homogeneous sampling method that is used in the qualitative methods. The homogeneous sampling method is a qualitative sampling method that involves selecting the individuals in a subculture or the individuals with many common characteristics. When a particular group is examined, for example, when the specialists in a field are interviewed, this method has been used (Gustavsson, 2007). Finally, after conducting 7 interviews and reaching the data saturation stage, the data collection stage was stopped. This occurs when more data that develops, modifies, increases, or adds to the theory are not entered into the study and do not change the existing classifications or do not make a suggestion to create a new classification (Gustavsson, 2007). Qualitative data analysis was performed after open coding steps, i.e., the collected data were listed in the form of precise, explicit, and short propositions. Then, the propositions were converted into subcategories according to their contents and concepts. . These subcategories were converted into major 34 Research on Addiction Quarterly Journal of Drug Abuse categories and cluster categories were extracted from them and formed the final skeleton of the research model.

Results After conducting the interviews, coding, categorizing, and reaching the cluster categories, the researcher achieved the paradigmatic pattern considered by Strauss and Corbin. In this model, the main category is a central phenomenon that is explored in the condition and context. In the current study, it is the examination of the sociological dimensions and functions of the NGO’s in the field of drug addiction. The causal conditions are the main causes and contributors from which the phenomenon under the exploration arises. Strategies mean that actors what behavioral and tactical strategies take due to causal conditions, and what measures and tactics take in the context and circumstances in which they are located? The underlying conditions are the conditions in which the conditions and contexts affect the main phenomenon and the intervening conditions mean the general moderating factors (Farasatkhah, 2016).

Causal conditions: how to obtain financial resources, the manager’s social relationships, the manager’s social background, the manager's Underlying Intervening social capital conditions: conditions: organizational the system order, providing of salary updated and and wage, diverse therapeutic specialism services, customer Phenomenon: The function of the NGOs in the field of addiction satisfaction, in the specialized treatment- institution knowledge of the institution members, the manager’s providence, performance Strategies: Communicating with the governmental organizations, evaluation, system communicating with the non- governmental institutions, communicating with international communities

Consequences: Structured and desirable function of the NGOs

As shown in the above model, there are several concepts effective in functions of the NGOs active in the field of treatment. Accordingly, these Taghi Azad Armaki & Fatemeh Sarami 35 organizations can be categorized based on the emphasis on these components to enhance their therapeutic functions: 1. Structured Non-governmental Organizations: The existence of the fundamental components including specialism, the manager’s personal characteristics, and the organizational order, not in the sense of what is implemented in the private organizations to achieve the maximum profit or is implemented in the governmental organizations with the aim of obtaining power and hierarchal decision-making; rather, the existence of an institutional order in order to better implementation of the treatment and rehabilitation process for the addicts are among the variables that can be considered as the factor for creating differences and categorizations among the active institutions in this domain. The meaning of specialism is not necessarily the relevant education in this area, although the results of the interviews, whether with the experts in this domain or managers, indicate that the existence of experience and expertise together can be a factor in the advancement and success of the NGOs in the area of treatment; as Afshar (Assistant director of demand reduction and development of public participation in the Drug Control Headquarters) also pointed out: "managers of the NGOs are divided into three categories: 1. The experienced managers who are the improved addicts; the specialist and scientific managers; 3. Managers who enter into this domain merely for the benevolent intention. All three categories are needed and an integrated look in the management of the nongovernmental organizations leads to its definite success, because no one succeeds alone. The results and statistics also confirm this". Or, according to one of the managers of the nongovernmental treatment organizations: "With regard to the use of individuals and scientific methods, our experts are all specialist and have academic education, and we use experience only when communicating with consumers. For example, our rescuers do not necessarily have education, however, they have experience that is very helpful". The manager's features included categories such as manager's social relationships, individual social capital, social background, and futures with varying qualities and degrees existed in the managers of the institutions. This difference caused the difference in performance, the degree of acceptability, and success of the studied institutions. In the following, some quotes from the NGO managers are mentioned: "I am so capable that all the people who once opposed my methods and my speeches, today are my best friends and colleagues. The conscious manager must make the opponent person to a consonant person". In this area, you should not make enemy for yourself, or you will not be able to continue". Society is in critical need of us, and we should not deprive the society of these services by making hostility. You must be able to show yourself and build trust, and all of these require the power of having social relationships”; "you should not enter to this area with hostility. Rather, the NGOs, as the interface between the government and the people, should use their relationships and social status effectively in order to take the people's voices to the statesmen 36 Research on Addiction Quarterly Journal of Drug Abuse more easily”. Moreover, the results of the qualitative interviews revealed that these organizations have a specific position and significant relationships in the international community, which is also important for promoting the status of the state. 2. Unstructured Non-governmental Organizations: This group of the non- governmental organizations does not have some features that can improve their structure to an organization. The most important distinction between the first and the second form of the nongovernmental organizations is the feature of the institutional order, the lack of which is salient in the group of the nongovernmental organizations without structure. Furthermore, this group of the nongovernmental organizations basically lack a coherent research and development system to assess and evaluate their performance; this prevents their productivity and dynamism at the expected level. Evaluation in the nongovernmental sector leads to promoting the resource management, customer satisfaction, helping the developmental role of these organizations, stability, and enhancing their global role (Rahimi, 2006). Weakness in some of the management features is one of the important factors in their lack of significant progress in achieving their goals. As mentioned in the first category, the social relationship of non-governmental organizations and the high level of social capital are the factors behind the success and acceptability of a non-governmental organization in public and governmental opinion. Because it primarily leads to attract the financial resources, which is one of the fundamental concerns of the group of the community-based nongovernmental organizations. "I have a social fear and I cannot speak in some places. I can say that I have been unsuccessful in 30 to 40% of my social relationships. Perhaps, if my social relations was better than this, I would be much more successful in my work. Most of the obstacles in my work is because of this weakness". The structural weaknesses has led these NGOs to be dependent on the governmental assistance to provide their financial resources. As a result, they structurally become the dependent governmental organizations and, in practice, turn into the governmental organizations. In addition, weaknesses in networking is another weakness of this type of the non-governmental organizations. The quotation from one of the managers of this group of organizations was as follows: "Our main financial source is the subsidy that we receive from the welfare organization. These days, due to the inflation, the benefactors also do not help much, but sometimes the consulting groups, the mosque, and Hosseiniyeh (a religious place), give some non-cash aids. There is no financial and economic benefit here; we only obtain our daily expenses. Here, the cost is 5000 dollars annually. If the government supports us, we can expand our service and reduce the burden on the government, but unfortunately there is no support. Our institution receives financial assistance from welfare organization". Moreover, Abbasi's idea (Director General of Treatment and Social Support of the Drug Control Headquarters) about this category of nongovernmental Taghi Azad Armaki & Fatemeh Sarami 37 organizations was as follows: in Iran, the nongovernmental organizations are a kind of labor market. In fact, some people who could not be attracted by the government for any reason turned to non-governmental organizations, most of them were looking for income, or gaining credit and reputation, as a result, they face several the difficulties. Because they did not have the items such as being optional, voluntary, and financial support, and are dependent on the government day by dat. As a result, the service quality decreases, and achieving the primary goals is not easy due to the occupational and economic perspective. Today, if the non-governmental organizations in the treatment domain do not have the governmental support, they will be closed, except for one or the two of them whose owners are wealthy". 3. Semi-structured Nongovernmental Organizations: These nongovernmental organizations have in-between features of the previous two forms. This meant that they do their best to develop their qualitative and quantitative services, and they sought to recruit specialist forces and evaluate their performance in order to improve their conditions. However, the weakness in the networking of the internal relationship with other branches throughout the country, as well as the lack of a coherent environmental relationship with other nongovernmental organizations prevented them from rapidly improving their performance. Another point that places these nongovernmental organizations in semi- structured status was the weakness in some of the features of the manager of the organization, especially the type and the extent of their social relations network. In the following, two quotations of the managers of this category of organizations are mentioned: "I am very interested in doing this and I hold meetings several times a year, but because there are divergence and a destructive look, it does not work"; we have relationships, however, they are not systematic and network-based. Informal relationship is high. We introduce references to each other, but there is no scientific relationship". As previously mentioned, this factor is one of the most important factors in the success of the performance and the level of acceptability of nongovernmental organizations by the society and even the state. This determines the progress of many other factors, including how to provide the financial resources, gaining the international status, and attract the expert volunteers.

Discussion and Conclusion As noted above, from the human perspective, the definition of civil society is identical to the public sphere, and therefore the public sphere includes the responsible activities in the private sector; for example, the voluntary businesses and groups that create a public voice and a shared space. A public sphere is similar to a civil center, a center where people can talk freely, honestly, and hopefully with the order about the issues influencing the society (Geisler, 2006). Finally, it can be stated that in spite of the shortcomings and problems that the NGOs are struggling with for various reasons, the quantitative and qualitative 38 Research on Addiction Quarterly Journal of Drug Abuse growth of these organizations is a great step toward the development of the country and the creation of the necessary contexts for people’s demand about the government’s services and, as a result, getting the governmental sectors smaller, and the increasing presence of people in various domains to solve the problems especially the social problems. The way for stability and internalization of the cultural affairs structurally and organizationally is through civil institutions. Civil communities are both a place for the presence of the ordinary people and a place for the elite’s interaction at the multiple levels. In a society where the conflicts and disagreements in solving the social and cultural problems are high, civil institutions play a mediating function and role (Azad Ermaki, 2011). The non-governmental organizations inform the people of the society and creating this awareness is accompanied with the demands of the people, and these demands make the government accountable. Informing the public strengthens the people’s monitoring of the society and the social disorders and problems dramatically decreases by the dominance of supervision. The powerful existence of the civil institutions and their interaction and conflict with the government institution can lead to the formation of the public sphere considered by Habermas and consequently to the social democracy. If people are not allowed to perform social activities or be isolated, they cannot rely on the support of the social networks. On the other hand, becoming a member of any social organization can bring a lot of resources to people. Using social capital by poor people can be utilized as an important tool to remove poverty. So, why this efficacy should not be taken into consideration in the anti- addiction programs? Undoubtedly, the future perspective of the management of addiction should focus on a new definition of the role of government and people on the one hand, and society and the economy on the other hand in the programs to fight against addiction (Civil, 2005). Encouraging these non-governmental organizations by the international communities to observe human rights standards and the approved principles and values in the treatment of drug addicts, the comprehensive and widespread look of the non-governmental organizations and paying attention to the prevention in addition to treatment, avoiding them from trial and error in the treatment has strengthened them during these years and they were assigned an international seat. Furthermore, according to the law of the 6th Development Plan, by the end of 1400, the government must reduce the addiction by 5% each year. In this program, it is emphasized that the people’s capacities should be utilized to reduce the addiction rate by 25% by the end of the sixth program. Based on the proposed model in the research findings, how to provide the financial support, the manager’s social relationships, and the manager’s social background were the main factors that directly affected the function of NGOs. Moreover, as stated in the categorization of the NGOs, the existence of components such as specialism, the manager’s personal characteristics, and the organizational order mean the existence of an institutional order in order to better Taghi Azad Armaki & Fatemeh Sarami 39 implementation of the treatment and rehabilitation process for the addicts were among the variables that have caused the creation of differences and categorization among the active institutions in this area. Specialism and the provision the up-dated services in the field of treatment as well as performing the performance evaluation measures on a regular basis are among the conditions and contexts that can enhance and improve the effectiveness of these organizations. Unfortunately, the weakness in the specialty and the estimation of the performance is one of the components that is considered among the deficiencies existing in most NGOs, especially in the area of treatment. The presence of this component in the structured nongovernmental organizations is one of the factors behind their success. Finally, it can be stated that assigning the social affairs to the NGOs have many benefits, among which are the deep understanding and recognition of the civil institutions of the social issues, increasing the public support, both financially and voluntarily in the area of social issues, increased concern for providing the quality services, and the increased public demand for conducting the effective interventions, and demand from the public towards the civil society until achieving the results. Finally, referring to a study titled "The Non-governmental Organizations in 2025" is fruitful; in that study, Anheier (2013) examines the role of these organizations in the future. In order to reach a precise answer, he examined the role of these organizations in the past and today in several respects: first, the non-governmental organizations have increasingly turned to an important part of the public management; some refer to it as the economy of the general welfare. Anheier considers the significant presence of the nongovernmental organizations in the domain of public health and welfare, as the producers who provide the most effective and reliable goods and services to the public, cost effective and profitable for the governments. Second, non-governmental organizations are essential for building a civil society, strengthening the social capital, and developing economies. Assuming that people, involved in the massive social networks, are not only less vulnerable to social harms, but economically are more efficient and politically show more involvement. Third, the existence of non-governmental organizations is essential for creating social legitimacy. Nongovernmental organizations are in fact a tool for creating transparency and increasing the legitimacy of the governments. Fourth, non-governmental organizations act as a source of innovation to solve the social problems. Indeed, non-governmental organizations offer better and more effective social innovations in comparison with the governmental organizations. The reason for this is the smaller scale and their closeness to local communities and people, which has made them more creative social actors in solving social problems. Reference Anheier, H. (2013), The Nonprofits of 2025, Stanford Social Innovation Review, September, Stanford University. 40 Research on Addiction Quarterly Journal of Drug Abuse

Anheier,H and Salamon, L. (2006) The non-profit sector in comparative perspective. In: Powell W and Steinberg R (eds) The Non-Profit Sector: A Research Handbook. New Haven, CT: Yale University Press, 89–116. Azad Ermaki, T. (2011). Iranian Hangout and Modernity. Tehran: Avaye Noor Publications. Falbab-Brown, Vanda. (2009). Shooting up: Counterinsurgency and War on Drugs: Brookings Institution Press. Farasatkhah, M. (2016). Qualitative Research Method in Social Sciences with Emphasis on Grounded Theory Method (GTM). Tehran: Agah publication. Geisler, R. (2006) Civil Society and Social Capital in Upper Silesia, A Region on its Way to the European Union.. East European Quarterly, Vol. 39, Issue 1 (Spring), pp. 103–127. Gustavsson B.(2007). The principles of knowledge creation: research methods in the social sciences. Cheltenham, Glos, UK; Northampton, MA: Edward Elgar. Habermas,J. The Structural Transformation of the Public Sphere,(1989) Cambridge: MIT Press. Hashemi, A., & Mokhtarian, H. (2010). Drug Economics; Cost Estimation. Social Issues in Iran (Social Science Letter), 1 (4), 151-175. Holab, R. (1996). Habermas, J.: A Critique in the Public Sphere, Translated by Hossein Bashirieh, Tehran: Nay Publications. Keshavarz Mohammadi, N., Zarei, F., & Parsinia, S. (2013). Health Education and Health Promotion in Iran: Past, Present. And Future. Journal of Health Education and Health Promotion, 1 (2). 5-8. Madani, S. (2005). Examination of Management Experience in Decreasing Demand for Substance Abuse during the Two Decades of 1979-2001, Center of Education and Research on Substance Abuse and Drug Dependency: Dariush Institute, United Nations Office on Drugs and Crime (UNODC) in Tehran. National Committee for Addiction Treatment (NCAT) (2011). Addiction treatment is everybody’s business. Retrived form NCAT website: www.ncat.org.nz Piran, P. (2000). Participatory Methods to Study Poverty: Annals of Poverty in Iran, Tehran: University of Welfare and Rehabilitation Sciences. Razzaghi, E., Rahimi Movaghar, A., & Madani, S. (2003). Report on the Rapid Examination of the Substance Abuse Status in Iran. Prevention Department of the Welfare Organization of Iran. United Nations’ Drug Control Program: Tehran. 176-178. Roshan Pajuh, M. et al. (2013). The Comprehensive Document on the Treatment and Social Protection of Addiction. Drug Control Headquarters. Roshan Pajuh, M. et al. (2015). National Survey of Households on the Prevalence of Substance and Psychotropic Use in the General Population of the Country: Drug Control Headquarters, General Office for Research and Education. Saberi Zafarghandi, M., Roshan Pajuh, M., Mirkazemi, R., & Bolhari, J. (2013). The Main Challenges Facing the Program of Integrating the Drug Demand Reduction of the Primary Health Care System in Iran: Report of a Specialized Meeting. Iranian Journal of Psychiatry and Psychology, 4 (4), 326-329. UNODC Research. (2000). World Drug Report. Retrieved from United Naition Office on Drugs and Crime Website:http://www.unodc.org/unodc/en/data-and-analysis/WDR- 2000.html UNODC Research. (2017). World Drug Report. Retrieved from United Naition Office on Drugs and Crime Website: https://www.unodc.org/wdr2017/field/WDR_2017_presentation_lauch_version.pdf Viterna, J. Clough, E and Clarke,K. (2015). Reclaiming the “Third Sector” from “Civil Society”: A New Agenda for Development Studies. Sociology of Development, Vol. 1, No. pp. 173-207. World Health Organization(WHO). (2010). World Health Report. Retrieved from WHO website: http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en/

Abstract Jurisprudence Objective: Due to various factors, such as the easy production of narcotics, the issue Fundamentals of the of addiction has become more prevalent in all human societies, including Islamic Prohibition of Drug Iran. Therefore, the present paper examines the jurisprudential principles of Use the prohibition of drug use. Results: From the public and certain Quranic verses, one can explicitly and clearly discover the religious prohibition of drug use. For Hashemi, H. , Mirzaei-Nejad, K. example, the pertaining reasons include the prohibition of ego-murder, the prohibition of removing wisdom, the necessity of avoiding filth and acts of evil, Hashemi, H. on top of which drug use lies. In addition, Associate Professor, Department of Law, certain hadiths also imply the prohibition Mofid University, Qom, Iran, Email: of this act, and the thinkers' rationale confirms the prohibition of this practice. Mirzaei-Nejad, K. Conclusion: The provision of the Ph.D. Student of Jurisprudence and the principles on the prohibition of narcotics Basics of Islamic law, Mofid University, can help authorities do their best to Qom, Iran eradicate this phenomenon with ease because of the availability of the religious law and religious prohibition on the use of Research on Addiction narcotic drugs. Preachers and scholars Quarterly Journal of also give religious motives to avoid this Drug Abuse act. Keywords: drug use, jurisprudential Presidency of the I. R. of Iran basics, religious prohibition, prohibition Drug Control Headquarters of self-murder, necessity of avoiding Department for Research and Education filths Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir/

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Introduction Today, the issue of drug addiction in Iran has created numerous problems. On the other hand, according to the fourth principle of the constitution of the Islamic Republic of Iran, all laws and regulations should be in accordance with Islamic principles. Therefore, it is essential to investigate whether "the ban on the use of narcotics is based on religious principles". Considering this necessity, as well as the fundamental questions in this regard, the aim of this study is to investigate the jurisprudence principles of the religious prohibition of drug use with reference to credible Islamic sources in order to overcome ambiguities in this regard. Undoubtedly, research on this subject requires a broad and innovative approach that can provide researchers with future jurisprudence principles. The fundamental question that the study seeks to respond to is: "Are there any trusted sources of jurisprudence in Islam for the prohibition of using narcotics?" According to this question, the most important research hypothesis is that Islam, as the school of thought that has put human salvation in material and spiritual dimensions on priority, has undoubtedly provided cast-iron reasons for the prohibition of drug use. Narcotic drugs have imposed irreparable damage on all countries in general and on Islamic countries in particular. The involvement of political motives in the distortion of the true face of Islam and the reversal of Islamic teachings by alien countries are among the other growing phenomena in Muslim countries. On the other hand, one can refer to economic goals in order to obtain huge illegitimate wealth that has urged death traders to produce industrial substances and change the pertaining chemical formula. With this process, they have been able to achieve different types of these substances with a different and destructive influence. In this article, we seek to explore more religious teachings and foundations in order to understand the position of Islam in relation to the use of narcotics. To this end, we will first try to introduce the most important foundations in this field; then we will discuss the Fatawa of contemporary jurisprudents regarding the use of narcotics and, ultimately, we will explain solid religious works affirming the ban on the use of narcotics.

1. Religious reasons for the prohibition of the use of narcotics In the following, we refer to various religious arguments regarding the prohibited use of narcotics.

1.1. Quranic Verses The first reason out of the four reasons used in Islamic jurisprudence is the Holy Quran. Therefore, we first discuss some reasons from the Word of Revelation that forbid the use of narcotics in any form whatsoever.

Hossein Hashemi & Kazem Mirzaei-Nejad 43

1.1.1. Prohibition of obtaining property in a void manner (unjust enrichment) One of the verses that proves the prohibition of narcotic use is Verse 29 of Al-Nesa Sura, according to which the murder of the ego is forbidden and prohibited in religious terms. The text of the verse is as follows: O' Believers, do not consume your wealth among yourselves in falsehood, except there be trading by your mutual agreement. And do not kill yourselves. Allah is the Most Merciful to you. In the exegesis of this verse, Ayatollah Makarem Shirazi states that according to this verse, any rape, fraud, falsehoods, usury transactions, transactions whose limits are completely unclear, the sale and purchase of goods with no rational and logic use, and the purchase and sale of the means of corruption and sin are all put under this general law. In addition, various narratives have interpreted the word "void" as gambling, usury, and the like, while they are the clear exemplary representations of this word, not exclusive. According to this verse, the late Saheb-e Javaher (Mohammad Hassan Najafi) has said: "Among the cases referred to by the above verse are the preservation of life, the removal of wrath and harassment, the prohibition of murder and killing, and the two narrations of Yaqub Ibn Salem and Dawood Righi are also backed up by this claim." Accordingly, it is imperative to preserve the self, eliminate the pressure and difficulty, provide comfort, and avoid self-murder. Hence, in the fatwa issued by Sheikh Alish -the scholar of Mālikī religion- it has been mentioned: "The successive use of narcotics causes some heat to be created in the body, which becomes a severe and destructive disease; therefore, it is included in the promise of God that has ordered us not to kill one another". Accordingly, we should not put the ego at some risks that lead to self-murder unless there is more important advisability, such as Jihad in the cause of God. And because the narcotics cause harm to health and well-being, and this issue has been medically proved, its use is forbidden. 1.1.2. Spirit of Islam's Invitation to Avoid Evils Islam is a religion of goodness and virtues, and the spirit of this school is not compatible with pollution. For this reason, all acts and deeds in disharmony with this spirit have been prohibited and forbidden. The following verse is the best reason for this claim: "And to those who shall follow the Messenger the Unlettered Prophet (Muhammad) whom they shall find written with them in the Torah and the Gospel. He will order kindness upon them and forbid them to do evil. He will make good things lawful to them and prohibit all that is foul. He will relieve them of their burdens and of the shackles that weigh upon them. Those who believe in him and honor him, those who aid him and follow the light sent forth with him, shall surely prosper." (Sura AL-ARAF, Verse 157). The jurisprudents and scholars interpret the above verse that the content of his invitation is in harmony with health principle. The pure items and what the 44 Research on Addiction Quarterly Journal of Drug Abuse healthy nature accepts are regarded Halal and the evil and hateful are considered prohibited. Narcotic drugs are evil, so their use is forbidden since the resulting harm is obvious to everyone and it keeps people in the chains of filth and degradation. 1.1.3. The Need to Avoid Evil Acts According to the spirit of the Islamic call that regards the stability and enhancement of wisdom as the source of human progress, any act that causes damage to this unique gem is an act of evil and disrespect, and Islam announces its dissatisfaction with the tendency toward such behaviors. The following verse is evidence of it: "Believers, wine and gambling, idols and divining arrows are abominations from the work of Satan. Avoid them, in order that you prosper./ Satan seeks to stir up enmity and hatred among you by means of wine and gambling, and to bar you from the remembrance of Allah and from praying. Will you not abstain from them?" (Sura AL-MAEDA, Verses 90 and 91). Tafsir Nemooneh says: "In Shi'a and Sunnist exegeses, there are various declarations about the first verse and are almost identical to each other. In Tafsir Dur al-Mansoor, it has been cited from Sa'd ibn Abi Waqqas that: "This verse was revealed about me; a man from Ansars (assistants) provided food for us and invited us; a crowd took part in his banquet and they drank in addition to eating his meal, which was before the prohibition of drinking in Islam. When their brains were warmed up, they began to mention their honors; little by little, the discussion became hot and came to a point that one of them took a camel's bone and knocked on my nose and broke it. I came to the service of the Prophet (PBUH) and I narrated the story. At this time, the above verse was revealed." 1.1.4. Prohibition of throwing yourself into a trap of death Self-esteem and human dignity have been emphasized in Islam in such a way that if someone is unimportant to him/herself, s/he will be considered a villain and should be avoided. In this regard, Imam Ali (AS) has said: "Do not sit down with filthy human". "Do not hope to receive good from anyone who is disgraced and humiliated in his/her own eyes". "Do not be afraid of someone who is unimportant in his/her own eyes." Accordingly, the Holy Quran has forbidden Muslims from such attributes and has not allowed them to throw themselves into the abyss of desolation. There is no destruction worse than narcotics, which not only the individual him/herself but his/her dynasty and ultimately the society will perish. The Holy Qur'an says: "Spend in the way of Allah and do not cast into destruction with your own hands. Be gooddoers; Allah loves the gooddoers" (AL-BAQARA/ verse 195). The beginning of the verse refers to the charity, but in the following, the statement "do not cast into destruction with your own hands" gives an important warning to humans. Drug addiction is one of the greatest examples of destruction and desolation. The statement "do not cast into destruction with your own hands" Hossein Hashemi & Kazem Mirzaei-Nejad 45 has a broad and wide-ranging concept that includes many other things, including that one does not have the right to drive dangerous roads (whether in terms of insecurity or atmospheric factors or otherwise) without the necessary predictions, one is not allowed to have the food that is likely to be contaminated with poison, or even to enter Jihad field without a plan and program. In all these cases, human beings will endanger their lives and be responsible. Thus, in today's society, the detrimental effects and disadvantages of narcotics have been scientifically and practically confirmed, and the consumption of drugs is, in fact, like the ingestion of dangerous poison that gradually enters the body and eventually leads to destruction or severe losses. Hence, it is forbidden and must be avoided. In the words of the late Allameh Tabataba'i, "This verse is used to deny the commission of any act that causes the destruction of human." 1.1.5. Prohibition of dementia The wisdom of humankind is a measure of good and evil, and any disruptions in the effectiveness of this valuable tool have been rejected and forbidden in the light of Islam. In the same vein, the first verse that prohibits the use of narcotics and anything that causes humankind's decline and dementia is verse 219 of AL- BAQARA Sura as follows: "They ask you about intoxicating drink and gambling. Say: 'There is great sin in both, although they have some benefit for people; but their sin is far greater than their benefit". Liquor refers to any drunken substance that causes dementia because it lexically means "to hide and cover". All the drunken substances cause mental deterioration and deter the distinctive power of the good and bad deeds of mankind and take away the power of thought and perception. "Slip" also refers to guilt and sin; that is, a condition which leads to the deprivation of humanity from gaining charity and causes wrath and distress to mankind. When this state comes to human wisdom and soul, it prevents them from reaching the main purpose of creation, i.e. human perfections and inflicts great harm to the body and soul. According to this verse, alcohol and narcotics religiously forbidden and banned since they impose many losses, cause the dementia of the human mind and perception and understanding, and dominate the false and transient lusts to social and normal behaviors in humans. 1.2. Narratives The second reason that the Islamic jurisprudent refers to is the narratives that have been left by the immaculate leaders. As the use of narcotics is prohibited from the Quranic point of view, narratives have also emphasized this prohibition the same as divine verses. Although narcotics have not had such a wide extension at the time of the well-known prophet of Islam (PBUH) and Imams (AS), many narrations in this regard have been quoted from the well-known Prophet Muhammad (PBUH) and the Imams (AS). 1.2.1. The first category of narratives The Shiite jurisprudent, late Mirza Hussein Noori, has narrated some statements in Mustadrak Al-wasa'il that confirms this claim that the use of narcotics is 46 Research on Addiction Quarterly Journal of Drug Abuse forbidden from the Islamic point of view. Below are some of these narratives: 1. "Ahl al-Bayt narrates that the Prophet (PBUH) has stated: One day will get for this nation when they use something called Bang (hashish); I hate them and they also hate me." 2. "You can say hello to Jews and Christians, but do not say hello to the person who uses cannabis (bang)." 3."The one who belittles the sin of taking cannabis is a disbeliever." 4. "A person who uses cannabis (Bang) is as if s/he has destroyed the house of Ka'bah seventy times and has killed seventy angels and seventy prophets, has set fire to seventy volumes of Quran, has thrown seventy rocks to the Lord, and s/he is even more distant from God's mercy than a sot, a usurer, and an adulterer." 1.2.2. The second category of narratives The following narratives also indicate the religious prohibition of the use of narcotics: 1. "Beware that any type of inebriant substance is forbidden and any kind of narcotics is forbidden. If something is inebriant in quantity and its small amount is forbidden as well". 2- "Anas ibn Hazifeh says that he wrote a letter to the Messenger of Allah (PBUH) on the subject that after the boycott of wine, people have turned to other drinks that are made from dates and raisins and are inebriant. These beverages are cultured in jugs of pumpkin, containers lined with crude oil, and vegetable containers, and are then poured into a musk, their lids are covered, and are offered to people." This news came to the Messenger of Allah (PBUH). Then, the Prophet rose up among the people and said: "This act (ugly) is done by those who are from the hell. Beware that any Haram, any lethargic material and any narcotic substance are forbidden. If something is inebriant in quantity and its small amount is forbidden as well". 1.2.3. The third category of narratives In the book, entitled "Tuhaf al-Uqul" authored by the late Hassan ibn Ali, known as Ibn Shu’bah Harani, and the book, entitled Wasā'il al-Shīʿa authored by Sheikh Al-Hurr al-Amili, this narrative has been mentioned: "Imam Sadiq (AS) narrates that eating what is harmful to human beings from herbs and vegetables, such as lethal poisonous plants, oleander, and the like, is forbidden." 1.2.4. The fourth category of narratives The fourth category of narratives banning the use of narcotics is as follows: 1. Imam Reza (AS) in a relatively long narrative expresses the philosophy of prohibited and halal foods for any kind of food or drink that has harmful to the body and mind: "May Allah have mercy on you, that the Lord did not allow any food and drink unless there is a favor and interest in it and did not proclaim anything forbidden unless there was a loss and destruction and corruption in it; so whatsoever that has benefit and strength for the body is lawful, and any harmful thing that destroys power or strength or is deadly is forbidden; for example, poison and dead meat and blood are prohibited." Here, although eating and drinking were initially referred to, but the whole concept is a general rule for boycotting certain objects. 2. This hadith, quoted from the immaculate Imam (AS), states that "whenever fasting harms man, then Iftar (breaking it) is Hossein Hashemi & Kazem Mirzaei-Nejad 47 obligatory" and this implies that harm to the self is forbidden; otherwise, iftar was not obligatory. If fasting with all its grandeur it is harmful to the body, it will be prohibited; thus, narcotics that destroys the foundation of the body and human life will be preferably forbidden. 3. Take care of refugees like yourself and do not harm them as you do not like you get harassed. According to the two above-mentioned hadiths, we find that anything harmful to human beings is forbidden, even if that thing is as obligatory as fasting; so, in the case of narcotics, as it hurts to the body in all its aspects, it can be said that its use is forbidden. 1.3. Rationale The third reason used for the issuance of the jurisprudent in the Shi'a school is the rationale by scholars that is used herein in the case of ban on narcotics. Terms, such as the construction of rational, general rationale, practices of rationale, approach of rationales, generality, rational conduct and action, etc., which are applied by the Shi'a religious scholars in the past two centuries, are in fact the same as generality or a branch of the generality, and it is defined as follows: "The rationale is the continuity of practice and the general method of logic and reason in conversations, transactions, and other social relations without regard to their religion and nationality"; "In other words, the meaning of the rationale is The continuity of practical action by scholars to us, i.e. a method and practice that is permanent and everywhere." However, some analysts claim that the rationale is of the orbit of the validity whenever the discoverer of the decree has obtained confirmation by the immaculate Imams since narcotics did not exist in the present form at that time. Therefore, it must be remembered that the infallible Imams (AS) have never confirmed any harm arising from the use of any kind of harmful substance. Hence, it is possible to observe their approval of the prohibition of narcotics as well. Therefore, it must be said that the rationale has always emphasized the prevention and prohibition of narcotics during history because one of the major concerns of the current world is the problem of narcotics, which has attracted the attention of the various strata of the population, the authorities of the armed forces, and international organizations due to global, psychological, financial, personal, family, legal, and social consequences of consuming these substances. In this regard, they have taken a wide range of measures to combat this phenomenon where numerous governmental and nongovernmental organizations have embarked on combating this phenomenon. In addition, journals, Broadcasting Organization, and religious leaders and scholars have talked about the harmful effects of narcotics, and addicts in the Islamic system are the most hateful people, and even women, children, fathers, and mothers suffer from addicts' problems. The importance of the case is so serious that all executive agencies have mobilized all capacities in favor of the health of the community and have mobilized all relevant organizations to prevent and combat 48 Research on Addiction Quarterly Journal of Drug Abuse this evil phenomenon. Moreover, throughout the world, despite the lack of common religious beliefs in this regard, there is a consensus because it is a rational belief. 2. Fatawa of contemporary jurisprudents regarding the prohibition of narcotics use Jurisprudents of the Islamic world, who have historically been the main contributors for the protection of intellectual and ideological frontiers, have also been vigilant in dealing with narcotics and have rescued practitioners from wonder and confusion. Of course, it is worth noting that almost all the authorities agree on the prohibition of narcotics. Here are a number of some of the fatawa issued by great contemporary Marjaswho have responded to the religious question of drug use: 2.1. Imam Khomeini a) The distribution of opium and heroin among our youth will destroy our nation. They themselves should see the issue and withdraw from drug use before they come to God's punishment and receive the whip. It is a felony, this is the invitation of our youth to destruction. It is the generation's corruption. b) This (narcotics) is a source of corruption; corruption must be eradicated to improve others. 2.2. Ayatollah Khamenei The use of narcotics is banned considering their harmful effects, such as the many personal and social costs involved in their use; for this reason, it is prohibited to gain revenue through the trafficking, maintenance, purchase, and sale, etc. of narcotics. 2.3. Ayatollah Makarem Shirazi Ayatollah Makarem Shirazi's view about the religious law of narcotics is as follows: a) "Drug use is one of the prohibited cases and various religious arguments point to its definite prohibition. It is imperative for all Muslims to avoid these evil things. Children, relatives, and friends should be strongly discouraged from narcotics. Anyone who contributes to cultivating, procuring, trafficking, and distributing these substances will be subject to divine punishment. Any revenue obtained from the issue is forbidden and illegitimate." b) Narcotics are banned in any form and any case, and the task of all those who are in charge of spreading it in any way is prohibited; their transactions are certainly forbidden. Drug cultivation is forbidden in the current conditions, and its agents' affairs are also forbidden. These acts are, in fact, similar to what the Prophet (peace be upon him) says about the wine that Allah has cursed ten tribes in relation to wine, that is, he has made away his mercy. Narcotic drugs are the same as and even worse than wine, and if such conditions were at the dawn of Islam, more severe Quranic verses would be revealed about narcotics; and this decree is well understood from the current principles of Islamic jurisprudence. The use of narcotics is one of the definite prohibitions of Islam and its material, spiritual, social, and economic losses are not hidden to any wise person; worst Hossein Hashemi & Kazem Mirzaei-Nejad 49 of all, the narcotics have become one of the most destructive colonial means." c) "The use of narcotic drugs and any activity around it are forbidden and among great sins, and the use of ecstatic and harmful pills is not permissible if there is significant harm or a source of corruption." 2.4. Ayatollah Boroujerdi "I have always written: It is necessary for Muslims and even all wise individuals to save themselves from these deadly poisons." And he has stated elsewhere: "Anything that eliminates wisdom is forbidden in Islam." 2.5. Ayatollah Fazel Lankarani "The use of narcotics in so far is not allowed at all as it impairs essential harm on the human body, disrupts all normal and natural personal and social affairs, prevents humans from performing their religious duties and affairs, and brings about other injustices." 2.6. Ayatollah Safi Golpayegani "The harm of these deadly toxins and their dangers to religion, faith and honor, independence, health of the soul and body, and all aspects of the society are clear. Any acts and transactions that cause the Islamic community to be deprived of immunity and lead to the risk of suffering from addiction to this poison are strictly forbidden. And forbidding wrong and preventing it, besides being a direct duty to the government, is obligatory to everyone according to religious rules and everyone should prevent this evil and other similar ones which would corrupt and ruin the Islamic ethics of society." 3. Religious works on the prohibited use of narcotics in different jurisprudence doors In various jurisprudence doors, it has been numerously quoted from Sunni and Shi'i religions about the effects of narcotics and their prohibition, each of which is briefly summarized here. 3.1. Ta'zir and Had The difference between the prohibited acts that create addiction in the self and the prohibitions that do not create addiction, including eating blood and dead meat should be assigned credit. If it does not create addiction, it should receive the religious penalty of Ta'zir. However, if it leads to addiction, it will receive the penalty of Had in addition to natural and religious punishment (cannabis consumption lies in this category). 3.2. Diyeh "Mobnaj refers to someone who seduces another person to drink something that removes wisdom. In this situation, the person has committed a felony similar to someone who has consumed hashish because it has caused a defect in his/her wisdom and body. Therefore, s/he must receive the penalty of Ta'zir and if someone has taken something secretly, his/her hand should be cut off after returning that thing."

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3.3. Food & Beverage a) "Small-scale and large-scale toxic substances are prohibited; however, eating small amounts, such as opiate, socmonia, and conium can be allowed when combined with other stuff. And every amount that is likely to harm the body or mind is not allowed." b) "Everything that is harmful to the body or the mind, such as stones, dirt, and poison is forbidden, even though it is a small amount unless it does not harm to the body and/or mind (Example: Large amounts of substances harmful to wisdom, such as opiate, nutmeg, ambergris, saffron, and hashish). c) "Forbidden food and beverage are those that decay wisdom, whether they are liquids, such as wine or solid, such as cannabis and opium." 3.4. Uncleanness "And the sentence: It harms the body or the mind, what is harmful to the body, such as toxins or to wisdom, such as opium and saffron, which are clean shows that the reverence of these substances are due to their harm rather than their uncleanness." 3.5. Prayer "Someone whose wisdom is destroyed by drinking inebriant materials, consuming bang and Hashish, and other things that can wipe out the wisdom is required to restore his/her lost prayers." b) "But anybody who loses his/her wisdom and mind by drinking inebriant substances is not required to compensate for that if s/he has consumed that substance merely for the sake of healing." c) "It was asked about a person who says his/her prayers and had hashish on his/her head. He replied: "The prayer is correct and it does not have any restoration because hashish is a clean drunken substance." 3.6. Rental "When we give what we can take a halal advantage of it to someone who uses it in an evil way, his/her money is forbidden according to the definite vote of Islamic jurisprudents because of what we mentioned from the arguments above. Therefore, the money obtained from the thing whose profits are not halal (such as narcotics) is preferably forbidden." 3.7. Divorce "If someone's wisdom is destroyed by drinking bangs and lethargic substances, its divorce will not come. Abu Hanifa is on the same verdict, and Shafi'i said that if drinking is for healing and wisdom does not go away, the divorce will not come yet; however, if his drinking is for fun and entertainment, the divorce will come into play. Our reason for this is that it was said in the first question that it is a consensus; engagement is also the principle of the survival and the occurrence of divorce is necessary because there is no reason for this type of divorce to come in the religion." 3.8. Sale a) "The purchase of poisons, such as cannabis and these kinds of herbs is permissible if they are sold for beneficial purposes; otherwise, it is not permissible." b) "One of the conditions of sales and selling is profit and interest, Hossein Hashemi & Kazem Mirzaei-Nejad 51 that is, religious benefits; the purchase of poisons is forbidden whether in low or high volume if it is deadly. However, if the purchase of low amounts of these substances, such as opiate is beneficial, it will not be forbidden." Discussion and Conclusion Narcotics as a pervasive phenomenon that has caused many problems for humankind, especially Muslims, has been a matter of concern to the Islamic leaders from the very beginning of the formation of Islam; and appropriate and effective solutions have been provided to tackle it. The verses, narratives, and rationale which have always been used by the Islamic jurisprudents and scholars to deduce religious rules are the basis for the principle of the prohibition of narcotics use. Based on these principles, narcotics are forbidden and prohibited because of the harms and disadvantages caused to the wisdom, the body, the family, the community, the government, and the state; therefore, the perpetrators will undergo worldly and legal punishments in addition to religious penalties. The Islamic jurisprudents who are defenders of the boundaries of opinion and thought have reached the consensus that narcotics should be included in the category of definitely prohibited substances. It is not permissible for any Muslim to use these substances and if they use these substances, they have committed a serious sin.

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Abstract Inefficiency Analysis Objective: Drug trafficking is one of the most significant social damage that can easily of Prevention undermine the cultural and social base of a country and its human dynamism. The Programs: Qualitative confluence of the psychological, social, economic, political and cultural factors has Research made this one of the most complex social damages of recent decades in the country. Accordingly, the adoption of programs with the prevention and empowerment approach to addiction has always been the focus of Niazi, M. , Norouzi, M. , attention. However, preventive programs have not been successful at many levels. In this Sharifi, E. , Khorramian, R. regard, the aim of this study was to analyze the inefficiency of prevention programs. Method: The present study was carried out with a qualitative approach and through grounded theory. The data were collected through a deep Niazi, M. interview with 33 consumers living in Ghaleh Assistant Professor, Department of Shour camp of Isfahan as well as managers, Sociology, Kashan University, experts, and therapists in the area of addiction Kashan, Iran in spring of 2016. These sample units had been selected via purposive sampling and the Norouzi, M. theoretical saturation criterion. The data were then analyzed using axial coding. Results: Ph.D. Student in Sociology, Kashan Axial coding led to the production of 14 University of Medical Sciences, categories and 66 sub-categories, which Kashan, Iran, Email: illustrate the causal and underlying conditions, [email protected] strategies, and consequences of the inefficiency of prevention programs from the perspective of Sharifi, E. both groups of participants in the research. M.A. Holder of Clinical Psychology, Some of these categories include non- Allameh Tabataba'i University, cooperative policies, inappropriate bureaucracy, cadre-oriented and actor-oriented Tehran, Iran cultural constraints, customization, and obdurate anarchy. Conclusion: From the Khorramian, R. perspective of both groups of participants, there M.A. Holder of Cultural Management, is a dual typology of weaknesses and Islamic Azad University of Khorasgan, deficiencies in the preparation, development, Isfahan, Iran and implementation of prevention plans, which, in turn, shows the content and formal denial of plans. In the first type of the strategy, obdurate anarchy is adopted by interviewees and, in the second type of the strategy, customization and Research on Addiction acceptance of failure in dealing with this Quarterly Journal of Drug phenomenon are adopted by the interviewees Abuse where such consequences as empiricism, friendship, and escape and insignificant access to plans come into existence. Presidency of the I. R. of Iran Keywords: addiction, prevention programs, Drug Control Headquarters grounded theory Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir/ 54 Research on Addiction Quarterly Journal of Drug Abuse

Introduction The distributed statistics indicate the increase in the number of drug users in Iran (Drug Control Headquarters, 2011). Although this increase may engender less concern in comparison with the population growth and the proportion of people at risk to the whole population, the presence of some factors will deter the generation of relative peace and solace: first, different estimates have been presented by authorities and various research. Second, the national and official studies indicate a decrease in the age of onset of drug use (Narenjiha, 2007). Third, the complications of drug use, especially non-traditional substances, are increasing (Nasehi, 2013). Fourth, the prevalence rate of addiction in the world is constant (United Nations Office on Drugs and Crime, 2010). This statement refers to the stability of the status quo with the reduced prevalence of drug use in some countries versus the increased prevalence of it in some other countries, like Iran (such as Iran). Fifth, people consider it as an unacceptable phenomenon (Ehterami, & Vatanparast, 2014). Therefore, planning to reduce the incidence and prevalence of addiction and drug use has been a priority in Iran's domestic politics during the recent years. Due to the nature of addiction, this phenomenon has always been ahead of the preventive program, in such a way that new substances appear first, and then the treatment and prevention methods are provided. Over the past two decades, several preventive programs have been implemented by various organizations. However, the growth of this phenomenon is observed in the society, in such a way that we have seen a decrease in the age of addiction and also an increase in addiction among women in the society in recent years (Niyazi, Nowruzi, Zarandi, & Ataei, 2017). Despite the various methods of addiction treatment, evidence and research have shown that the most effective and the most recent treatment methods for addiction have also been accompanied by high rates of relapse. The reason is that the pathogenic environment undermine any progress made in the treatment of the addicted patients (Zavar, Habibi, & Hasanvand, 2016). Therefore, prevention provides a logical alternative for the psychological and physical immunization. The basic assumption of the prevention strategies is that prevention is better than substance abuse, and is easier, less expensive, and more effective than treatment (Younesi, & Mohammadi, 2006). Addiction prevention in fact means the primary prevention of the processes leading to addiction, including the tendency toward consume, consumption for test, occasional consumption, abuse, and dependency. In other words, addiction prevention means preventing those who have never used drug to turn into those who tend to use drug, preventing those who tend to use drug to turn into for-test consumers, preventing the for-test consumers to turn into the occasional consumers, preventing the occasional consumers to turn into substance abusers, and preventing the substance abusers to turn into addicts or drug-dependent users. To abusers and prevent them from becoming drug addicts or drug addicts (Sarami, 2010). Addiction prevention programs are designed at three levels: Mohsen Niazi et al 55 primary, secondary, and tertiary with awareness-raising, affective training, substitution development, and social influence approaches. The goal of primary prevention is to keep the healthy and non-addicted people away from drug; it is provided through informing and awareness-raising methods about the high-risk behaviors and complications of drug abuse which is done by public media and organizations such as Ministry of Education, the Ministry of Health, the NGO’s, and the municipality. The goal of secondary prevention is to provide quick and timely treatment and prevent the repeated use of drugs, with regard to the target community and the amount of drug use. In secondary prevention, by reducing substance abuse and teaching cognitive and behavioral skills, efforts are made to maintain the balance in drug use and to withdraw addiction. In the tertiary preventing, the rehabilitation of addicts is done by the supporting groups (Sohrabzadeh, 2011). Today, in the area of drug prevention, most countries have abandoned the criminal prosecution and have started to address the social prevention issues, which requires the cooperation and participation of the civil society organizations, such as NGOs and community-based programs. In the current laws of our country, there are many direct and indirect mentions to the need to take preventive measures in various areas including addiction. In the constitution, attention to the macro factors in prevention can be found in the third, eighth, tenth principles, the principles inserted in Chapter III (rights of the nation), the twenty-ninth, thirtieth, and thirty first principles which obligated the system to provide the minimum basic needs. In addition, in clause 5, principle 156, the Judiciary explicitly is obligated to take the appropriate measures to prevent the occurrence of crime and to reform the criminals. Moreover, the enactment and announcement of the general policies of the system in the fight against drugs in October 2006 by the Supreme Leader has been another positive step in the codification of legal documents for the prevention of addiction (Mohammadi, 2017). During the half century after designing the first preventive plans, various programs and strategies for the prevention of drug abuse have been introduced and implemented (Botvin, Griffin, & Williams, 2001). The history of designing and implementing the first prevention programs in the country dates back to the 1980s. In that years, the welfare organization of the country implemented community-based addiction prevention programs with the health promotion perspectives and social-environmental models (Report of the Welfare Organization of Iran, 2010). However, despite the enactment of the document on addiction prevention and the various measures that have been defined, approved, and announced by the highest authorities over the past decades, for some reason such as poor convergence between different organizations and the weak presence of some of these organizations, there seems a long distance to achieve the desired results. 56 Research on Addiction Quarterly Journal of Drug Abuse

Hence, concerns about the harmful pharmaceutical, social, legal, health, and economic effects caused by substance abuse have made it necessary to take new measures to expand the preventive strategies for addiction (Amari, Pashasharifi, Hashemian, & Mirzamani, 2011). The issue of prevention can be affected from various biological-psychological and sociological aspects. Obviously, the authorities and the statesmen’s positive ideas about the cooperation of psychiatrists, psychologists, physicians, sociologists, and all important institutions including families, schools, and many related institutions can help to make the preventive programs more complete and more effective. Therefore, this conclusion that the most effective preventive method is a comprehensive and community-based approach that targets a wide range of etiology determinants is an important and beneficial point in reforming the preventive approaches. Definitely, the role of people and those who are faced with this problem and the government’s less involvement in the area of fighting against and reducing addiction lead to the success of these programs. In order to ensure about the effectiveness of training programs related to substance abuse prevention, it is essential that these trainings be carefully evaluated. Kranzelic, Slehan, & erkovic (2014) argue that investing in developing and designing the preventive training courses without the principles such as linking the courses and activities to theories and research, developing courses based on a comprehensive needs assessment, the planning and evaluating are ineffective. According to these researchers, principles and elements that are effective in preventing the high-risk behaviors should be taken into account in the courses and programs. In their studies, Buhler, Schroder, & Silbereisen (2008) considered the characteristics of an effective preventive program as related to implement the programs including the duration of the program, the frequency of the program, the size of each project, as well as the conceptualization of the programs, such as the theoretical approach in the methodology, content, and evaluation. Others, such as Tobler et al. (2000), in investigating 207 global programs for substance abuse prevention, have pointed to the size and type of the program and the evaluation of their effectiveness. What is inferred from other studies is that the prevention programs are divided into three categories of effective, ineffective, and detrimental; the programs have the iatrogenic effect in the final category. That is, the phenomenon or problem results from the program itself (Moose, 2005). Therefore, the evaluation of the prevention programs is always a necessity to find out the extent of their effectiveness and their weaknesses and strengths. Given that the preventive programs have not had much success, the prerequisite to achieve better results is analyzing the status quo in terms of the problem itself (the phenomenon of addiction) and in terms of assessing the methods and countermeasures that have been used so far. Then, by having the access to the existing documents, facilities, opportunities, etc., you should plan and offer a solution for each culture and group separately. Such a gap is now felt more than ever, because now we are faced with the complexity and negative Mohsen Niazi et al 57 consequences caused by the prevalence of drug use and also with more various problems (Sarami, 2017). In this regard, the purpose of the present study is to analyze the causes of the inefficiency of the prevention programs from the perceptive of consumers, therapists, and experts in the field of drugs through the qualitative method and grounded theory. Accordingly, the research question is presented in the following general questions: What conditions have been effective in the low efficiency or inefficiency of the preventive plans and programs? How do the participants of this study understand, interpret, mean, and represent their experience of confronting with the preventive programs? What the strategies do they take based on these mental meanings? What are the consequences of taking the above-mentioned strategies by the participants?

Method Population, sample, and sampling method In this research, the grounded theory which is a qualitative research method was used. Qualitative research refers to any type of research whose findings have not been obtained through statistical processes and for quantitative purposes (Corbin, & Strauss, 2008). Ground theory is an inductive method that develops theory from the data that are regularly obtained from social research (Glaser, & Strauss, 1967). Using this method, the researcher analyzes the studied phenomenon in its context and current situation, and the possibility to understand the social processes and the individuals’ mental nature from the phenomenon under study will be provided for him. The participants of this study are 20 addicts living in Ghaleh Shour residential-therapeutic camp of Isfahan, as well as 13 managers, experts, and therapists in the field of drug and addiction. The purposive sampling method has been used to select the participants. Among the ten strategies that Potton proposed for sampling, two strategies of sampling with maximum variety and snowball sampling were used in this study (Potton, 1994) and, finally, with considering the theoretical saturation, a total of 33 individuals was selected from both groups for the process of collecting and analyzing the data.

Procedure In the qualitative study, especially in the grounded theory, data collection and analysis are carried out simultaneously to help to develop a theory based on the data. (Corbin, & Strauss, 2008; Glaser, & Strauss, 1967). The main technique used to collect data was the deep interview. The duration of each interview varied from 70 to 120 minutes depending on the situation, the interview procedure, and the participants’ willingness. Interviews were conducted between April and June 2016. After the formation of the general lines of the interviews by concepts and categories, a series of open-ended questions was designed and this process continued until the stage of theoretical saturation. The recorded data obtained from the interviews were coded based on three stages of the grounded 58 Research on Addiction Quarterly Journal of Drug Abuse theory (open coding, axial coding, and selective coding). Moreover, to achieve the reliability criterion, three techniques of auditing, member check (Creswell, 1994), and validation of analytical comparison studies were used.

Results In the first phase of open coding, 66 codes were extracted in this study. These codes were reduced to 14 major categories in the axial coding. These categories include the following categories. Content denial, visual denial, non-cooperative politics, top-down stance, inappropriate bureaucracy, structure-oriented cultural constraints, actor-oriented cultural constraints, production-distribution and consumption characteristics of substances, lack of access and escape from the plans, friendship, empiricism, breaking the norm, customization, and surrender. In selective coding, these categories were abstracted into a core category entitled the "Content and visual Denial" of the plans. In the following, each of the categories and subcategories along with quotations from the participants were presented and explored. 1) Content denial: This category is extracted from a total of 6 more detailed concepts and refers to those cases that take into account the internal features of the programs and preventive plans, including information, training skills and methods, and services. This information usually includes knowledge about the substances and their impact, as well as local laws on drug use, and consider these features unequal and insignificant as compared to the content dimension of substance abuse and other sources. The secondary concepts of this category are as follows: (A) Lack of attention to the multi-factoriality characteristics of addiction: from the perspective of many people, the major weakness of the prevention programs is seeing the phenomenon of addiction as a single factor and devoting the major attention to the individual: "In their program, they only blame the person himself". B) The programs are not complete and comprehensive: another weakness that the clients of the prevention programs have pointed out is that the content of the programs are not comprehensive and are not consistent with the characteristics of the target group: "Only a few issues of addiction are repeated ... In decision-making and implementing the program, people who should be attended are not taken into consideration". C) Ignoring the realities of the society: the programs’ mismatch with the realities of the society. In other words, since the programs are demonstrative, many clients of the preventive programs do not pay attention to it. For example, the emphasis on the negative aspects of the substances: "drugs have also some advantages, but when they just say about its negative points nobody listens to them." Failure to introduce a suitable substitutes for drug in the programs: "Always tell about avoiding drugs, but no one tells what to substitute for drugs", and failure to talk about the problems of the addicts' life in the programs leads the clients not to establish a good relationship with them: "they do not understand the addicts and do not talk about their problems and difficulties." These three factors were the Mohsen Niazi et al 59 main factors that the clients of the preventive programs and the interviewers have pointed out and have focused on the demonstrative and formality aspects of the prevention programs. D) Content weakness of the programs: The emphasis on the poor content of the prevention programs has been a remarkable point in most interviews. Content and executive weaknesses, the repetitious state of the programs, and lack of attractiveness for audiences have led to a reduction in the scope of program’s effects on the clients: "People do not learn anything from what they say and from their programs, they always repeat the cliché. So, it is boring and tedious." E) Health / disease confrontation: According to the majority of the interviewees, the executers of the preventive programs attempt to separate the healthy and successful patients from the drug users by drawing a bipolar of health and disease. While, this way of dealing with drug users makes them to doubt about the truth of the preventive programs. The first step in the success of any prevention plan is to gain the trust and to respect the clients of the programs: "If you mean the problem of the health of the young people, I know people who both use hashish and do exercise... they're not right when they say glass is addictive." F) the scientific weakness of the programs: the lack of conformity between the programs and new sciences such as psychology and not using the specialists in planning and designing the preventive programs are other points that the interviewees have emphasized in counting the reasons for the inefficiency of the prevention plans: "Many consumers suffer from mental problems before turning to addiction. However, they do not pay attention to this issue in the programs ... the addicts themselves know and understand the substances better and more than most experts. " 2) Visual denial: This category is extracted from seven secondary concepts, meaning the structure or form of the type of program, the clients, methods, and its executive mechanisms. In this case, the visual and format aspects of the plans are evaluated unequal and insignificant in comparison with the structural dimension of the drug abuse, including the extent of production and distribution, etc. (A) Lack of informing and planning from the early ages and school: "awareness should be made in the form of formal education at schools and from the lower educational levels"; (b) Failure to follow the priority order in the implementation of the prevention programs: "Programs are not implemented according to the order of primary, secondary, and tertiary preventions"; (c) Prevention programs are not early-efficiency:" The nature of prevention programs is their late-efficiency "; d) lack of proportionality between the volume of the prevention programs and the volume of drug supply and demand in the society:" The number of prevention programs is not adequate. While, the amount of substances in the society is excessive, ". E) Lack of continuity of the programs: "The cross-sectionality of many plans makes them ineffective”. (F) The programs are not purposeful: "The programs are mostly implemented in the form of trial and error "; (g) lack of operational and functional aspects of the programs: "they only talk, they just want to report and talk about what they have 60 Research on Addiction Quarterly Journal of Drug Abuse done". There are seven secondary concepts that criticize the prevention programs with respect to their structure. 3) Non-cooperative policies: This category has been extracted from three secondary concepts and includes the factors that point to the non-cooperative view of the plans and their lack of relationship with their target group. A) Not attracting the public participation and cooperation in the prevention programs, b) lack of attention to the non-governmental organizations and groups, and c) the singularity of the official media in terms of informing about addiction are three more secondary concepts that are emphasized by the interviewees below. 4) A top-down stance: This category has been extracted from 9 more secondary concepts and focuses on the organizational policies that are based on a top-down look, being prescriptive or dominative, and being normative. The concepts of this category are: a) the lack of a sense of necessity in providing statistics and reports to the audience: "When their plans are performed, they don not talk about the results and about whether they had been useful or not. Whenever they distribute their statistics, it's okay and positive; surely, people do not trust their programs ", b) lack of attention to the role of research in prevention, c) an arbitrary look in considering addiction as a crime or an illness:" At the end, I did not understand that drug addiction is a crime or an illness. If it is a disease, why the addicts are still treated like the delinquents? Considering the designers' knowledge about the prevention program as a reference: "They think they are more knowledgeable than others, but they know nothing about the prevention," e) To politicize the prevention programs in their own favor: "Whenever they need the youth, or whenever the election is approaching, they will be compassionate and talk about preventing addiction ", and) lack of the executive guarantee for the rules and lack of continuity: "what is written in the law about addiction and dealing with it is not implemented or is temporary"; (e) The introduction and implementing the programs in an imperative manner and from a high position: "Whenever they had a contemptuous look at the young people, they failed. It is a rule. They decide and perform by themselves and they do not ask about our ideas", f) Prevention is not a priority and addiction is not a concern:" Organizations are usually involved in other problems and addiction has no place in those problems", and g) The organizations are reluctant to accept responsibility in this area and work to rule in terms of preventing: "When no organization accepts its responsibility, the results will be that". 5) Inappropriate bureaucracy: This category is extracted from a total of 7 more secondary concepts and refers to a set of problems and inconsistencies, and administrative and systemic disorganizations. The more secondary concepts include the less efficiency of judicial agents in relation to the distributors, the isolation of the programs from other macro policies, profiteering from the failure of preventive programs, weakness in management and implementation, inadequate allocation of financial resources for handling prevention, lack of Mohsen Niazi et al 61 monitoring on the programs, the inconsistency of the preventive organizations, and doing parallel work. 6) Structure-oriented cultural constraints: This category is extracted from a total of 4 secondary concepts and includes those shortcomings that the macro structures of the country have in creating inappropriate cultural conditions, and mainly refers to the predisposing and intensifying factors of drug abuse. Lack of culturalization, lack of respect for citizenship rights, unfavorable social factors and lack of access to the healthy recreation are four secondary concepts that the interviewees mentioned. 7) Actor-oriented cultural constraints: This category is extracted from a total of 4 secondary concepts and refers to the cultural shortcomings and deficiencies of the actors themselves and lack of cultural and educational skills, including youth and families. These factors are proposed regardless of the cultural facilities provided by the organizations and administrators. A) Ignorance of the society and families about the needs of the youth: "Society and families know nothing about the problems and needs of their young children"; b) Youth unawareness and weakness in behavioral and personality dimensions: "The youth morale is the morale of escape from the law and, unfortunately, many young people have poor beliefs." (C) The family's unawareness about the consequences of addiction and inattention to the prevention programs:" The society and most families are unaware and largely ignore the recommendations of the prevention programs "; and (d) the conflict of the citizenship rights and some preventive plans:" The laws and rights of citizens lead to inability in dealing with addiction”. 8) Production, distribution, and consumption features of drugs: This category is extracted from a set of six more secondary concepts and refers to the properties of substances that are effective in the stages of drug production and distribution, and plays an intervening role in intensifying or facilitating substance abuse. It also refers to those characteristics that occur after drug use and generally have an intervening role in drug abuse. Concepts such as: (a) Easy access to drugs: "As long as the mean time for access to substances is less than 20 minutes, one cannot expect the success of many of the prevention projects"; (b) The very strong distribution network for drug trafficking: "The biggest obstacle to the prevention is the strong drug trafficking gangs "; (c) Cheap drug access versus the costly prevention programs: " Many types of drugs are cheap, while programs that are run as prevention programs are much more costly. "D) Significant profitability of drug trafficking: "The profitability of drug trafficking raises the motivation and the risk of doing it and reduces the efficiency of prevention plans. E) The possibility of making industrial drugs at home with chemical compounds; and F) the variety and pleasure of the substances: "the pleasure of using substance is not comparable with anything. Everything has its specific enjoyment." These are a total of 6 more secondary concepts that has been emphasized by the interviewees in the above-mentioned category. 62 Research on Addiction Quarterly Journal of Drug Abuse

9) Lack of access to and escape from the plans: This category is a total of six other secondary concepts, and refers to the lack of diversity of the programs in order to cover all the age, sex, demographic, and geography groups, which leads to the individuals’ unwillingness to have access or use the benefits of the plans and being addressed by the plans. The secondary concepts that have been frequently highlighted by the interviewees are: (a) Lack of geographical, regional, and demographic coverage of the plans: "The plans are more targeted to men and boys," b) not covering all age groups in the plans: "With regard to the broad range of substance users, the programs do not cover all ages"; c) Gender bias: “it seems that girls and women are not confronted with addiction". d) Disciplinary measures being more prominent than the educational and training measures:: "So far, most preventive programs have been done by the police, rather than being educational," e) Escape: "Sir, what if one is not gonna prevent addiction? "; and f) attraction of the substance and the repulsion of the plans: "If someone gets involved with drugs, it is clear that he replaces the pleasure of the drugs with the words that are said in the programs. Drugs provides relaxation at least to a few hours, but what about the plans? " 10) Friendship: This category that has been extracted from a total of 2 more secondary concepts and refers to the set of actors' attitudes in referring to the friends and peers in terms of substance abuse. Two Concepts A) Referring to the friend’s perceptions: "I have learnt about the pros and cons of drugs through my friends ... friends are more likely to understand us than planners"; and (b) Lack of attention to the youth requirements have been the most frequent concepts of this category mentioned by the interviewees. 11) Empiricism: This category is extracted from a total of 2 more secondary concepts and refers to considering the immediate experience of drug abuse as a criterion for deciding about it. The importance of understanding the experience of drugs and the direct exposure to the consequences of its consumption are the main concepts that fall within this category: "nobody knows about drug and its bad consequences until he himself can experience it... Some individuals do not accept anything unless they experience mere failure. " 12) Breaking the norms: This category has been extracted from four secondary concepts, and refers to as a set of active reactions by the actors in challenging the objectives of the designs, and in some ways they can be considered as the unwanted or reverse results of the designs. Concepts such as: a) lack of respect for individuality: "Everyone has the authority of his own body; should the others decide about our bodies?", B) Excessive normalization: "the more restrictions and prohibitions, the more pertinacity will be," c) Escape from health: " We do not want to use substance because it reduces the lifetime"; and (d) Escape from coercion: it has been the most frequent concept that has been emphasized by the interviewees which are included in the above-mentioned category. Mohsen Niazi et al 63

13) Customization: This category is extracted from four other secondary concepts and refers to a process that occurs in the long term due to the multiplicity of substance abuse and has a passive and silent nature. Conformity with the community, worry about non-admission in the environment, breaking the obscenity of drug addiction, and the social acceptance of addiction are among the concepts that fall within this category: "The prevalence of drug addictions has reduced the obscenity of addiction in the society. We have seen many addicts, and it’s natural for us. Now, when all the people use drugs, we're going to use as well. 14) Surrender: This category is extracted from three more secondary concepts and refers to a process that takes the individuals into accepting the existing conditions of substance abuse, and is highly passive and sometimes even confirmatory. Concepts a) pervasive temptation: "Wherever you go, there are temptation to drag use. While I know that I cannot withdraw it forever, why do I hurt myself", b) obeying the will of the group: "When all of my friend use drugs, why should I give up? At least, I use cannabis“, and c) Lack of resistance option:" Many people under the environmental pressure and availability of conditions for drug use, eliminate the possibility of resistance". These are the three concepts from which the above-mentioned category is derived.

Discussion and Conclusion Everyday life, despite its simplicity and banality, has certain complexities and features that make it difficult to understand its details for those who live in it; in most cases, the everyday knowledge of the individuals and social groups is limited to the their knowledge about the position and the conditions of their particular social and economic status. Such social groups are less likely to speak about their special situation and the emotions resulting from it. Paying attention to the constructivism of actors and how and why they were exposed to drugs and psychedelics abuse in this study is due to the fact that the experiences, emotions, and the semantic and discourse network formed among the actors were largely a neglected topic. This issue has been a reason for developing and implementing the plans and programs aimed at preventing substance abuse, which, despite the good intentions and efforts, achieving positive results and preventive goals has been at a low level. Failure to evaluate the outcomes of the plans and prevention programs, lack of feeling necessity to explore the perceptions, the existing positioning among the youth as a group at risk, as well as lack of awareness about the need to explore the constructivism of the officials and experts who are involved with the subject of abuse as a group that employs experimental and practical measures in this regard, are among the factors that have undermined the effectiveness of preventive plans and led to the repetition and reproduction of similar preventive procedures and practices. The access to the successful prevention programs is possible when exploring the constructivism of the actors as the main performers in the field of daily life being considered as the basis for 64 Research on Addiction Quarterly Journal of Drug Abuse the preventive design and measures and the basis for decision making as the main and most direct narratives of their experiences, and give priority to them. The series of research interviews led to the discovery of a twofold typology of the weaknesses and shortcomings of the plans and prevention programs by consumers, experts, and officials. The first type observes the content denial of the designs. Interviewed people found the starting of this constructivism after experiencing drug abuse as a pleasant or relaxing experience of plans. The interviewees considered the underlying pressures and disorganizations, such as the environmental pressures and cultural deficiencies caused by macro structures, as the source of the impact; and also introduced the interventional and intensifying conditions such as consumption and qualitative features of drugs very powerful and attractive as compared with the content of the preventive programs. If we accept that everyday life is an area of conflict and consensus, then we will get a better understanding of what is called strategy. In Foucault's words, power is always accompanied by resistance, and the representation of the forms of the emergence of power often differs from what power government demand. One of the examples is the obstinate norm-breaking. Where a person, under the influence of normative content of designs, tries to dissent in his beliefs and teachings, he or she will accept the prescriptive norms. However, there are another ways of exposure to which the interviewees have repeatedly referred. In this case, the person focuses on his attitude and behavior, and the result is the feeling of hesitation and denial of the content that the interviewees have frequently talked about. The doubts and denial of the content of the plans by the individuals are correspondent with the adoption of an obstinate norm-breaking strategy, which are resulted from the following sentences: "what if one is not gonna prevent addiction?", or " we do not want to use substance because it reduces the lifetime", or ""everyone has the authority of his own body; should the others decide about our bodies?" In this case, what happens as a consequence is the reference to the personal experiences of drug abuse, or relying on the peer group’s perceptions and their behavior patterns in dealing with drug abuse or both consequence. This is the manifestation of a view that everyday life is a battlefield. The power that is seeks actions, and the actor that finds denial as a tool for the rejection of this power. In Foucault's literature, this resistance is the subject when he tries to abandon himself from the control of power and to maintain his minimum. In the context of our discussion, power here is the equivalent of a top-down policy, and it is the basis of the management and implementation of the plans that the actor starts to deny it through the obstinate norm-breaking strategy. Therefore, although one can review and recreate his assumptions under training or implementation of the plans, as it is apparent in the context of the interviews and the results of the research, when the structures attempt to employ their norms at different and diverse levels and from various channels including Mohsen Niazi et al 65 the prevention plans, they will eventually create actors who deny the content at different areas and at the conscious and unconscious levels. Denial, which by including the conflict and doubt in the content of the plans, targets the basis of the norms, and this can be very risky, because it not only does not satisfy the desired results of the designs, but also makes the concept of the norm meaningless and unstable. The second type is the visual denial of the plans. In this regard, inappropriate properties in the domain of administrative bureaucracy along with the interventions such as the production-distributive characteristics of narcotics and psychedelics and in its underlying conditions, i.e., the actor-oriented cultural constraints, lead to the visual denial of the preventive plans and the adoption of two strategies of customization and accepting failure in exposure to substances. Meanwhile, the interviewees stated that the contribution of disorganization and weaknesses in the systematic and bureaucratic dimensions of organizations is significant. But what is worth to evaluate is pointing an accusing finger at the actors and families as the underlying conditions, which is a reminder of the defensive mechanism of blaming the victim in the discussions of psychology of crime and social psychology. The aforementioned causal conditions along with the underlying factors with the production-distributive characteristics of the substances leads to the visual denial of the plans; for some, it leads to the escape from the plans compared with access to the drugs, and for others, it leads to the reluctance to the access to the plans compared with the desire to the access to the drugs. What is striking is that as long as this constructivism belong to the experts and the officials, the risk of the two abovementioned consequences of accepting failure and customization can diminish the plans to the level of working to rules. In this way, the occurrence of the customization makes the prevention not being a priority for the officials and experts, and the acceptance of failure will also result in the mere inactivity of organizations. It should also be noted that as long as this constructivism belong to the actors, the risk of the two abovementioned consequences can severely reduce the social sensitivity to addiction. Therefore, attention to the elimination of the bureaucratic constraints as a causal condition, trying to reduce the supply of substances and production-distributive characteristics as the intervening conditions, and changing the actor's awareness as the underlying conditions are important. The visual model obtained from the data on the causes and consequences of inefficiency of the prevention programs is shown here.

66 Research on Addiction Quarterly Journal of Drug Abuse

Causal conditions non-cooperative policies, inappropriate

bureaucracy

Phenomenon structure- content denial-visual the production- oriented and distributive and denial actor-oriented consumption cultural characteristics of

constraints substances

Intervening Intervening conditions

obstinate norm- breaking, Underlying Underlying conditions customization,

acceptance of failure strategies

empiricism, friendship, and lack

of access to and escape from the ces plans consequen

Figure 1: The visual Model Obtained from the Data on the Causes and Consequences of Inefficiency of the Prevention Programs Reference Amari, H., Pasha Sharifi, H., Hashemian, K., & Mirzamani, M. (2011). Investigating the Impact of Prevention Program on Risky Behaviors (Conduct Disorder and Coping Behaviors Disorder) among Adolescents at Risk of Drug Use. Quarterly Journal of Social Security Studies, 7 (26), 61-81. Botvin, G.J.; Griffin, K.W., & Williams, M. (2001). Drug abuse prevention among minority Adoleescents: Post test and one-year follow up of school-based preventive intervention. Prevention Science, 2(1), 1-13. Buhler, A., Schroder, E., and Silbereisen, R.K. (2008): The Role of Life Skills Promotion in Substance Abuse Prevention: a Mediation Analysis. Health Education Research. 23, 4, 621- 632. Corbin, J. , &Strauss, A (2008). Basics of qualitative research. Third Edition, London: sage publicatious. Creswell, J. W (1994). Research design. London: sage. Ehterami, M., & Vatanparast, A. (2014). Challenges and Strategies for Preventing Drug Addiction in the Neighborhood. Quarterly Journal of Social Health and Addiction, 1 (1), spring, 2014, 9-22. Glaser, B, G. &A. L. Strauss (1967). The discovery of grounded theory, Sterategies for Qualitative Research. London: Weidenfeild and Nicolson. Kranzelic, V. Slehan, M., F. & erkovic, D. (2013). Prevention Science as a Base for Substance Abuse Prevention Planning-Lessons Learned for Improving the Prevention.Kriminologija & Socijalna Integracija, 21(2), 61-75. Mohammadi, A. (2017). Preventing Addiction with the Approach of Socializing the Fight against Drugs and Utilizing the Capacity of Public Organizations. Journal of New Advances in Behavioral Sciences, 2 (11), September 2013, 85-100. Mohsen Niazi et al 67

Mohammadi, M., Jazayeri, A., Rafiei, A., & Jowkar, B. (2005). Research on Family and Individual Variables at Risk of Substance Abuse. Journal of Rehabilitation, 6 (1), 31-36. Moos, R.M. (2005): Iatrogenic Effects of Psychosocial Interventions for Substance Use Disorders: Prevalence, Predictors, Prevention, and Addiction. 100 (5), 595-604. Narenjiha, H. (2007). Rapid Assessment of Drug Abuse in Iran (Research Project) . University of Welfare and Rehabilitation. Nasehi, A. (2013). An Analysis of Addiction Trends over the Past Two Decades. Retrieved from the Drug Control Headquarters, www. dchq.ir. Niyazi, M., Nowrouzi, M., Zarandi, M., & Ataie, P. (1396). Qualitative Study on the Prevalence of Substance Abuse in Women's Beauty Salons and Sports Halls (Research Project). Drug Control Headquarters, Office of Research and Education, March, 2017. Patton, M. Q (1994). How to use Qualitative methods in evaluation. London: Sage. Report of the Welfare Organization of Iran (2003). Office for Prevention and Addiction affairs. Sarami, H. (2010). Comprehensive Document of Primary Prevention of Addiction. Office of Research and Education of the Drug Control Headquarters. Sarami, H., Ghorbani, M., & Minouei, M. (2014). Four Decades of Research on Addiction Prevalence in Iran. Quarterly Journal of Research on Addiction, 26, 29- 52. Sarami, H., Rahimi Movaghar, A., Rafiei, H., & Amin Esmaeili, M. (2017). Comprehensive Document of Fighting against Drugs, Psychedelics, and Prerequisites with a Social Approach. Drug Control Headquarters, Office of Research and Education, Nov. 2017. Sarami, H., Rahimi Movaghar, A., Rafiei, H., Madani, S., & Vameghi, M. et al. (2011). Comprehensive Document of Primary Prevention of Addiction. Presidential, Drug Control Headquarters, Cultural and Prevention Department, Feb. 2011. Sohrabzadeh, M. (2011). Urban Management and Prevention of Addiction. Tehran, Sociologists. Tobler, N., Roona, M., Ochshorn, P., Marshall, D., Streke, A.,& Stackpole,K. (2000). Schoolbased adolescent drug prevention programs: 1998 metaanalysis. Journal of Primary Prevention, 20, 275–336. UNODC. (2010). Recent statistics and trend analysis of illicit drug markets. http://www.unodc.org Younesi, J., & Mohammadi, M. (2006). Application of the Information Dissemination Approach in Addiction Preventive Programs among Adolescents. Journal of Knowledge and Behavior, 4 (16), 1-10. Zavar, T., Habibi Kalibar, R., & Hasanvand, M. (2016). Content Analysis of the Educational Packages of Addiction Prevention Pertaining to Welfare Organization. Quarterly Journal of Research on Addiction, 10 (39), autumn, 2016, 45 -62.

The Effect of Abstract Transcranial Direct Objective: Drug addiction is one of the most important health issues because of Current Stimulation the difficulty of achieving sustainable treatment and high rates of relapse (tDCS) on Drug Use despite the need for detoxification and medical and psychological interventions. Craving and Cognitive The aim of this study was to investigate Self-Control in the effect of transcranial direct current stimulation (tDCS) on the degree of Substance Abusers substance use craving and cognitive self- control in substance abusers. Method: This research was indeed a pilot study with randomized assignment in experimental and control groups with pre-test and post-test. The number of 40 Khosravian, B., Solimani, E. opiate dependent patients presenting to methadone treatment centers was selected by random sampling. After responding to questionnaires of craving and cognitive self-control, they were randomly divided into experimental (n=20) and control (n=20) groups. The measurement tools used in this study Khosravian, B. were Franklin's Craving Questionnaire Ph.D Student, Urmia University, Urmia, (2002) and Grasmick's Cognitive Self- Iran Control Inventory. Therapeutic sessions Solimani, E. of tDCS included 20 minutes of F3 Assistant Professor, Urmia University, anodic stimulation and F4 cathodic Urmia, Iran, E-mail : stimulation with a flow rate of 2 mA. [email protected] Results: The results of multivariate covariance showed that the mean scores of groups in the degree of craving and cognitive self-control were different in the post-test phase. Conclusion: It is hereby concluded that tDCS can reduce depression and increase cognitive self- control in substance abusers. Therefore, Research on Addiction therapists can use this treatment as an Quarterly Journal of addiction treatment method. Drug Abuse Keywords: transcranial direct current Presidency of the I. R. of Iran stimulation, drug use craving, cognitive Drug Control Headquarters Department for Research and Education self-control

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70 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction is a chronic and progressive condition characterized by features such as compulsive behaviors, uncontrollable craving, drug seeking behavior, and continuous substance consumption along with detrimental social, psychological, physical, familial, and economic consequences (Dawe, Gullo, & Loxton, 2004). According to the definition of addiction proposed by the World Health Organization in 1996, the term "addiction" is defined as "any substance that enters the living body and causes a change or modification in the existing property and activity of the living organism". The Diagnostic of Statistical Manual of Mental Disorder (5th Ed.) refers to the presence of one of the cognitive, behavioral, and physiological symptoms as the important feature of substance abuse disorder that makes people continue drug use despite the significant problems associated with drug abuse. In addition, this diagnostic manual also suggests that substance abuse brings about some metabolic changes in brain circuits (especially in people with severe disorders), which may also remain after detoxification (Diagnostic and Statistical Manual of Mental Disorders, 2013). One of the most controversial topics that we face with regard to the treatment of addictive disorders is craving, temptation, or eagerness of consumption. Tiffany, & Drobes (1991) defined craving as a term that covers a wide range of phenomena, including the expectation of reinforcing effects and a strong tendency to drug use. Hormes, & Rozin (2010) defined craving as "one's highly strong sense and urgent demand for something in such a way that it is impossible to concentrate on anything else than the subject matter". Various studies have shown that drug use craving is recognized as a central phenomenon and the main cause of continued abuse, as well as addiction relapse after therapeutic courses. Studies have also shown that the long-term use of drugs is associated with high levels of neuro-psychiatric deficiencies and there is ample evidence that there is an increased risk of cognitive impairment as a result of substance use even after addiction abstinence (Eckardt, Chen, Lin, & Yang, 2005). One of the cognitive variables associated with substance use is cognitive self- control where a wealth of pertaining evidence has shown that individual differences in cognitive self-control can play a role in the therapeutic outcomes of substance-related disorders. Self-control is an intrapersonal conflict between logic and desire, cognition and motivation, and planning and inner action whose result is the domination of the first part of each of these pairs on the latter (Gilbert, 2005). The reinforcement of the self-control belief system increases the individual's readiness to avoid smoking craving. As a result, success in reducing the smoking rate is strengthened by the belief in self-control (Shapiro, Astin, Bishop, & Cordova, 2005). Hence, individuals with low self-control are prone to turn to drug use and get trapped in subsequent problems (Gilbert & Irons, 2005). Behroz Khosravian & Esmaeel Solimani 71

According to cerebral imaging, Dorso Lateral Prefrontal Cortex (DLPFC) plays an important role in craving as well as mood and cognitive disorders (Da Silva et al., 2013). Similarly, according to these studies, some changes have been detected in brain prefrontal lobe, especially in DLPFC during addictive disorders. These cerebral changes, which are associated with drug use craving, are intensified by the strong desire for drug use and disrupted inhibition control (Jansen et al., 2013). One of the treatment methods used to regulate the DLPFC activity and, as a result, to reduce craving and cognitive disorders, is transcranial direct current stimulation (tDCS). A simple tool is used in this method, which passes a continuous and mild electric current from the head by means of the large electrodes placed on the head. The effectiveness of this method is contingent on the direction of the electric current. Anodal stimulation increases the brain activity and arousal, and cathodic stimulation, on the contrary, reduces this activity (Nitsche et al., 2003). This technique is regarded some sort of top-down processing (Moos, Vossel, Weidner, Sparing, & Fink, 2012; Wright, & Krekelberg, 2014). The logic of using tDCS as a treatment for addiction and drug craving is that the DLPFC, which plays an important role in the top-down mechanisms of inhibition control and reward mechanisms, malfunctions in these disorders (Goldestein, & Volkow, 2002). In this regard, research findings on patients addicted to alcohol, cocaine, crack or cigarette have shown positive effects of tDCS on quality of life (Klauss, Penido Pinheiro, Merlo, de Almeida, Fregni, & Nitsche, 2014; Batista, Klauss, Fregni, Nitsche, &, Nakamura-Palacios, 2015) or on drug use craving (Boggio et al., 2008; Fecteau et al., 2007; Batista et al., 2015). Fregni, Liguori, & Fecteau (2008) investigated the influence of tDCS on the reduction of induced craving by symptoms in cigarette smokers and showed that the stimulation of the right or left prefrontal cortex by tDCS results in the decrease of craving. Trojak et al. (2016) showed that tDCS can reduce the degree of alcohol consumption in alcoholic patients. Klauss et al. (2014) indicted a lower rate of relapse during six months in patients with alcohol drinking disorder treated by tDCS. In the same way, Wietschorke, Lippold, Jacob, Polak, & Herrmann (2007) showed that frequent tDCSs can lead to long-term behavioral changes, including reduced drug use craving and reduced drug abuse. In this regard, Wietschorke, Lippold, Jacob, Polak, & Herrmann (2016) showed that tDCS on the prefrontal cortex caused a significant decrease in craving for alcohol drinking. Previous studies have observed the beneficial effects of tDCS on attention and executive functions (Fecteau et al., 2007; Gladwin, den Uyl, Fregni, &Wiers, 2012), and showed that this stimulation requires high top-down cognitive control (MacDonald, ACohen, Stenger, & Carter, 2000). In the same vein, Matochink et al. (2003) argue that the consumption of drugs, such as cocaine affects those brain structures that play a major role in 72 Research on Addiction Quarterly Journal of Drug Abuse behavioral control. In this regard, it has been proven that the repeated use of cocaine brings about metabolic and structural abnormalities in areas, such as prefrontal lobes, which play a significant role in executive control. It has also been revealed that persistent drug users show several psychosocial neurological defects in evaluation tests of executive functions (Garvana & Hester, 2004). Garvana & Hester (2004) argue that the reduced ability in impulse control in cocaine addicts is associated with the reduced activity of anterior cingulated cortex and frontal lobe, i.e. two areas that are thought to play a very important role in cognitive control. In this regard, another study showed that smoking, alcohol consumption, marijuana use, and consumption of other drugs have a negative relationship with self-control (Sussman, Dent, & Leu, 2003). Chauchard, Levin, Copersino, Heishman, & Gorelick (2013) also concluded that self-knowledge, self-control, health concerns, interpersonal relationships, and social acceptance are likely to have a pivotal role in individuals' abstinence after quitting drug use. The reduction of craving is currently the first important phenomenon in relapse; and the psychological symptoms and signs which play a major role in individuals' desire for substance and the return to its use are the treatment challenges. Also, cognitive functions, such as attention, control, and cognitive resilience that lead the person to drug-related stimuli can be used to identify the factors associated with drug uses' orientation. Thus, in the present study, we aimed to investigate the effect of transcranial direct current stimulation on craving and cognitive self-control among substance abusers. Therefore, the main question of the present study is formulated as follows: Does tDCS have an effect on craving and cognitive self-control in opiate abusers?

Method Population, sample, and sampling method Regarding the nature and objectives of the research, the present study is a quasi- experimental research with pre-test and post-test, in which an experimental group and a control group existed. The statistical population of the present study contains all male abusers in Miandoab city who presented to treatment and rehabilitation centers in 2017. In this way, 40 addicts under methadone treatment being volunteer to participate in the study and enjoyed the necessary entry criteria were selected via random sampling method. The candidates who did not have the necessary criteria for entering the research were excluded and the next volunteers were replaced. This process continued until saturation. After sample selection, 20 subjects were randomly assigned to both experimental and control groups. The experimental group received tDCS. The entry criteria of the study were complete informed consent from participants, age range of 20 to 40 years, drug dependence, the fixed amount of consumed drugs (methadone, buprenorphine, etc.) until the end of the plan, and having education above primary school. Exit criteria were history of treatment with tDCS for any Behroz Khosravian & Esmaeel Solimani 73 disorder, presence of acute and chronic psychological and physical disorders other than addiction, addiction to non-opioids, history of seizure or head injury, having metal or prosthesis or cranial implantation, and being left handed.

Instruments 1- Craving Questionnaire: This questionnaire, developed by Franken, Hendriks, & Van den Brink, consists of 14 items (2002). The questionnaire has been extracted from Alcohol Craving Questionnaire, which is used for heroin dependents. However, due to its capability to measure overall drug use, it was later used to measure the craving of other drugs, as well. It examines the current state of craving and has three sub-scales, namely desire and intention, negative reinforcement, and perceived control over substance use. The questionnaire is scored based on a 7-point Likert scale (strongly disagree to strongly agree). Franken et al. (2002) obtained the Cronbach's alpha reliability of this scale equal to 0.85 and reported the values of 0.77, 0.80, and 0.75 for the components of desire and intention, negative reinforcement, and perceived control, respectively. Mousayi, Mousavi, & Kafi (2012) reported the total Cronbach's alpha of 0.96 for opium users, 0.95 for crack users, 0.90 for methamphetamine users, 0.94 for heroin inhalers, 0.94 for heroin sniffers, and 0.98 for heroin injectors. In this study, Cronbach's alpha was obtained equal to 0.90 for this questionnaire. 2. Cognitive Self-Control Inventory: This scale is a 23-item instrument and has been developed by Grasmick et al. (1993) to assess individuals' cognitive self-control. The items are scored on a 5-point Likert scale from strongly disagree (1) to strongly agree (5) where the low score indicates high cognitive self-control and vice versa. According to previous research, the factor analysis led to the extraction of only one factor. Respondents' scores on this scale show good correlation with other self-control cognitive measures and its coefficient was obtained equal to 0.81. This questionnaire has been translated and used by Aliverdinia (2009) in Persian and has been reported for acceptable content and formal content. Also, the internal consistency of the questionnaire was reported to be 90%. Cronbach's alpha coefficient of this scale was reported 0.86 in a study (Basharpour et al., 2013). In this study, Cronbach's alpha was obtained equal to 0.88.

Procedure For the conduct of the present study, the necessary permission was obtained from the relevant University of Medical Sciences and Welfare. Subsequently, the researcher presented to the addiction centers under the supervision of the relevant organizations for sample selection. Before the administration of the experiment, participants sat for the pre-test. Prior to answering the questionnaires, the respondents were provided with the necessary information about the research objectives, questionnaires, and how they were to respond to the questions. In the intervention phase, the tDCS device, namely Oasis pro with 74 Research on Addiction Quarterly Journal of Drug Abuse tDCS made by MIELEO Company was used. Participants in the experimental group were treated with tDCS from the skull for 10 sessions (one session every other day). The anode electrode (stimulating) was placed on the dorsolateral left prefrontal cortex (F3) and the cathode electrode (inhibitor) on the dorsolateral left prefrontal cortex (F4). Then, two milliamperes of direct electric current was passed from cranium for 20 minutes. Also, since this research is of an interventional nature, the ethical standards and criteria of the American Psychological Association and the Iranian Psychological and Cognitive Organization, such as informed consent, respect for the principle of confidentiality, the priority of physical and psychological health, presentation of the results after the completion of the research, etc. were observed. After completing the intervention sessions, the research variables in the post-test were measured in both experimental and control groups. Data were then analyzed using multivariate analysis of covariance.

Results The mean value of the experimental group's age was 32 years and that of the control group was 31 years; and the mean value of the consumption duration for the experimental group was 11 years and for the control group was 12 years. In addition, 11 participants in the experimental group and 12 ones in the control group were married. The descriptive statistics of the research variables are presented in Table 1.

Table 1: Descriptive statistics of the research variables for each group and test type Variable Test type Experimental group Control group Mean SD Mean SD Desire and Pretest 17.05 3.45 17.11 3.35 Intention Posttest 14.82 2.29 17.05 3.03 Negative Pretest 20.70 4.22 20.55 4.14 Reinforcement Posttest 17.47 2.52 20.44 3.89 Perceived Pretest 20.52 4.37 20.44 4.25 Control Posttest 17.64 3.40 20.38 4.29 Total craving Pretest 58.17 11.80 58.11 11.47 Posttest 49.94 7.60 57.33 10.41 Cognitive self- Pretest 65.23 12.60 71.66 14.76 control Posttest 71.05 14.89 71.05 14.85

Multivariate covariance analysis should be used to evaluate the effectiveness of the intervention. Before running this analysis, the assumption of normal distribution of the data was measured via Shapiro Wilkes test. The results indicated that the distribution was normal. Also, to test the equality of error variances was assessed via Levene's test and the results are presented in Table 2.

Behroz Khosravian & Esmaeel Solimani 75

Table 2: Results of Levene's test for examining the equality of error variances in the research variables Variable F DF Sig. Desire and Intention 1.33 33 0.25 Negative Reinforcement 0.79 33 0.38 Perceived Control 3.64 33 0.06 Total craving 0.000 33 0.98 Cognitive self-control 0.91 33 0.07

As it has been shown in Table 2, the assumption of the equality of error variances has been observed in all variables (P> 0.05). Therefore, multivariate covariance analysis was soundly run and the results showed that there is a significant difference between the two groups the combination of variables. In other words, the intervention was effective (Effect size = 0.736, p<0.001, F = 12.820, Wilks' lambda = 0.264). Univariate Analysis of Co-variance was used to examine patterns of difference, as shown in table 3.

Table 3: Univriate covariance of analysis examining the effectiveness of intervention in the research variables Sum of Mean Effect Variable Df F Sig. squares Square size Desire and Intention 38.23 1 38.23 26.01 0.0005 0.491 Negative Reinforcement 82.74 1 82.74 41.93 0.0005 0.608 Perceived Control 61.97 1 61.97 19.24 0.0005 0.416 Total craving 256.18 1 256.18 33.07 0.0005 0.551 Cognitive self-control 248.05 1 248.05 19.70 0.0005 0.422

As it has been shown in Table 3, there was a significant difference between the two experimental and control groups in the components of desire and intention, negative reinforcement, perceived control, and total craving (P <0.001). In other words, tDCS has significantly reduced craving in the post-test group. There is also a significant difference between the two groups in cognitive self-control variable (P <0.001) and tDCS could increase cognitive self-control in the experimental group during the post-test phase.

Discussion and Conclusion The aim of this study was to investigate the effect of tDCS on drug use craving and cognitive self-control in substance abusers. The findings of this study showed that tDCS has a significant effect on reducing the craving and its components in substance abuse patients. These results are consistent with the research findings reported by Boggio et al. (2008), Fecteau et al. (2007), Batista et al. (2015), and Wagner et al. (2007). In order to explain these findings, it can be argued that although the action mechanism of this method is not well understood, evidence of possible changes caused by Repetitive Transcranial Magnetic Stimulation is attributed to the effect on 76 Research on Addiction Quarterly Journal of Drug Abuse neurotransmitters and neuroplasticity of neural cells (Ziemann, 2004). Repetitive Transcranial Magnetic Stimulation has been introduced as a tool for the study and treatment of addictive disorders due to its effect on cortical irritability and dopaminergic neurotransmitters. Repetitive high frequency TMS (rTMS) has been proved effective in the change of dopaminergic neurotransmitters; and the effectiveness of rewarding and its reinforcing effect on underlying structures have been also proved in previous studies (Camprodon, Martinez.Rega, Alonso, Shih & Pascual-Leone, 2007). In order to account for these results, one can also refer to the reinforcement sensitivity theory, known as the nerve adaptation model, that views drug use craving due to the interconnection of neural circuit, neural substrate, and brain reward systems. Long-term changes in cortical irritability under the influence of rTMS on dopamine neurotransmitters can be an explanation for these results, and these are the underlying mechanisms of craving due to the high sensitivity of the dopamine neurotransmitter that lead to the increased reinforcing prominence of drugs. Amigdala, nucleus accumbens, some parts of dorsolateral prefrontal cortex in the memory, reward, and basal nodes are involved in the craving phenomenon. In particular, dorsolateral prefrontal cortex is an area that plays some part in rewards, motivation, and decision-making, and is a location for integrating motivational and cognitive information and creating preventive behaviors (Goldestein, & Volkow, 2002). In fact, stimulation in the dorsolateral prefrontal cortex can cause dopamine depletion in the subcortical lobe of caudate nucleus (Fitzgerald, Daskalakis, Hoy, &Farzan, 2008) and, then, it leads to the direct stimulation of target areas. Therefore, the effect of the stimulation also extends to the other hemisphere, and subcortical activity is stimulated in the neural network connected to the stimulation parts (Camprodon et al., 2007). In this regard, various studies (Franken, & Muris, 2006; O’Connor, Stewart, & Watt, 2009) show that rTMS in the right and left prefrontal cortex leads to the decreased behavioral activation system in substance abusers. Therefore, the decreased activity of the behavioral activation system can be used as a mediator for decreasing craving through rTMS in this area. A wealth of research in this area on animals has shown that anodic stimulation increases neuronal firing and cathodic stimulation results in contrary outcomes. Therefore, it is assumed that the increase in the activity of both the right and left prefrontal lobes leads to a decrease in craving (Fregni et al., 2008). The dorsolateral prefrontal cortex is one of the most important lobes of the prefrontal cortex and is responsible for recognizing and identifying actions, assessing the future outcomes of current behavior, and predicting outcomes and social control. Therefore, a possible mechanism that can make the stimulation of this area lead to a decrease in drug craving is that this stimulation increases social control or increases the ability of participants to suppress their tendencies. Also, according to studies conducted in this area, it can be argued that the increasing or decreasing stimulation of the left or right prefrontal lobe can disrupt the Behroz Khosravian & Esmaeel Solimani 77 balance of activity in the two hemispheres and, therefore, the stimulation of left and right dorsolateral prefrontal cortex can reduce craving for drug use. Also, the results of this study showed that tDCS has a significant effect on cognitive self-control of substance abusers. These results are consistent with the studies conducted by Sussman et al. (2003), Chauchard et al. (2013), and MacDonald et al. (2000). People with low self-control have difficulty predicting long-term negative outcomes. In this way, they review their addictive behavioral consequences to a lesser extent. On the contrary, people with high self-control are more likely to feel guilty and get motivated for treatment because they can easily identify the negative future of their behavior as harmful and costly (Chauchard et al., 2013). In this regard, Joyce, & Meador-Woodruff (1997) suggested that the cortical distribution of dopaminergic cortex and nerve receptors may lead to various patterns of cognitive disorders among drug abusers. For example, dopaminergic receptor D1 is present primarily in the anterior neocortex, especially in the prefrontal cortex. Although addictive substances have distinct effects on brain functions, they are common in some activities, such as the increase of the dopamine system. Given cognitive processes that are disrupted by narcotics through their impacts on hippocampus and prefrontal cortex structures, it has been shown that narcotics may increase apoptosis process (scheduled cell death) and neurogenesis inhibition (neural tissue formation) (Nyberg, 2012). The apoptosis process is associated with morphine-based tolerance, and the morphine apoptotic effect is blocked by naloxone (an opioid receptor antagonist) (Hu, Sheng, Lokensgard & Peterson, 2002). Therefore, electrical stimulation can mitigate the cognitive defects by coping with the apoptosis process and also facilitating the neurogenesis process. This research had some limitations, such as the employment of self-reporting tools for data collection, the lack of a sham group (sham stimulation), and the conduct of the research on one gender (men). Therefore, it is suggested that future studies employ other data gathering tools, sham group, and both genders. In addition, according to the obtained results, therapists are recommended to use direct transcranial electrical stimulation as an intervention method for the treatment of addicted people. The consideration of biological and neurological infrastructures can act as a step towards improving the treatment of substance abuse and identifying precise neurological pathways by means of advanced and advanced systems, such as functional magnetic resonance imaging and CT scan in order to determine the effectiveness of this method.

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Abstract Addict Women’s Objective: Addiction among women has extra negative damages because of its Lived Experience in essential role in family and parenting. The present study aimed to explore the factors Tehran: effective in women and girls’ tendency to drug use and to develop a theoretical Development of an model in this sphere. Method: Grounded theory, along with a qualitative research Explanatory Model method was used in this study. The addicted women presenting to Chitgar Women's Addiction Withdrawal Camp in Tehran from 2014 to 2016 constituted the statistical population of this study and 30 women were selected via theoretical sampling. Results: Three major themes, including harm-proliferation family Hajiha, Z., Bahrami Ehsan, H., (containing five categories of Rostami, R. inappropriate parenting, drug use in family, family conflict, disconnection with family, and establishment of destructive relations), vulnerable individual conditions (containing four categories of vulnerable individual characteristics, high mental pressure, self-cure, and Hajiha, Z. establishment of destructive relations), Ph.D. Student of Health Psychology, and unsuccessful marriage (containing Tehran University, Tehran, Iran, Email: five categories of unsuccessful marriage, Bahrami Ehsan, H. high mental pressure, helplessness feeling, Professor, Department of Psychology, self-cure, and establishment of destructive University of Tehran, Tehran, Iran relations) were recognized as effective Rostami, R. factors in tendency to drug abuse. Also, Professor, Department of Psychology, two main types, namely resisting women University of Tehran, Tehran, Iran (consisting of categories of resistance against drug abuse and long-term withdrawals along with slips) and submissive woman (consisting of categories of submission to drug abuse and numerous short-term withdrawals along with consecutive slips) were extracted. Finally, a theoretical model was proposed. Conclusion: According to the findings of Research on Addiction this study, it is possible to identify the Quarterly Journal of women and girls vulnerable to drug abuse Drug Abuse and set preventive planning for them. Presidency of the I. R. of Iran Keywords: addict women, damaging Drug Control Headquarters family theme, vulnerable individual Department for Research and Education conditions theme, unsuccessful marriage theme, grounded theory Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir

82 Research on Addiction Quarterly Journal of Drug Abuse

Introduction The physical and mental health of women is of great importance because of their significant role in family and parenting. Hence the issue of women addiction has always been one of the most important issues in all societies. The harm caused by addiction is highly extreme in the family and society' however, women or mothers' addiction will multiply the damage. Unfortunately, in Iran, women's addiction rates are rising. The population of addicted women in Iran in 2008 was estimated by Headquarter to be 114,000 people, that is, between 6% and 8% of the population of drug addicts (Drug Control Headquarter, 2007). But according to the latest report released by the Ministry of the Interior and Drug Control Headquarter in 2013, there are 1 million and 325 thousand addicts in Iran. If this population is considered as a household size, about 6 million Iranians are directly involved in the phenomenon of narcotic drugs. In this regard, women constitute 10% of the addicts' population (Drug Control Headquarter, 2017). Addiction was traditionally considered a male-specific disease. Although the prevalence of drug use disorders among men is higher than that in women, evidence suggests the convergence of these rates among women, especially among younger people. Women are increasingly involved with the occupations that were previously male-oriented and, thereby, they are more likely to consume drugs and alcohol. This convergence is associated with the onset of drug use at an early age. The primary use of the substance is associated with a higher risk of dependence, which is more pronounced in women than men. Addictive disorders are the main source of death in women who are more sensitive to the physiological effects of some substances than men and, thereby, they are reported to have a higher chance of the comorbidity of sexual disorders and psychiatric disorders. At the childbearing age, women are at risk for prenatal complications and even the children born with fetal alcohol effects and complications. For this reason, in terms of women's addiction, special emphasis should be placed on prevention, treatment, and research (Galanter, & Kleber, 2015). Addiction in women has widespread social and familial harm. Women who suffer from substance abuse disorders often have psychological and social characteristics that also impair their child-rearing responsibilities. In these circumstances, only the women who have long been distanced from the consumption of drugs, have received adequate support services, and have had a high income and are able to re-care their children compared to other addicted women (Grant et al., 2011). About 20 percent of adults who are being treated for substance abuse disorders are living with children. The women treated with substance abuse are twice as likely as men to live with children. Parents' abuse reduces family resources, such as food and money, and confronts parents with serious birth defects. It also provides the basis for the formation of addiction in children (Solis, Shadur, Burns, & Hussong, 2012). Family violence and physical and mental abuse in childhood, as well as birth defects in the individuals whose mothers have had a history of addiction during pregnancy are more prevalent Zoha Hajiha et al 83 than those whose mothers have experienced no history of addiction during pregnancy. The creation of genetic background for addiction in children, mother use of opium and other substances during lactation, the use of narcotics for childhood cure, inadequate care on part of the addicted mothers, poverty and poor familial conditions, divorce arising from mother addiction, and addicted mothers' prescription of drugs as a sleep drug for infants and children are among the most effective factors in addiction during childhood, adolescence, and younghood (Khajeh Daluyi, & Dadgar Moghadam, 2013). In general, female substance users refer to social stigma, humiliation, rejection from family and society, and extreme poverty as their most fundamental problems. Many women experience homelessness and physical and sexual abuse (Rahimi Movaghar, Malayerikhah Langroudi, Dalbarpour Ahmadi, & Amin Esma'eali, 2011) and, thereby, they experience employment in low- income businesses, commitment of social deviations, inappropriate family relationships, physical and mental problems, and penalty of imprisonment as consequences of the phenomenon of addiction (Danesh, Niazi, & Maleki, 2013). As gender differences are effective in the procedure of drug use onset and its withdrawal, narcotic drugs also have different effects on both genders. According to global statistics, addiction in women is more dangerous than that in men. For example, the time interval from the first experience of drug use to drug injection in men is eight years, while this process takes an average of two years in women. In this way, women become heavily dependent on drugs six years earlier than men. This makes it harder for them to cure and, thus, the physical, psychological, and social consequences of drug use are also increasing in women (Nouri, 2010). In the field of drug addiction, the most important and most effective action is the identification of the underlying factors of drug use and prevention of people from drug abuse. The prevention of the occurrence of addiction saves a lot of costs and improves the physical and mental health of the community. As it was mentioned earlier, women's tendency to drug use is increasing in Iran and women constituted about 10% of the total population of addicts in 2007. Women and mothers' addiction has more devastating and widespread effects both on the consumer and the family and society than men's addiction. In the domain of women's addiction, some research has been conducted and published to date. However, taking a glimpse of past research has shown that both the quantity and quality of research in this area generally suffer some pitfalls, Rarely can one find related studies that have taken a special look at the causes of the incidence of addiction in women and the prevalence of drug use. The selection of a qualitative method for the conduct of this research is due to the complexity and multiplicity of this phenomenon, which is completely related to the nature of the research subject. The study of some areas, such as how one experiences phenomena, such as addiction is more consistent with qualitative methods. Qualitative methods help with the revelation of the less 84 Research on Addiction Quarterly Journal of Drug Abuse well-known phenomena and also help to gain a new look on them (Strauss & Corbin, 1998, translated by Mohammadi, 2011). The in-depth study of addiction is not feasible with purely quantitative methods and existing questionnaires. The employment of observation and in-depth interviews will allow for the examination of a wider dimension of this phenomenon. On the other hand, the nature of the addiction experience is in a way that it leads the sufferer to cognitive and mental defects. This greatly affects the individual's ability to engage in quantitative pen-and-paper research that needs a strong understanding, attention, memory, and recognition. In addition, some people with substance abuse have a lower level of education and literacy and this makes them unable to respond to questionnaires soundly. All these reasons justify the need for the conduct of a comprehensive qualitative research that fills this research gap and proposes a broad and modern explanatory model for women's addiction. This model should identify the individuals exposed to harm and can be used to prevent other women and girls from substance abuse.

Method Population, sample, and sampling method The population of this study included the addicted women who presented to Chitgar women addiction center in Tehran from 2014 to 2016. The sample of this study consisted of 30 addicted women who were observed and interviewed in depth upon their consent. A theoretical sampling method was employed for sample selection method. This method is specific to the qualitative method of grounded theory. The aim of theoretical sampling is to maximize the possibility of comparing events to determine how a category changes in terms of its characteristics and dimensions. This method allows the researcher to select those sampling paths that can have the most theoretical efficiency. The theoretical sampling method is based on open coding methods, axial coding, and selective coding. The criteria for the entry of people to the research were the minimum eight days of purification and complete physical detoxification from the drugs, the minimum mental and cognitive ability to answer questions, individuals' willingness to participate in the research, and their consent to record their information. The exit criteria were a purification of less than eight days, mental and cognitive impairment to answer questions, and their reluctance to participate in the research. After each interview, the data were analyzed and the path to the next sample selection was illustrated to the person (Strauss & Corbin, 1998, translated by Mohammadi, 2011). As a general rule, for conducting qualitative research, at least 20 to 30 interviews are recommended in the data collection process (Bazargan, 2010). With regard to the research objective (the study of addicted women's experience), the research method (grounded theory), and logic of research sampling (theoretical sampling), one should select the sample units with the maximum experience in the phenomenon under study (substance use) in all the Zoha Hajiha et al 85 directions (duration, amount of consumption, injuries caused by substance use, etc.).

Instrument To do this research, in-depth interview and observation were used as data collection tools and the grounded theory method was used for data analysis. Data collection was carried out simultaneously with their continuous analysis after the first interview; and the required information was gathered using deep interviews. Each interview lasted from 30 to 60 minutes, and the total interviews were completed from July 2015 to July 2016 during one year. The interviews were conducted at the camp, as it was mentioned earlier. In the grounded theory method, the researcher should enter the interview setting with a blank mind and should have a minimum bias for the maximum discovery of concepts. In the course of the interview, based on the general purpose of the research (discovery of lived experience), participants were asked to provide information about all the previous and current pre-existing conditions associated with their addiction. By means of interview techniques, such as active hearing, feedback, and summarization by the researcher, the depth of the interviews was heightened and the process of data collection was facilitated. Then, these data were analyzed through grounded theory. In the grounded theory, data are interpreted and analyzed through data coding. The process of data coding is implemented during data collection in order to determine what data should be collected in the next step. The three stages of open coding, axial coding, and selective coding are performed on the data obtained from interviews and observations. Open coding takes place during several steps: breaking down, labeling and conceptualizing categories, discovering categories, and naming categories. After the discovery and naming of categories in open coding, axial coding begins. At this stage, using a paradigm or a pattern model, some links are established between the discovered categories and the information gets interconnected in a new method. This relationship between categories is made in the form of a model that includes five parts as follows: causal conditions (causal conditions are the events that indicate the occurrence or growth of a phenomenon and are ahead of the intended phenomenon in terms of time), grounded conditions (these conditions refer to the specific conditions in which action/interaction strategies are developed for managing, controlling, and responding to a phenomenon), intervening conditions (they are more general and wider conditions that affect the howness of acts/interactions), action/interaction strategies (they refer to how to handle, deal with, accomplish or sensitize phenomena in the background or in the particular situation), and consequences (actions and reactions). These domains deal with or control the phenomenon of addiction. These consequences may be real or implicit or be at present or in future. The bases of selective codecs have been set at the axial coding stage. In the selective coding, the focal category is 86 Research on Addiction Quarterly Journal of Drug Abuse selected and other categories get connected to the focal domain consistent with the grounded theory model (Strauss, & Corbin, 1998, translated by Mohammadi, 2011). In order to conduct the research evaluation, the criteria of qualitative research evaluation (plausibility of data, transferability of data, dependability of data, and confirmability of data) have been used. In order to confirm the plausibility of the data, member check was employed and seven professors of the University of Tehran (addiction experts) provided their opinions. In addition, peer check and reference to previous studies as a benchmark were used. To confirm the data transferability, the number and characteristics of the research participants, the limitations of the research participants, the length of the data gathering sessions, and the total time spent on data collection have been specified in advance. In order to confirm the dependability, the design path of the research, details of the data collection, and the research implementation have been specified. Finally, in order to verify the confirmability of the data, the reason for and the basis of selecting the research method, the participants, and the method of analysis have been explained (Andrew, 2004).

Results Most substance abusers were placed in the young age group of 20 to 34 years old (70%) and the lowest number of drug abusers was placed in the adolescent group aged 11 to 19 years (33.3%). The lowest onset age of drug use was 13 years old and the highest age was 42 years old. The mean value of onset age of drug use was 23.7 years. In terms of education, 13 respondents (43.33%) had degrees below high school diploma and 14 participants (46.66%) held high school diploma degrees; three of them (10%) had a bachelor's degree, and none of them had a degree higher than bachelor's. In terms of marital status, 9 respondents (30%) were married, 10 ones (33.33%) were divorced and 11 ones (36.66%) were single. The number of five married and divorced women (26.31%) had no children, six of them (31.57%) had one child, six of them (31.57%) had two children, and two of them (10.52%) also had three children. A total of 19 children were boys and 5 of the children were girls. The number of 18 participants (60%) were self-employed; 8 ones (26.66%) were secretaries, accountants, and salespersons; two participants (6.66%) were hairdressers; and four participants (13.33%) were nurses and house cleaners. Four participants (13.33%) were living by means of stealing and selling subsistence goods. Only three participants (10%) had state-owned businesses and 9 ones (30%) were unemployed. Regarding residence status, none of the respondents were living in the north of Tehran. Three participants (10%) were living in East of Tehran, two participants (6.66%) were living in the west of Tehran, 9 of them (30%) were living in the south of Tehran, and 10 ones (33.33%) were residents of the cities other than Tehran but were temporarily living in Tehran. Due to the lack or absence of women's addiction centers in the cities, all women from the cities Zoha Hajiha et al 87 other than Tehran had relatives or friends who had introduced them to Tehran because of being acquainted with this drug addiction center. Six participants (20%) lived in the State Welfare Organization of Iran or were homeless and did not have a definite living status. The number of 30 interviews was conducted with these individuals and each of these interviews was analyzed independently. The process of conducting interviews was that the researcher carried out 25 interviews with addicted women and saturation was achieved in terms of the discovery of concepts and categories related to drug use in addicted women and girls. No new concepts were added to the research and no new categories emerged with the conduct of the next five interviews. In this way, the researcher ensured about the theoretical saturation. By analyzing all interviews with open coding method, 15 categories were identified and named. By making a kink among these categories in the axial coding step, the categories were embedded in the components of the background theory model and constituted the causal or prior conditions, intervening conditions, grounded conditions, action and interaction strategies, and consequences. Based on selective coding, the focal category (the girls and women's' experience of drug use) was discovered and all categories got connected to the focal category. Finally, the components of the theoretical model of the girls and women's experience were derived from substance use (Table 1).

Table 1: Components of the Ground Theory Model Components of Categories the ground related to each Characteristics of categories theory model part of the model Causal or prior Inappropriate Lack of parental supervision conditions parenting Inappropriate emotional relationship Parental dominance and violence against child Divorce and separation of parents Lack of parental support and guidance Consumer parents and persuading children to consume drugs Consumption in Consumer members the family Easy access to drugs through the addicted member Conflict in the The existence of intellectual, ideological and religious family differences Lack of coordination, trust, and acceptance among members Disconnection Running away from father's house and escape with family Immigration Extensive feeling Feeling of helplessness of loneliness Feeling sad about family neglect and exclusion Establishment of Relational void with a healthy friend of the same gender malicious Consumer friends of the same gender relationships Drugs preparation through friends pf the opposite gender as rewards Opposite-gender addicted friends or drug sellers 88 Research on Addiction Quarterly Journal of Drug Abuse

Table 1: Components of the Ground Theory Model Components of Categories the ground related to each Characteristics of categories theory model part of the model Vulnerable Dissatisfaction with the body individual Impulsivity features Concealment and fear of expressing reality Aversion to females Inability to reject others' proposals Rumination Curiosity and inquiry Unsuccessful Arranged marriage marriage Marriage despite family disagreement Living with an addicted spouse Husband's physical and psychological violence against the wife Failure to adhere to marital relations Divorce or separate life High Variety of roles and responsibilities psychological The occurrence of sudden crises pressure Self-medication Arbitrary use of drugs and substances Background Girls and Field of action conditions women's' The effects of short-term and long-term use of the substances experience of Individual, family, and community's reactions drug use (focal category) Action and Resistance to Attempt to exit home and camp in different ways interaction consumption Drug use withdrawal by taking refuge in religion strategies Drug use withdrawal with the help of family Surrender against No serious attempt in drug use withdrawal consumption Exacerbation of substance use with the aim of ignoring the problems Ending life Consequences Long-term Temporary retake of support from family and friends withdrawals from Temporary return to work and earning money drug use but with Temporary care of children slipping A massive feeling of hopelessness by relapse into drug use Multiple short- Destruction of the trust and support of family and surrounding term withdrawals people with successive Undermined self-esteem slips Acceptance of life under the domination of addiction Exposure to severe financial problems Discredited social image

Given the large volume of findings obtained from this study, only one part of this theoretical model, i.e., "consequences" section, has been chosen and detailed in order to clarify the way to achieve these categories and components of the model. For the detailed consideration of other parts of the model, one can refer to the Master's Thesis authored by Hajiha (2016). Zoha Hajiha et al 89

In the open coding phase of interviews, two categories of long-term withdrawals along with slips and numerous short-term withdrawals along with consecutive slips were discovered. Then, at the axial coding stage, these two categories constituted the Consequences part of the theoretical model. The coding process, and the two categories along with their definitions, features, and conceptual codes are presented below: Long-term withdrawals along with slips: Definition: A person is in a position who is motivated to withdraw from drug use for various reasons, such as having a child and, thereby, s/he will enjoy sufficient family and community support and can withdraw from substance use for a long time. However, since the phenomenon of addiction is relapsive, the person may undergo some slips and reuse drugs (Long-term withdrawal refers to the minimum yearlong withdrawal) for some reasons like facing life crises, such as the death of loved ones. The analysis of the interviews regarding the category of long-term withdrawals along with slips has led to the extraction of four concepts. Each attribute has been presented with a definition and a sample of the conceptual codes from which the desired attribute has been discovered. Temporary retake of support from family and friends: Definition: When a person who has been separated from his/her family due to his/her addiction and who has not been trusted by his/ her family withdraw from substance use for a long time and obtains the support and trust of the family once again. However, this trust and support is again undermined by the retake of substance for any reason and the person will not be accepted by the family. Conceptual code: Shiva says: "I experienced a 2-year purification the previous time. I thought I would not be addicted again, but I got into a slip. Then after two weeks of drug use, I came back to the camp for the second time. During the two years, my family was very happy and affectionate, but again I ruined everything". Temporary return to work: Definition: A person who has lost his/ her job and income due to his/her addiction can re-engage in work when s/he stops drug use for a long time and can earn some income. But this often happens temporarily, and s/he loses his/her job again with slipping and retake of drugs. Conceptual code: Monireh says: "I used to be a tailor, arrange wedding tablecloths, and do artistic works before addiction. During the one and a half years that I had stopped drug use, I gained money by selling rhinestones". Temporary re-care of children: Definition: A person who has avoided taking care of his/her children due to addiction or has been deprived of the responsibility of taking care of his/her children may return to his/her children again when s/he stops substance use for a long time. However, by slipping, this responsibility is taken away from him/her. Conceptual code: Akram says: "My son was 7 when I began drug use. For this reason, he lived with my mother. To be able to take care of him, I was clean for one year, but I slipped into drug use and he was separated from me again". 90 Research on Addiction Quarterly Journal of Drug Abuse

A massive feeling of hopelessness by relapse into drug use: Definition: Slipping after a long and hard period of withdrawal from drug use, in addition to its family and job-related consequences affects the person mentally. The person feels very disappointed with his/her slip and tries to return to the conditions without consumption. Conceptual code: Rokhsareh says: "I stopped drug use for three years in N.A. Association. Four years ago, in a car accident, I lost my father, mother, two brothers, and nephews, and I again slipped after three years of being clean. For this reason, I suffered severe depression for nine months, and got treated with medicine and shock. It's a pity I relapsed into it for three years of purity". Category of numerous short-term withdrawals along with consecutive slips: Definition: A person makes an impulsive decision to withdraw from substance use, and lacks the necessary and adequate conditions, such as the proper environment, the proper and principled method of addiction withdrawal, as well as family support, self-confidence, etc. For this reason, s/he slips into drug use again and again repeatedly, which, of course, leads to the destruction of his/her own image and the weakening of his/her self-esteem (Short-term withdrawal is the one less than two weeks). The analysis of the interviews regarding the category of numerous short-term withdrawals along with consecutive slips led to the extraction of four attributes. Each attribute along with a definition and an example of the conceptual code from the desired attribute has been presented below. Destruction of the trust and support of family and surrounding people: Definition: When the family and surrounding people get disappointed with the person's ability to return to a healthy life, they will lose their trust in the individual and they strongly reduce their efforts to make the addicted member withdraw from drug use with the removal of their support. Conceptual code: Marziyeh says: "I have withdrawn from drug use from 20 to 30 times so far but I have not been able to bear it for three days. It was just a four-month period of my life that I was far away from cigarette, pills, and alcohol. My sister left me alone and is on the out with me". Undermined self-esteem and acceptance of life under the domination of addiction: Definition: The person's repeated withdrawals and slips are more damaging to the consumer than others. The person who has experienced many abortive withdrawal attempts and has been also humiliated and insulted by his/her family will witness strongly damaged self-esteem. Conceptual code: Mahnaz says, "I was 13 years old. I withdrew many times, but the current 15- day stay at the camp is my lengthiest withdrawal duration. I'm tired of and disappointed in myself. I have a high degree of craving. Should I have craving every day? How do I live?" Severe financial problems: Definition: Numerous withdrawals and slips are not only a serious obstacle to work and money earnings, but also they make it financially difficult for the individual to prepare the cost of drugs for a long time. Zoha Hajiha et al 91

Conceptual code: Ghazaleh says: "I withdrew drug use several times. I was in the House of Sun for a while time where I was cleaned for about ten days with methadone, but I reused drugs. I begged in the queues of gas and petroleum in Varamin and I got the money for buying drugs". Discredited social image: Definition: One of the reasons for repeated attempts of a person to withdraw from drug use is his/her efforts to restore his/her social image in society. To be re-accepted by society and find a better position in society, the person attempts withdrawal; however, any abortive attempt will leave the person further away from the situation s/he had previously had. Conceptual Code: Masoumeh Rajabi says: "I am unaware of my children, I called them 3 months ago when I was at the camp and had withdrawn and made an appointment to see them. They said that they would see me in a location where no relatives and friends would not see them because they would feel embarrassed that their mother was addicted". As it was mentioned earlier, intervening conditions (mediators) are the conditions that facilitate or limit the action/interaction strategies in a particular context and are the more general and wider conditions influence the action/interaction process. Since these conditions exert different influences on different people, they have not been extracted in the form of a category. After the analysis of the interviews, 10 components of economic problems, educational problems, physical and mental problems, type of self-image, family support, personal life events, employment, having a child, having a guidance manual for withdrawal, and a withdrawal model as the intervening conditions (mediators). Among the categories pertaining to the causal conditions of women's tendency to substance abuse, three themes, namely Harm-proliferation Family, Vulnerable Individual Situations, and Unsuccessful Marriage have been extracted (Table 2).

Table 2: Themes and Categories Constituting the Theme Theme Categories of themes Inappropriate parenting, consumption in the family, conflict in the Harm-proliferation family, disconnection with the family, and the formation of Family malicious relationships Vulnerable Vulnerable individual characteristics, high psychological pressure, Individual self-medication, and formation of malicious relationships Situations Unsuccessful marriage, high psychological pressure, feelings of Unsuccessful homelessness, self-medication, and the formation of malicious Marriage relationships

With the integration of the types of women's action and interaction strategies, and the outcome of these strategies, two types of resistant women and submissive women in relation to female abusers have been extracted (Table 3). 92 Research on Addiction Quarterly Journal of Drug Abuse

Table 3: Types and categories constituting the type Types Categories forming each type Resistant Resistant to consumption, long-term withdrawals but with slips Surrender to consumption, multiple short-term withdrawals with Submissive successive slips

A summary of the theoretical model of women and girls' experience of drug use is presented in Figure 1.

Intervening conditions Causal conditions  Economic and educational  Harm-proliferation problems Family Background conditions  Physical and psychological  Vulnerable Individual  Field of Action problems Situations  The short-term effects of  Type of self-image  Unsuccessful marriage substance use  Family support  The long-term effects of  Personal life events substance use  Employment  Individual, family, and  Having a child community's reactions  Have a guide manual  Having a withdrawal model

Women and girls' experience of drug use

Strategies  Resistance to drug use (resistant type)  Surrendering to drug use (submission type)

Consequences  Long-term withdrawals along with slips (resistant type)  Multiple short-term withdrawals with successive slips (surrender type)

Fig. 1: Theoretical Model of Women and Girls' Experience of Substance Use

Discussion and Conclusion After analyzing the interviews via grounded theory method, the components of the theoretical model of women and girls' experiences of drug use were presented as follows:  Causal conditions: three themes of harm-proliferation family, vulnerable individual conditions, and unsuccessful marriage Zoha Hajiha et al 93

 Background conditions: field of action, short-term and long-term effects of drug use; individual, family, and community's reactions  Intervening conditions: economic, physical, mental, and educational problems, type of self-image, family support, personal life events, employment, having a child, having a guidance manual, and having a withdrawal model  Women's action and interaction strategies: Resistance to drug use, surrender to consumption  Consequences of women's action and interaction: long-term withdrawals along with slips, multiple short-term withdrawals along with successive slips The category of inappropriate parenting indicates dysfunctional parenting styles that encourage substance use. The authoritative parenting style increases the motivation for alcohol consumption and use of psychotropic substances in adolescence (Matejevic, Jovanovic, & Lazerevic, 2014). This finding is also in line with the research carried out by Matejevic et al. (2014) where the parenting style based on exclusion and extreme support was revealed to be the predominant parenting style among alcoholic or substance dependent juveniles. This findings is also consistent with the research done by Calafat, Garcia, Juana, Becana, & Fernández-Hermida (2014) where the authoritarian and permissive parenting styles have a significant correlation with substance abuse in adolescents compared to authoritarian parenting. The inappropriate parental category also correlates with Ney's theory (1985) where such indicators as parental acceptance and exclusion, parents' methods of behaving towards children, and parental punishment are considered to be related to children's delinquency. This is also consistent with the results of research conducted by Khademi, & Ghana'atian (2009) and Solis et al. (2012) where parents' addiction and separation and parental substance abuse have been identified as the main causes of substance abuse in children. The category of drug use in family is in the same line with Edwin Sutterland's learning theory which explains the learning of deviant behavior through association and relationship with the perpetrators. In fact, it is consistent with the research findings reported by Khademian, & Ghana'atian (2009); Bayati (2010); Cano, Solanas, & Mari-Klose (2012); Danesh et al. (2013); and Kelishmi, Nouri, & Ramazanzadeh (2015) where it was found that substance use by one of the family members, close relations with substance users, and easy access to drug use are among the main causes of addiction in women. The categories of family conflict and disconnection with the family due to the differences in opinions, beliefs, and thoughts among family members; and lack of coordination, trust, and acceptance among family members are consistent with the findings reported by Danesh et al. (2013). Conflict and disconnection with the family are ultimately associated with the formation of the extensive feeling of loneliness and sadness, which is consistent with the research 94 Research on Addiction Quarterly Journal of Drug Abuse conducted by Rahimi Movaghar et al. (2011) who consider the humiliation and exclusion of children by the family and parents effective in the formation of addiction in women. These emotions provide the grounds for the formation of psychological problems, such as anxiety and depression, and lead women to consumption of drugs. The category of the formation of malicious relationships, which involves engagement with drug users of both genders, is consistent with Ronald Akers's social learning theory (1988). Akers believes that people's involvement in criminal behavior is associated with the frequency of relations and greetings and the imitation of individuals' patterns who show criminal and delinquent behavior. This relation and engagement with offenders provides a pattern of crime and delinquency (Akers, 1988, as cited in Rasoulzadeh Aghdam, Jafari, Sa'adati, & Yousef Aghdam, 2015). Learning theories and conditioning have also referred to drug use in social situations. If this issue causes friends' approval and acquisition of a special position for the individual, it will have a boosting effect (Benjamin Sadock, Virginia Sadock, & Pedro Ruiz, 2015, Translated by Raza'ea, 2015). The category of the formation of malicious relations is also consistent with Cloward and Ohlin's theory of differential opportunity, which asserts that socially deviant individuals' access to a proper environment for playing their deviant role and the continuation of this role by means of group support and encouragement is the main factor for the formation of perverted behaviors. This category is consistent with the research findings reported by Cano, Solanas, & Mari-Klose (2012); Danesh et al. (2012); and Tavakoli, Mohammadi, & Yarmohammadi (2012), who have pointed to the broad role of close relationships with drug abusers and friends in the onset of women's addiction. The category of vulnerable individual characteristics includes features, such as concealment and the fear of expressing the reality and the inability to reject others' proposals, which is consistent with Parsons's (1995) belief referring to the lack of proper development of the necessary skills in childhood for success in life. This issue leads to young girls and boys' failure in obtaining job opportunities and getting married and makes people anxious, insensitive, and inordinate that form feelings of anger and hatred towards others. Since individuals regard family as a sacred institution, they push this anger and hatred towards a replacing source like the self. Therefore, they provide a source for their own tranquility by turning to drugs. Characteristics of impulsivity, curiosity, and curiosity and search are also referred to as individual vulnerable characteristics, which are consistent with the results of studies carried out by Schreiber, Grant, & Oldaug (2012); Azami et al. (2014); Asadi Mojreh et al. (2015); and Marquez-Arrico & Adan (2016). These research findings point to the role of impulsivity in substance abuse and the high level of impulsivity in addicted people. In the same way, Tavakoli et al. (2013) have referred to curiosity an effective factor in women's tendency to drug abuse. Zoha Hajiha et al 95

The category of unsuccessful marriage includes arranged marriage, marriage despite family disagreements, living with an addicted spouse, husband's physical and psychological violence against the wife, failure to adhere to marital relations, and divorce or separate life. This finding is consistent with various research results. Women's familial disorder (Khademian, & Ghana'atian, 2009), disunity between the woman and husband's family (Bayati, 2010), and family disagreement have been referred to as the causes of women's tendency towards drug use. Ghasemi Roshan (2009) and Farkhojasteh, Abdollahi, & Ghasemzadeh (2014) have mentioned the role of dissatisfaction with life and marital relations in women's addiction. Khademi, Laghayi, & Alikhani (2009) and Tavakoli et al. (2013) have referred to women's living with addicted husbands, drug use at husband's request, and the availability of drugs as the main reasons for women's addiction, which are consistent with the category of unsuccessful marriage. The category of high psychological stress refers to women's exposure to various roles and responsibilities as well as sudden crises and, thereby, it is one of the factors contributing to the formation of mental problems in women and their tendency to substance abuse. This is consistent with Parsons's finding (1951) who describes the individuals' inability to face failure in life situations as a factor effective in the tendency towards drug use, and is also in agreement with Agniou's view where crime is considered to be some kind of compatibility with tension. Agniou believes that a person's exposure to life-threatening events, such as loss of someone or something that is great for the person is one of the deviating factors. Sometimes stressful events that others create for the person and the negative acts of others, such as being exposed to abuse, cause deviation in one person (Javanmard, 2011; as cited in Danesh et al., 2013). Women face critical situations, such as diversity of roles and responsibilities due to different reasons like divorce, illness or death of their associates, especially their husbands and parents. On the one hand, they do not have the ability to deal with the problems; on the other hand, the community and the people around them expect women to face and solve problems. This imbalance between the expectations of others and the level of individual abilities encourages women to consume drugs. According to this statement, Merton (1949), in his theory, has pointed to the goals approved by society and the ways to achieve these goals. He refers to the goals, interests, and intentions that the culture of society has defined and determined. These goals and intentions have been approved for all members of the community and form an ideal reference and are raised as the issues that are worth making efforts. The problem is that the emphasis which is culturally placed on some goals does not fit with the amount of emphasis placed on the means to achieve these goals (Merton, 1949, as cited in Gorbani et al., 2014). This causes individuals to use any method to achieve goals and, thereby, deviations appear. The category of high psychological pressure and women's inability to deal with difficulties is consistent with the research findings obtained 96 Research on Addiction Quarterly Journal of Drug Abuse by Khademi et al. (2009), Garousi, & Dolatabadi (2011), and Kelishami et al. (2015). The category of self-medication refers to the arbitrary use of drugs and substances by women in order to reduce mental and psychological distress. Individuals may embark on self-medication by taking different drugs and taking advantage of their effects. Some individuals drink alcohol to control panic and some others take opioids to control anger. The use of amphetamines is also commonly used to reduce depression and relieve its symptoms among drug abusers (Sadock et al., 2015, translated by Raza'ea, 2015). Self-medication can be accounted for by learning theories and conditioning. According to these theories, drug use persists because of the consequences it has for the individual. Drug use strengthens its own antecedent behaviors by eliminating distressing conditions. Considering the above-mentioned factors in the realm of effective items in women's tendency to drug use, it is possible to identify people at risk of harm and to mitigate the increasing trend of this problem by the implementation of preventive programs. Finally, it should be noted that the phenomenon of addiction in women is a very complex and multifactor phenomenon that affects all aspects of women's lives. Therefore, it is necessary to pay attention to it. The limitations of this research are as follows: The sample of this study included the addicted women and girls who had taken steps to withdraw from substance use. Therefore, the obtained theoretical model does not include the women and girls who do not attempt withdrawal from addiction; in addition, the possibility of conducting an interview with the addicted women and girls' family was not provided for the researcher. In relation to these individuals, information has been collected indirectly through addicted people; and the possibility of examining the situation of addicted women and girls after completing the withdrawal program and departure from the camp has not been provided for the researcher. It is suggested that future studies should look at the status of women and girls who have not attempted addiction withdrawal; the situation of women and adolescent girls who refer to camps should be compared with those who do not present to addiction treatment clinics; the family of addicted women and girls should be extensively investigated; the status of addicted women and girls after the completion of the withdrawal program should be also examined; the status of addicted women and girls in Tehran should be compared with those of other cities in Iran; and the activities of camps and drug addiction treatment clinics should be also evaluated seriously. Reference Andrew K. Shenton. (2004). Strategies for ensuring trustworthiness in qualitative research projects. IOS Press; 22, 63–75. Asadi Mojreh, S., Mahmoud Alilou, M., Bahadori Khosroshahi, J., & Khorsand, M. (2014). Quarterly Journal of Research on Addiction, 8 (32), 119-135. Zoha Hajiha et al 97

Azami, Y., Sohrabi, F., Borajali, A., & Choupan, H. (2014). The Effectiveness of Emotion Regulation Training based on Grass Modeling in Reduction of Impulsiveness in People with Opiate Dependence, Quarterly Journal of Research on Addiction, 8 (30), 127-142. Bayati, P. (2010). Socio-cultural Context Effective in Drug Addiction among Women, Quarterly Journal of Research on Addiction, 4 (14), 7-15. Bazargan, M. (2010). An Introduction to Qualitative and Mixed-method Research Methods: Common Approaches in Behavioral Sciences. Tehran: Didar Publication. Book of the Year of Drug Control Headquarters (2008). Tehran: Secretariat Publication of the Drug Control Headquarter. Calafat, A., García, F., Juana, M., Beco˜na, E., Fernández-Hermida, J. (2014). Which parenting style is more protective against adolescent substance use? Evidence with in the European context. Drug and Alcohol Dependence, 138, 185–192. Cano, A.J., Solanas, S.E., Marí-Klose, M., Marí-Klose, P. (2012). Psychosocial risk factors in adolescent tobacco use: negative mood-states, peer group and parenting styles. Adicciones 24, 309–317. Danesh, P., Maleki, A., & Niazi, Z. (2013). Grounded Theory on Causes of Women's Addiction Imprisoned in Central Isfahan Prison. Quarterly Journal of Socio-Cultural Development Studies, 1 (4), 541-591. Farkhojasteh, V., Abdullahi, R., & Ghasemzadeh, S. (2014). Comparison of Lifestyle, Attachment Styles, and Marital Satisfaction between Addicted and Normal Women in Tehran, Bi-quarterly Journal of Police-Social Investigations of Women and Family, 2 (1), 5-21. Galanter, M., Kleber, H. (2004). Textbook of substance abuse treatment (3th Ed.). Washington, DC: American Psychiatric Publishing, Inc. Garousi, S., & Mohammadi Dolatabad, K. (2011). Explaining the lived experience of addicted women, Quarterly Journal of Sociology of Women, 2, 2, 55-76. Ghasemi Roshan, E. (2009). From women's addiction to family disruption, Quarterly of Women's Book, 22, 1-18. Ghorbani, E., & Feizabadi, H. (2014). Examining sociological views of social deviations, Quarterly Journal of Law Enforcement of North Khorasan, 1, 3, 97-120. Grant, T., Huggins, J., Graham, C., a, Ernst, C., Whitney, N., Wilson, D. (2011). Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not. Children and Youth Services Review. 33, 2176– 2185. Iranian Monthly. (2013). Interview with Head of the Drug Control Headquarters, 27-30. Jafarzadeh Kelishmi, M., Nouri, R., & Ramazanzadeh, F. (2015). Drug use profile in addicted women, Journal of Neyshabour University of Medical Sciences, 3 (1), 49-55. Khademi, N., Laghayi, Z., & AliKhani, A. (2009). The Study of Consumption Pattern of Addiction among Women Referring to Damage Reducing Center, Quarterly Journal of Research on Addiction, 3 (12), 79-90. Khademian, T., & Ghana'atian, Z. (2009). Investigating the Social Factors Affecting the Addiction of Women in Rehabilitation Centers and Reduction of the Injury of Tehran Women (Rebirth Center and House of Sun Center), International Journal of Social Sciences, 2 (14), 59-85. 98 Research on Addiction Quarterly Journal of Drug Abuse

Khajeh Dalouyi, M., & Dadgar, M. (2013). Mother Addiction in Pregnancy and Child Addiction in Adolescence and Younghood, Iranian Journal of Obstetrics Gynecology and Infertility, 16, 52-71. Marquez-Arrico, J., Adan, A. (2016). Personality in patients with substance use disorders according to the co-occurring severe mental illness: A study using the alternative five factor model. Personality and Individual Differences. 97, 76–81. Matejevic, M., Jovanovic, D., Lazerevic, V. (2014). Functionality of family relationships and parenting style in family of adolescents with substance abuse problems. Procedia - Social and Behavioral Sciences, 128, 281 – 287. Nouri, R. (2010). Industrial Society and Addiction to Industrial Substances. Journal of Rebirth, Tehran: Rebirth. Rahimi Movaghar, A., Malayerikhah Langroudi, Z., Delbarpour Ahmadi, S., & Amin Esma'eali, M. (2011). Qualitative study of women's needs for treatment of addiction, Iranian Journal of Psychiatry and Clinical Psychology, 17 (2), 116-125. Rasoulzadeh Aghdam, S., Jafari, G., Sa'adati, M., & Yousefi Aghqdam, R. (2015). Sociological study on the contribution of structural factors and social learning in juvenile delinquency in marginalized areas of Tabriz city, Journal of Urban Sociological Studies, 6 (17), 143-178. Sadock, B., Sadock, A., & Pedro R. (2016). Synopsis of Psychiatry: Behavioral Sciences Clinical Psychiatry, (Translated by Farzin Raza'ea). Tehran: Arjomand Publication. Schreiber, L. R. N., Grant, J. E. & Odlaug, B. L. (2012). Emotion regulation and impulsivity in young adults. Journal of Psychiatric Research, 46, 651- 658. Solis, J., Shadur, J., Burns, A., & Hussong, A. (2012). Understanding the diverse needs of children whose parents abuse substances. Current Drug Abuse Reviews, 5, 135– 147. Strauss, A., & Corbin, J. (2011). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, translated by Afshar, Tehran: Nay Publications. (Date of publication in original language 1998). Tavakoli, M., Mohammadi, L., & Yarmohammadi, M. (2013). Study of the status and trend of substance abuse and substance dependence in Iranian women, Quarterly Journal of Research on Addiction, 14 (5), 30-37.

Abstract Causal Relationship Objective: The aim of this study was to between Spiritual model the structural relationships between spiritual intelligence and Intelligence and addiction potential with mediating role of Addiction Potential meta-cognitive beliefs and educational hardiness in Azad University students of with the Mediating Tehran. Method: A descriptive- correlational research method with a Role of Meta-Cognitive causal nature was used in this study. The Beliefs and Academic statistical population of this study consisted of all students of Azad Hardiness University of Tehran in the academic year of 2016-17. From among this population, 361 students were chosen via random cluster sampling method and responded to Zargar's Addiction Potential Scale, Halton & Wells's Metacognition Questionnaire, Saberi, Z. , Farokhi, N. , Namvar, H. King's Spiritual Intelligence Self-Report Inventory, and Benishek & Lopez's Academic Hardiness Scale. Results: Saberi, Z. Using structural equation modeling and Ph.D. Student of Educational Sciences, path analysis, spiritual intelligence, with Islamic Azad University, Saveh Branch, mediating roles of metacognitive beliefs Saveh, Iran and educational hardiness could explain Farokhi, N. 10% of addiction potential among Associate Professor of Educational students of Azad University of Psychology, Allameh Tabataba'i Tehran. Additionally, spiritual University, Tehran, Iran, Email: intelligence had a direct effect on [email protected] addiction potential. Conclusion: Namvar, H. Considering the predictive power of the Assistant Professor, Department of mentioned variables, one can use the Educational Sciences, Islamic Azad findings of this study for developing University, Saveh Branch, Saveh, Iran addiction prevention programs and formulating educational interventions in addiction withdrawal clinics. Keywords: spiritual intelligence, meta- cognitive beliefs, academic hardiness, and Research on Addiction addiction potential Quarterly Journal of Drug Abuse

Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir/ 100 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction is the person's comprehensive suffering from a substance or narcotics, in such a way that it makes him physically and psychologically dependent and affects all his individual and social behaviors. Today, addiction, as the most important social damage, has attacked on the human community. Due to the progressive nature of addiction in all aspects of life, in addition to its physical and psychological impacts on the addict, the health of the society has also been damaged socially, economically, politically, and culturally; it has also influenced all age groups. (Badri Gargari, 2014). Previous studies have shown that various psychological factors play a significant role in the individual’s suffering from addiction and addiction potential (Moazen Nasab, & Javdan, 2017). For example, the deterrent role of spirituality and religion can be mentioned in getting infected by addiction and drug abuse. Religion and spirituality have a great influence on all aspects of life, and the relationship between religion and addiction has been an important subject matter and has reached to acceptable results (Garcia, Babarro, & Romero, 2017). For instance, Raiya, Pargament, Mahoney, & Stein (2008) have stated that religion creates a sense of well-being and, according to Mackie & Smith (2000), can influence on the human behavior. Having religious beliefs is one of the factors that can be effective in preventing and reducing psychological disorders, and also its related problems such as suicide, drug addiction, depression and anxiety. In this regard, spiritual intelligence is one of the relatively new structures in the area of psychology of religion, which has recently been considered by the researchers as one of the positive and protective factors associated with substance use and other psychological damages (Dev, Kamalden, Geok, Ayub, & Ismail, 2018) among the youth (Sohrabi, & Naseri, 2012). Spiritual intelligence is a set of abilities, capacities, and spiritual sources that its application increases the adaptability (Nourbakhsh, & Molavi, 2015). According to King (2008), spiritual intelligence has four components of existential thinking, personal meaning production, conscious state expansion, and transcendental awareness. Marashi, et al. showed that there is a negative relationship between spiritual intelligence and addiction preparedness. People with lower spiritual intelligence are more likely to be addicted (Marashi, Na’ami, Bashlideh, Zargar, Ghobari Bonab, 2012). Research on the etiology of substance abuse have also mentioned other factors such as personality traits and have addressed the strong role of the individuals’ personality traits in interaction with other environmental factors in the onset and continuation of the problematic use of drugs (Carou, Romero, & Luengo, 2017). Among these traits, the psychological hardiness can be mentioned. Psychological hardiness has been assumed as a multi-components construct, including commitment, control, and challenge. From the psychodynamics perspective, all people have some degrees of psychological hardiness (Benishek, & Lopez, 2001). In that study, the Zahra Saberi et al 101 emphasis has been on the academic hardiness as a framework for understanding how students can react to the academic challenges (Benishek, & Lopez, 2001). Psychological hardiness makes individuals able to have a proper performance against the stressful events and full of tension situations of life. Psychological hardiness creates a particular internal attitude that affects people's way of coping with different life issues (for example, academic, occupational, social challenges, etc.) (Moradi, Ebrahimi, & rad, 2018). Kobasa, Maddi, & Kahn (1982) considered the construct of hardiness as a source of resistance in confrontation with the stressful events of life. In fact, it can be stated that the individuals with a high level of psychological hardiness are less likely to suffer from physical and psychological damages such as addiction against the environmental stressful events. Hardness is a fundamental feeling of control that allows a person with hardiness to draw and have access to a list of strategies that ultimately lead to the development of optimistic visions against the stressful events (Yasaminejad, Golmohammadian, & feli, 2011). Therefore, the hardiness feature can reduce the addiction potential in humans and act as a protective factor. Although some theories pertaining to drug use and the tendency toward drug use concentrate on the individuals’ personality traits (Modaresifard, & Maredpour, 2016), in other theories, such as cognitive-behavioral theory, it is assumed that the tendency to drug use and dependency on it is a learnt behavior that is acquired through conditioning and cognitive mediators (Gorman, 2001). For substance dependency, cognitive interventions also focus on cognitive mediators, which mainly include identifying and modifying the drug-related experiences and extracting and rebuilding beliefs and fundamental cognitions (Parks, Marlatt, & Anderson, 2004). One of the new approaches in the area of etiology and treatment of many psychological disorders such as addiction is Wells’s Metacognitive Model (Wells, & Matthews, 2009, quoted from Ghadimi, Karami, and Yazdanbakhsh, 2014). It suggests that the psychological disorders and addiction are created and maintained through the sustained pattern of thinking (worry or rumination), attention strategies associated with monitoring and threats, avoidance, and thought suppression, which together lead to the formation of a cognitive-attention syndrome. This syndrome results in failure in correcting the maladaptive beliefs with self and increasing the access to negative information about self (Ghadimi, et al., 2014). Metacognitive beliefs are the beliefs that a person has about his thinking and its processes (Janeck, Calamari, Riemann, & Heffolinger, 2003; quoted by Sa'ed, Yaghoubi, Roshan, & Soltani, 2011). Drug dependency in short term acts as an adaptive coping strategy to regulate emotion, but it is considered as maladaptive in the long term as it causes dependency and generating negative emotions (Spada, Nikcevic, Giovanni, & Wells , 2007; Spada , Zandvoort, & Wells , 2007). Several studies have shown that there is a relationship between metacognitive beliefs and addiction potential as well as drug dependency 102 Research on Addiction Quarterly Journal of Drug Abuse

(Spada, & Wells , 2008; Hajloo, Sadeghi, Nadinloei, & Habibi, 2014). Moreover, research show that meta-cognition and spiritual intelligence are related to each other in many components. Canada, Murphy, Fitchett, Peterman, & Schover (2008) found that cognitive strategies of positive coping with against life events in people with higher spiritual intelligence are more than those with low spiritual intelligence. Karri, Stanley, Cohen, & Hicks (2007) found that people with high spiritual intelligence use meta-cognitive processing more and individuals with low spiritual intelligence use negative meta-cognitive processing more. Although several studies have examined the relationships and contribution of each components of the spiritual intelligence, academic hardiness, and meta- cognitive beliefs in addiction or addiction preparedness, the causal effect of the relationship between these variables in an interaction model on addiction potential has not been studied so far. The action on addiction has not been investigated. Previous studies have shown that spiritual intelligence, meta- cognitive beliefs, and academic hardiness have a certain degree of impact on addiction and addiction preparedness. However, since the individuals’ psychological organization is multidimensional, and the tendency toward substances is influenced by a set of factors not one or two factors, it is necessary to examine the effects of such factors by using the conceptualization of multivariate models. By doing so, not only the one-to-one effect of these variables, but also their cumulative effect by considering the moderating or mediator factors are examined precisely. The current study aims to investigate the causal model of addiction potential by considering the role of spiritual intelligence in university students. It seeks to answer the question of whether the spiritual intelligence by mediating meta-cognitive and academic hardiness is able to predict addiction potential in university students. Investigating the variables mentioned in the current study in the form of the causal model and the effectiveness of each of them in the proposed model according to Fig. 1 can help to develop new knowledge in this field.

Meta-cognitive Beliefs

Addiction Spiritual Intelligence Preparedness

Academic Hardiness

Fig. 1: The Conceptual model of the Relationship between Spiritual Intelligence and Addiction Potential by Mediating Meta-cognitive Beliefs and Academic Hardiness Zahra Saberi et al 103

Method Population, sample, and sampling method Regarding the purpose, the present study was of fundamental type, and had a descriptive-correlational method with a causal nature. Data analysis was performed using the structural equation modeling which is based on covariance and AMOS software. This approach is used to estimate the coefficients of paths and factor loadings by minimizing the difference between a sample-based covariance matrix and a model-based covariance matrix. The population of the study consisted of all university students of Azad University of Tehran who were studying in the academic year of 2016-17. A multi-stage cluster sampling method was used to select the sample. From among the Azad Universities of Tehran, Azad University of Tehran (the Central Branch) was randomly selected and then, the research sample was randomly completed in different faculties of the same university. Since there were 15 clear factors in the current study, and regarding the minimum sample size required for factor analysis (20 samples for each factor) (Habibi, 2012), the minimum sample required for this study was 300 people. Considering the possibility of loss and the aim of reducing the probability of the second type error, the sampling process continued until 361 people were chosen. The method of collecting information was the field method.

Instruments 1. Addiction Potential Scale: This questionnaire was developed according to the psychological, social, and cultural conditions of the Iranian society by Zargar (2008). It is made of the two factors, 36 items, and 5 lie detector items. In the first factor (active potential), the majority of the items are related to antisocial behaviors, the desire to use drugs, positive attitude toward drugs, depression, and emption seeking respectively. In the second factor (passive potential), most of the items are associated with lack of self-expression and depression. Scoring is done based on a continuum ranging from zero (totally disagree) to three (totally agree). The foreign version of the Addiction Potential Scale is one of the three subscales of the Minnesota Multiphasic Personality Inventory which has been developed by Weed & Butcher (1992) (quoted by Haji Hassani, Shafi Abadi, Pirsaghi, Kianipour, 2012). In Iran, the internal consistency of this scale in the study of Zargar and Ghaffari (2009) was 0.90 and Cronbach's alpha of the first and the second factor were 0.91 and 0.75 respectively; its criterion and construct validity were acceptable. In this study, Cronbach's alpha was 0.87. 2. Meta-cognition Questionnaire: The initial form of this questionnaire was 65 items that was designed by Cartwright-Hatton and Wells (1997) to investigate worries and the intrusive thoughts. The utilized version of Cartwright-Hatton and Wells meta-cognitive questionnaire consists of 30 items that later was created by Cartwheel Hatton and Wells (2004), similar to the original form, in order to measure the meta-cognitive beliefs (Wells , 1997,1995; quoted by Cartwright-Hatton & Wells , 2004). This questionnaire consists of five subscales 104 Research on Addiction Quarterly Journal of Drug Abuse of cognitive confidence, positive beliefs about worries, cognitive self- consciousness, dangerous and uncontrollable thoughts, and the need to control thoughts (Cartwright-Hatton & Wells , 1997; quoted by Wells & Carter, 2001). Responses are calculated based on the 4-point Likert scale (totally disagree (1) to totally agree (4)). The minimum score obtained in this test is 30, and the maximum is 120; the total score of metacognition is obtained from the sum scores of the subscales. The Cronbach's alpha coefficient for the subscales was in the range of 0.72 to 0.93, the test-retest reliability for the total score, after 22 to 118 days, was 0.75, and 0.59 to 0.87 for the subscales (Cartwright-Hatton & Wells , 2004). In Iran, using the Cronbach's alpha coefficient, Shirin Zadeh Dastgiri (2006) reported the internal consistency coefficients as follows: 0.91 for the total scale; for the subscales, it was reported in the range of 0.71 to 0.87. He reported that the test-retest reliability of this test in the 4-week interval for the whole scale was 0.73, and it was in the range of 0.59 to 0.83 for the subscales. In the present study, the internal consistency for the whole scale was 0.82. 3. Spiritual Intelligence Self-report Inventory: Spiritual intelligence self- report inventory was developed by King in 2008 based on the theory of Self, in order to measure the mental abilities of spiritual intelligence. It has 24 items and evaluates the capabilities pertaining to the spiritual intelligence in four main dimensions of ability including the critical existential thinking, personal meaning production, transcendental awareness, and conscious state expansion. The individuals determine their agreement or disagreement with each of the statements on a 5-point Likert scale. In order to obtain the score of each subscale, the scores of the questions are added; to obtain the total score of the test, the score of all the 24 statements should be added and the 6th statement should be reversely scored. King (2007), in a study on 619 university students, reported that the Cronbach's alpha coefficient of this test was 0.95; the Cronbach's alpha coefficients of the critical existential thinking, personal meaning production, transcendental awareness, and conscious state expansion were 0.88, 0. 87, 0.89, and 94/0 respectively (King, 2007). In Iran, Aghababaei, Farahani, and Rahimi Nejad (2010) implemented this test on 580 university students and religious students at Howzeh, and reported that the reliability coefficients for the subscales of conscious state expansion, personal meaning production, transcendental awareness, critical existential thinking, and total test were 0.75, 0.75, 0.70, 0.70, and 0.88 respectively. In that study, Cronbach's alpha for the whole scale was also 0.85. 4. Academic Hardiness Scale: This questionnaire was developed by Benishek and Lopez (2001) and measures the components of commitment, challenge, control of effort, and control of affect. Benishek and Lopez (2001) reported that the internal consistency of this scale was 0.82; for each of the components of commitment, challenge, control of effort, and control of affect, it was 0.91, 0.88, 0.91, and 0.81 respectively. In Iran, this test has been translated and the total Cronbach Alpha has been reported to be 0.83. It has 40 items and the scoring is Zahra Saberi et al 105 based on totally disagree (1) to totally agree (5). The scoring in items 1-15-16- 17-20-21-22-27-29-32-35-37-39 is reversed. In this test, the high score indicates high academic hardiness (Zaghibi Ghannad, 2013). The total Cronbach alpha in the current study was 0.81.

Results The participants’ mean age was 24.01 (standard deviation=12.7 years). The youngest subject was 18 years old and the oldest was 62 years old. 195 people (54.3%) were female and 164 people (45.7%) were male. 292 people (83.9%) were single and 56 people (16.1%) were married. 89 people (24.7%) were studying in Faculty of Fundamental Sciences, 95 (26.3%) in Faculty of Engineering, 91 (25.2%) in arts, and 86 (23.8%) in Faculty of Humanities. The descriptive statistics of the studied variables are presented in Table 2. Table 2: Descriptive Statistics of the Studied Variables in the Sample Group Variables Mean SD Skewness Kurtosis Minimum Maximum Total cognitive beliefs 68.04 13.41 0.19 0.97 30 120 Cognitive conflict 12.04 3.9 0.319 -0.458 6 24 Positive beliefs 12.14 3.75 0.571 0.252 6 24 Cognitive self-consciousness 16.04 3.63 0.057 -0.220 6 24 Danger and 13.71 4.11 0.329 -0.096 6 24 uncontrollability of thoughts The need to control 14.15 3.55 0.049 0.183 6 24 thoughts Total academic hardiness 126.3 13.81 0.51 0.32 94 176 Commitment 12.97 3.18 0.225 -0.375 4 20 Challenge 60.27 6.86 0.488 0.138 43 87 Control of effort 20.27 4.95 0.304 0.338 7 35 Control of affect 32.86 5.45 0.270 0.562 14 50 Addiction potential 33.49 19.47 0.79 0.41 0 105 Passive addiction potential 10.95 4.46 -0.051 -0.194 0 24 Active addiction potential 22.53 16.51 0.870 0.316 0 81 Total spiritual intelligence 54.56 17.62 0.03 -.30 7 96 Critical existential thinking 16.42 6.1 -0.096 -0.520 0 28 Personal meaning 11.46 4.6 -0.167 -0.525 0 20 production Transcendental awareness 15.74 5.25 -0.071 -0.224 0 28 Conscious state expansion 11.05 4.2 -0.010 -0.322 0 20

The correlation matrix of the studied variables is presented in Table 2. Table 2: Correlation Matrix of Research Variables variables Spiritual intelligenceMeta -cognitive Hardiness Addiction spiritual intelligence 1 - - - Meta-cognitive -0.034 1 - - Hardiness 0.235** 0.114** 1 - Addiction preparedness -0.239** -0.139** -0.224** 1 *<0.05, **<0.01 106 Research on Addiction Quarterly Journal of Drug Abuse

As you can see, there is an inverse relationship between addiction potential and other areas of the study. There is also a direct relationship between spiritual intelligence and academic hardiness. There is also a direct relationship between metacognitive beliefs and academic hardiness. However, there is no relationship between spiritual intelligence and metacognitive beliefs. The Goodness of fit indices of the model are presented in Table 3. Table 3: Checking the Fitness of the Measurement Model after Two Stages of Correction 흌ퟐ Goodness of fit indices ퟐ ⁄ RMSEA GFI IFI CFI 흌 풅풇 Initial model 696/503 6/449 0.123 0.842 0.727 0.723 The corrected model 1 321/471 3/004 0.075 0.9 0.9 0.899 The corrected model 2 285/507 2/693 0.069 0.913 0.917 0.916

Acceptable cut-off scores <3 <0.1 >0.9 >0.9 >0.9 As shown in Table 3, the observed variables measure the latent variables in an acceptable way. The results of the confirmatory factor analysis of the measurement model are presented in Table 4. Table 4: Parameters of the Measurement Model in Factor Analysis Parameter Standard Standard Test Parameters estimation parameter error statistic

Spiritual intelligence

Transcendental awareness 1 0.81

Conscious state expansion 1.13 0.81 0.07 15.36**

Personal meaning production 1.35 0.87 0.07 17.05** 1.26 0.85 0.07 16.69** Critical thinking Addiction potential

Active addiction 1 0.35

Passive addiction 1.02 1 0.14 7.15** Academic hardiness

Commitment 1 0.62

Affective 0.42 0.38 0.08 5.24**

Effort 0.69 0.5 0.11 6.32**

Challenge 0.54 0.64 0.08 6.79** Metacognitive beliefs

Cognitive conflict 1 0.61

The need to control thoughts 1.22 0.75 0.13 9.39**

Positive beliefs 1.03 0.64 0.11 9.06** Danger and uncontrollability of 1.28 0.72 0.12 9.76** thoughts

Cognitive self-consciousness 0.72 0.45 0.10 9.96** As you can see, the standard factor loadings are greater than 0.32, which according to Tabachnick and Fidel's view indicate the model's approval. Based on Tabachnick and Fidel's views, the factor loadings of 0.71 are standard, and greater than that are excellent; factor loadings between 0.63 to 0.7 are very good, factor loadings between 0.55 to 0.62 are good, factor loadings between 0.45 and 0.55 are relatively good, factor loadings between 0.32 and 0.44 are low, and factor loadings lower than 0.32 are weak. As illustrated in the above table, the Zahra Saberi et al 107 lowest factor loading belongs to active addiction with the value of 0.35 and the highest factor loading belongs to the personal meaning production of with the value of 0.87. In general, the results indicate that all the observed variables measure their respective latent variables in an acceptable way. Table 5: Determining the Effects of the Studied Scales without Considering the Mediator Variables Standard Paths Effect Total C.R. Sig. error Meta Spiritual intelligence → 0.03 0.03 0.03 0.93 0.35 cognitive Spiritual intelligence → Hardiness 0.22 0.22 0.05 4.44 0.001 Meta cognitive → Hardiness 0.17 0.17 0.06 2.79 0.005 Addiction Hardiness → 0.51 0.51 0.25 2.03 0.04 potential Addiction Meta cognitive → 0.11 0.20 0.27 0.43 0.66 potential Addiction Spiritual intelligence → 0.33 0.43 0.15 2.20 0.02 potential The above table shows that apart from the relationship between spiritual intelligence and metacognitive beliefs and the relationship between metacognitive beliefs and addiction, other relationships had a significant effect on their respective variables; in such a way that the significance of the effect of the relationship between spiritual intelligence and academic hardiness and addiction was observed. Metacognitive beliefs had a significant effect on the academic hardiness; and the academic hardness had a significant effect on the addiction potential. Finally, spiritual intelligence had a significant and acceptable effect on the university students' addiction potential.

Table 6: Determining Direct and Indirect Effects by Considering the Mediator Variables Indirect Total effectDirect effect effect

Mediator Paths Sig. variable

error error error

parameter parameter parameter

Standard Standard Standard Standard

β β β 0.031 0.033 0.031 0.033 ------0.35 Spiritual intelligence- --- metacognitive Spiritual intelligence- 0.22** 0.03 0.22** 0.05 0.005 0.006 Metacognitive 0.001 hardiness 0.17** 0.063 0.17** 0.063 ------0.005 Metacognitive-hardiness --- -0.51* 0.25 -0.51* 0.25 ------0.041 Hardiness-addiction --- Metacognitive-addiction -0.20 0.15 -0.11 0.27 -0.09 0.05 Hardiness 0.66 Spiritual intelligence- -0.43** 0.14 -0.33 0.15 -0.10** 0.02 Metacognitive-0.027 addiction hardiness 108 Research on Addiction Quarterly Journal of Drug Abuse

Results show the predictive power and the effects of each of the studied variables in the hypothesized model. Furthermore, the results of this study reveal that spiritual intelligence by mediating academic hardiness and metacognitive beliefs can explain and predict 10% of the addiction potential in the university students.

Discussion and Conclusion This study indicated that the variables of spiritual intelligence, metacognitive beliefs, and academic hardiness have a significant effect on addiction potential. These three variables had the ability to predict 10% of the drug potential variable. The examination of this model revealed that the model of the causal relationships of spiritual intelligence with the mediation of metacognitive beliefs and academic hardiness had a desirable goodness of fit. Previous studies, such as the results of the study conducted by Thalbourne (2007), have shown that religious beliefs can influence the individuals’ other personality and cognitive constructs. However, so far, no study has investigated the effect of spiritual intelligence relationships by the mediating role of cognitive variables (such as metacognitive beliefs) and personality traits (such as hardiness) in a model. Spiritual intelligence includes having meaning and responsibility toward life and values, having a sanctity in life, having a balanced understanding of the material and spiritual values, and believing in the improvement of the world. Spiritual intelligence is necessarily the basis of effective and efficient performance of rational and emotional intelligence (Emmons, 1999; Zohar & Marshall, 2000). Therefore, logically, spiritual intelligence should play a determining role in addiction, and at the same time should affect other cognitive and personality constructs. The examination of the model showed that spiritual intelligence has a significant, direct, and negative relationship with the probability of the tendency toward addiction. The more a person has higher spiritual intelligence, the less likely he will be toward drug use and addiction. Previous studies (for example, Marashi et al., 2012) have shown that the individuals with higher spiritual intelligence have more adaptability and protect their psychological health in stressful conditions. This finding means that university students with higher spiritual intelligence are less likely to use substance. Yong, Hamann, Borland, Fong, and Omar’s (2009) study revealed that 85 percent of Thai Buddhists and Malaysian Muslims believed that religious teachings and attitudes had led them to stop smoking. Other studies also represent a negative correlation between having religious attitudes and the tendency toward substance abuse. Among these studies, one can mention the studies conducted by Leigh, Bowen, and Marlatt (2005), Regnerus and Elder (2003), Stewart (2001), and Zargarr et al. (2008). At the heart of the spiritual intelligence are both the construct of intelligence and the construct of spirituality. It allows the individuals to perceive situations Zahra Saberi et al 109 and conditions better and flexible as much as possible, and, in fact, allows the individuals to see the situations and conditions of life in their control and look for more ability in their own to manage them (Tirri, 2006). Moreover, in explaining the findings of that study, it can be stated that due to the role of spirituality and its domination on all aspects of human life, spirituality plays a determining role in preventing a person from the tendency toward narcotics (Siegle & Senna, 1997). Perhaps the reason for observing the significant relationship between spiritual intelligence and academic hardiness in the present research can be attributed to this. Spiritual intelligence as the ultimate intelligence that represents the semantic issues and includes the psychological adaptability capacities, is based on non-material aspects and includes spiritual sources, values, and characteristics that enhance our performances (Akbari Zadeh, Bagheri, Hatami, & Hajivandi, 2011; Safari, Jenaabadi, 2015). The findings of previous research indicated that having religious attitudes and beliefs is accompanied by reduction of psychological stresses and prevention of high- risk behaviors such as smoking, alcohol and other drugs consumption; religiosity and spirituality decrease the impact of life pressures on the tendency toward drug use, and over time, develop this ability in individuals to reduce the amount of drug use and start the withdrawal process more easily and quickly (Wills, Yaeger, & Sandy, 2003). In other words, the individuals with high spiritual intelligence, in issues such as believing that God helps humans in the difficulties as well as believing that human is a free creature and is responsible for his actions and that he can reach calm through prayer, the reactions of these individuals in coping with psychological pressures are affected; and the high spiritual intelligence plays an influential role in reducing their tendency toward drugs with the purpose of relieving their pains. Spiritual intelligence was also related to academic hardiness and could significantly predict this variable. Religious people, because of their inner beliefs, evaluate the stressful events differently and show greater compromise and hardiness in different situations. In the current research, spiritual intelligence was also related to the academic hardiness which is consistent with the findings of the studies conducted by Yavari, Nouri, & Hasan Abadi (2015), Sheikholeslami, Sotoudeh Navroudi, Zeinali, & Talebi (2013), Turiano, Whiteman, Hampson , Roberts, & Mroczek (2012), and Sanchez & Nappo (2008). Being religious can moderate the effects of the severe crises in life. The components of the system of giving meaning to life which are influenced by religion (including beliefs, expectations, and goals) act as the central point of a person’s emotions and actions (Silberman, 2005); it also leads the person to show greater hardiness against problems, have more control on his behaviors and actions, feel less stressful in the time of tension and less vulnerability treats him, and in fact, he has a better mental health and finally shows a lower tendency toward addiction. 110 Research on Addiction Quarterly Journal of Drug Abuse

Findings showed that spiritual intelligence did not have a significant relationship with metacognitive beliefs. The literature on the relationship between spirituality and metacognitive beliefs has contradictory results (Silberman, 2005). It is accepted by most researchers that the higher the individual's level of religiosity, the meaning that he gives to himself and the world around him will be more accompanied by a sense of being valuable and purposefulness; in such a way that in the time of the appearance of stress and tension acts like a shield or protection. Through his cognitive beliefs, the individual moderate the psychological stress. This point was shown in the present study so that metacognitive beliefs were related to the academic hardiness variable and predicted it significantly. Of course, more future research is needed to further clarify the relationship between spiritual intelligence and metacognitive beliefs. In the end, considering that strengthening religious beliefs at all stages of life is a preventive measure to reduce psychological disorders, the findings of the current study can be taken into account, especially in the framework of drug abuse and addiction prevention programs in adolescents and young university students. These findings suggest that with education and promotion of religious beliefs, it can be expected that the tendency toward drug use in adolescents and young people will be significantly reduced. One of the limitations of this research is lack of information and previous modeling in the area of examining the relationship between spiritual intelligence constructs and addiction potential. Despite the fact that it was revealed that spirituality can have a significant impact on reducing the likelihood of the tendency toward substance, there was little information about the details of the relationship between such constructs and addiction potential. It is suggested that the hypothesized model in this research be investigated in other groups (e.g., students, employees of the offices and occupations) in order to maximize the generalizability of the results. Since the results of this study revealed that spiritual intelligence and academic hardiness as deterrent factors play a role in addiction prevention, it is recommended that the role of these factors in reducing addiction tendency be investigated in interventional researches and clinical trials. As a practical recommendation, it can be stated that the provision of the necessary trainings with the aim of increasing spiritual intelligence to the students and university students can play a significant role in reducing the growing dependency of these age groups to drug use. Regarding this probability that gender and gender-related factors might be involved in the relationship between spiritual intelligence and academic hardiness with addiction potential, it is suggested that the role of spirituality and spiritual intelligence in the probability of tendency toward drug use among women and men be investigated in subsequent researches. Zahra Saberi et al 111

Critical thinking

Personal meaning production Spiritual intelligence Transcendental awareness

Conscious state expansion Cognitive conflict

Positive Commitment beliefs

Cognitive Effort Academic Metacognitive self- hardiness beliefs consciousness

Challenge Uncontrollability

Affective Thought control

Active addiction Addiction potentail Passive addiction

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Abstract The Effect of Objective: The present study was Subliminal conducted to determine the effect of subliminal presentation of smoking pictures Presentation of on addiction potential, addiction acknowledgement, and addiction craving. Method: A quasi-experimental research Smoking Pictures method along with pretest-posttest/ control group design was employed in this study. on Addiction The statistical population of this research included the male smokers who had Potential, Addiction presented to Rasht addiction treatment clinics (District one) in 2017. From among Acknowledgement, them, 40 men were selected through convenience sampling method and were and Addiction randomly assigned to one experimental group (n=20) and one control group (n=20). Craving The Iranian Addiction Potential Scale (Zargar, 2006), Addiction Acknowledgement Scale (Weed et al., 1992), and Drug Craving Scale (Somoza et al., 1995) constituted the data collection instruments. Following the administration of the pretest, smoking pictures were Shabahang, R. , Rezaei, S. , subliminally presented to the experimental Bagheri Sheykhangafshe, F. group, while the control group was exposed to subliminal neutral color pictures. After completing the task, both groups were subjected to the post-test. Results: The Shabahang, R. , results of this study showed that there was a M.A. Student in General Psychology, significant difference between the mean Tehran University, Tehran, Iran, ranks of addiction craving scores in the Email: [email protected] experimental group, which means that the Rezaei, S. , rate of craving increased in the Assistant Professor, Department of experimental group in comparison with the Psychology, Guilan University, Rasht, control group. However, there was no Iran significant difference in variables of Bagheri Sheykhangafshe, F. addiction potential and addiction M.A. Student in General Psychology, acknowledgement (P> 0.05). Conclusion: Gu ilan University, Rasht, Iran Considering the significant effect of subliminal presentation of smoking pictures on addiction craving, the subliminal presentation can be used in clinical settings Research on Addiction as a therapeutic and preventive method for Quarterly Journal of Drug reducing addiction craving. Abuse Keywords: subliminal presentation, smoking pictures, addiction potential, Presidency of the I. R. of Iran addiction acknowledgement, addiction Drug Control Headquarters craving Department for Research and Education Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir

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Introduction Research on the question of whether external information can be effective on perceptions, motivations, decisions, and emotions, in different areas of psychology such as an organization (O'Helman et al., 2012) , Excitement (Zejunc, 1980), Clinical (Jones et al., 2013), cognitive (Keylestrom, 1987) and social (Fazio, 2001) is expanding (quoted by Van in Plog, Burrowschat, Versluis, & Verkoyl, 2017). Subliminal presentation is a classical but controversial topic in empirical psychology (Dehaene & Changeux, 2011). How much information and knowledge can be obtained through subliminal presentation, and how this non-significant cognitive process occurs, is still known as a familiar and challenging topic (Armstrong & Dienes, 2013). Research shows that many of the complex mental behaviors and mental activities of humans take place without consciousness. The nonsensical processing refers to situations where an unobtrusive stimulus on thoughts, emotions, actions, learning, or memory is effective (Kawakami & Yoshida, 2015). In fact, the results of studies indicate that high-level mental processes from activation to implementation and, finally, completion of the action can be carried out completely unconsciously (Hassin, 2013). As individuals continuously encounter a large amount of information, unconscious processes act as an adaptive process that enables the person to make signs and thereby identify and interpret changes in the environment and quickly begin to respond to behavioral consciousness before it can get more information (Wilson, 2002). Various studies indicate that sublingual induction is possible in brain activation. Neurons respond to thalamic inputs in the cortex. Of course, even peripheral stimuli that are unable to produce complete cortical responses and which are not sufficiently intelligent to detect can cause cortical activity (Ferrè, Sahani & Haggard, 2016). The growth of interpersonal trust can take place before and under consciousness (Huang & Murnighan, 2010). Perceptual grouping can also occur in the absence of consciousness (Montoro, Luna, & Ortells, 2014) and, of course, many other studies that show unconscious and unlucky are active in many processes. In fact, unconscious and unconscious can play an important role in many psychological, behavioral, cognitive, emotional, and even physiological and neurological aspects. Subliminal induction is a subset of cognitive unconsciousness in which the stimulus is not consciously perceived (Hassin, 2013). Subliminal induction occurs through an automated process that people are not aware of, reinforcing a number of beliefs. People are not able to protect themselves against this type of persuasion however (Verwijmeren, Karremans, Stroebe, & Wigboldus, 2013). In fact, subliminal messages can have a variety of effects on thoughts and behaviors (Hassin, 2013). Evidence suggests the effectiveness of Subliminal presentation of figures, words and brands in many aspects such as judging people (Bargh & Pietromonaco, 1982), advertising judgment (Channouf, 2000), self- Reza Shabahang et al 117 actualization (Baldwin, Carrel & Lopez, 1990). ), attitudes (Zajonc, 1980) and behaviors (Brasel & Gips, 2011) (quoted by Légal, Chappé, Coiffard, &Villard- Forest, 2012). Subliminal messages can be used to facilitate the processing of conscious information (Van den Bussche et al., 2009), impact choices and decisions (Bermeitinger et al., 2009), change mood (Monahan et al., 2000), increase the motivation (Arts et al., 2008), the effect on intent and intention (Hassin et al., 2007), impact cognitive mechanisms (Lau & Passingham, 2007), and even change political attitudes and the intention to vote (Hassin et al. 2007) (According to Shabahang, Soltani Shal, Nikogoftar, & Hakim-Javadi, 2017). Also, studies on subliminal induction indicate the impact of this method on a variety of subjects such as facilitating the voluntary action preparation (Le Bars, Hsu & Waszak, 2016), early perceptual analysis of targets, and the evaluation and selection of goals (Lu, Zhang, Hu, & Luo, 2011), source evaluation (Legal et al., 2012), beliefs and attitudes (Krosnick, Jussim, & Lynn, 1992), and predisposition (Smith, Dijksterhuis, & Chaiken, 2008). In fact, according to research findings, it should be acknowledged that subliminal information and data can be meaningfully explained beyond conscious consciousness. In fact, individuals can detect the incomplete object's back-end configuration in subliminal-scenes (Mudric & Koch, 2013), solve the logical problems presented subliminally (Karpinski et al., 2016), and induce from the sequence of images and pairs of subliminal words (quoted from Shabahang et al., 2017). In general, various studies have shown that subliminal induction can be effective, although under certain conditions and by taking into account a few points (Bretmininger et al., 2009; Karremans, Stroebe, & Claus, 2006; Verwijmeren et al., 2011 ) In this regard, according to a number of points and considering them, subliminal induction is recognized as an efficient and feasible method. Therefore subliminal perception and induction as well as subliminal messages are subjects that can relate to a wide range of phenomena and cause different consequences. One of the most important and prevalent phenomena that can be studied by subliminal perception and induction is addiction, a phenomenon that seems to be uncontrollable in spite of different approaches to prevention, treatment and control, and requires more innovative methods for prevention, treatment and control. Addiction is considered to be a fundamental issue in various aspects of health, which is defined as a behavior with a defect in control and harmful consequences. Addiction refers to a disordered in which a person has an emotional behavior which has initially had delightful effects. In general, these delightful effects are due to changes in the Mesolimbic dopaminergic system. Of course, many neurological and hormonal systems such as Mu opioid, Serotonin, Norepinephrine, Anandamide, and hypothalamic-pituitary-axis (HPA) are also effective (Brewer & Potenza, 2008; Volkow & Wise, 2005; quoted by Sussman, Lisha & Griffiths, 2011). Addiction can include various aspects such as internet addiction, pathological gambling, compulsive sexual behavior, compulsive

118 Research on Addiction Quarterly Journal of Drug Abuse buying, exercise dependence, addiction to food and even addiction to work (Zilberman, Yadid, Efrati, Neumark, & Rassovsky, 2018). ). One of the broadest and most important dimensions of addiction is drug and tobacco addiction. Alcohol and drug abuse is one of the most important and most prominent problems of mental health in contemporary societies (Weed, Butcher, McKenna, & Ben-Porath, 1992). Drugs, alcohol, tobacco, opium, heroin and many other synthetic and semi-artifacts being misused are a major part of today’s world. These materials not only affect the health of the individual but also directly affect the economy, the social, cultural and other dimensions of the lives of people (Kamkari & Shekarzada, 2012). Drug related disorders are also associated with a wide range of psychotic symptoms and disorders (Miller, Shields, Campfield, Wallace, & Weiss, 2007). Addiction potential, addiction acknowledgement, and addiction craving are some of the most important concepts of addiction. Addiction potential (addiction readiness) evaluates the readiness of vulnerability to drug abuse, whether or not a person is currently abusing drugs (Qadimi, Karami & Yazdanbakhsh, 2014). In fact, addiction readiness suggests that some people are susceptible to addiction and if they are exposed to it, they get addicted, while if they do not have the potential, they will not get addicted. In other words, before the person uses drugs, the condition and readiness for drug abuse is developed which is considered as readiness for addiction (Zeinali, Vahdat and Hamednia, 2007). Research findings show that unhealthy developmental backgrounds, addiction potential, and addiction readiness play a major role in the formation of addiction (Zeinali, 2013). Addiction acknowledgement also implies the acceptance and confirmation of addiction and drug abuse. Moreover, considering addiction craving, Rosenberg (2009) defines craving as a personal and multidimensional phenomenon in which the one tries to gain desirable feeling and win over undesirable ones. In fact, addiction potential, addiction acknowledgement, and addiction craving, are important aspects affecting the addiction process. Based on this, it is possible to make changes in addiction potential and addiction acknowledgement by using subliminal induction which might ultimately lead to changes in the addiction process. Little research has been done on the use of subliminal induction in addiction. But it's important to note that much of the studies in this regard report the effectiveness of subliminal induction in addiction. Palmatier & Bornstein (1980), using subliminal symbiotic stimulation as treatment adjunct, succeeded in maintaining more unwillingness to smoke. (As cited in Thornton, Igleheart & Silverman, 1987). Schurtmann, Palmatier & Martin (1982) found that when subliminal symbiotic stimulation in 6 sessions was given to the participants in a two-week period, the participants in the subliminal experimental group significantly participated more than those in the control group in the therapy program. In their research on heroin addicts in New York VA methadone clinic, Thornton, Igleheart & Silverman (1987) selected 47 addicts and placed them in Reza Shabahang et al 119 experimental and control groups. In addition to the usual methadone treatment program, both groups were subjected to verbal sublingual messages for 24 sessions (4 times a week for 6 weeks). For the experimental group the message "Mother and I are one" and for the control group the message "People are walking "were presented. The results of the study showed a significant reduction in the use of heroin and other prohibited drugs during the post-intervention period in the experimental group as compared with control group members. Also, Lundal et al. (2008) state the existence of subliminal distortions in addiction. In Lundal et al.’s (2008) study, subliminal images were presented to three non-smokers, smokers deprived for 12 hours and non-deprived smokers groups. The results showed that smokers group showed an error in the processing of smoking-related stimuli, while this did not occur in the non-deprived smokers group as well as the non-smokers group. Regarding the role of perception, induction and presentation of subliminal induction and messages in relation to a wide range of different phenomena and outcomes, studying the effect of subliminal induction on addiction as a phenomenon resistant to many treatments is required. . The lack of sufficient and of course original research in this regard, especially in Iran, underscores the importance of examining the role of subliminal induction in addiction. In sum, it is important to understand whether subliminal induction affects addiction potential, addiction acknowledgement, and addiction craving or not. The purpose of the present study was to investigate the effect of subliminal presentation of smoking pictures on addiction potential, addiction acknowledgement, and addiction craving.

Method Participants, sample, and sampling method A quasi-experimental research method along with pretest-posttest/ control group design was used in this study. The statistical population of this research included male smokers who had presented to Rasht addiction treatment clinics (District one) in 2017. Based on Cochran's Sample Size Formula, 40 men were selected through convenience sampling method and were randomly assigned to one experimental group (n=20) and one control group (n=20). The entry criteria for participants were: being a man, a smoker, between 20 and 40 years old as well as the consent of the participants. Exit criteria were physical and psychiatric visible disorders. It should be noted that all necessary licenses were taken from the relevant organizations before the research was carried out. Also, ethical considerations, including explanations regarding the subject, tools, and research objectives were fully respected in this research. After sampling and assigning the participants into the experimental and control groups, the participants were transferred to an environment having a laboratory with calm, and stress-free conditions to minimize the effects of extraneous variables and therefore reduce the possibility of obtaining results contrary to reality.

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Instruments 1. Iranian Addiction Potential Scale: This scale was designed by Wade et al. (1992), whose Iranian format was developed by Zargar (2006) in terms of the psychological and social status of Iranian society. The Iranian addiction readiness scale is composed of 36 items and 5 scales of the lie detector, which consists of two active-addictive sub-scales including antisocial behaviors, desire to use drugs, anxious attitudes, depression and excitement, and the passive addiction sub-scales including non-assertiveness and depression. Items are based on a Likert sale from I totally disagree (zero) to fully agree (3) with higher indicating more readiness for addiction and less grades as less willingness to addiction. Zargar, Najarian, and Naiami (2006) report the Structural validity correlation of this questionnaire as (0/45) using SCL-25 and the criterion validity of the scale is reported by conducting Cronbach's alpha 0.90. In another study Zarger et al. (2008) suggest a suitable validity and reliability for Iranian Addiction Potential Scale. The scale validity using Cronbach's alpha coefficient for the whole scale, active and passive scales was 0.90, 0.91 and 0.75, respectively. 2. Addiction Acknowledgement Scale: This scale was designed by Wade et al. (1992) to measure the inclination to alcohol and drug use, which consists of 13 items. Kurdmirza (2008) states that the validity of the Addiction Acknowledgement Scale is 0.75 using the Cronbach's alpha (quoted by Akbari Zardkina and Zandi, 2016). Rostami, Nosrat Abadi and Mohammadi (2007) reported Cronbach alpha of 0.73, and Minooei and Salehi (2002) report 0.62. in this study which was conducted on a sample of 1,000 high school students and 200 volunteer addicts, the addiction acknowledge scale could distinguish between people with Drug abuse potential and normal people. 3. Drug Craving Scale: This test is an 8-item self-report tool developed by Somoza et al. (1995) which evaluates the duration, frequency and severity of drug craving on a 5-point Likert scale from 0 to very high (4) Measures. This test has shown a high correlation with the severity of addiction, and its Cronbach's alpha coefficient is reported to be 88% (quoted by Basharpour, Mohammadi & Asadi Shishegaran, 2017). 4. The Geneva Smoking Pictures: Khazaal, Zullino, & Billieux’s study (2012) is a collection of smoking-related images containing 60 images related to smoking Khalil, Zollino & Bilox (2012) presented a set of images to 91 participants in their research to evaluate images based on classic emotional pictures validation which is designed by international affective picture system (NIMH center for the study of emotion and attention, 2002). Images were scored based on three dimensions of value (from positive to negative), emotional arousal (from high arousal to low arousal) and dominance (from concave to prominent). Participants were also evaluated by Fagerström test for nicotine dependence. Standard ratings for value, arousal and dominance of images were appropriate. Also, the results indicated a relationship between the arousal and Reza Shabahang et al 121 prominence of the images with a greater dependence on nicotine. Finally, the Geneva Smoking Pictures base provides images for researchers in the field of nicotine and tobacco.

Procedure After selecting the samples they were randomly assigned into experimental (20 participants) and a control (20 participants) groups. Then the addiction potential, addiction acknowledgement and addiction craving scales were presented to participants in both groups. After completing the pre-test, members of the experimental group were exposed to subliminal smoking images. Control group members were provided color subliminal images. The images were made using the Picture to Exe software and then were presented to the participants. In order to present subliminal effect each image was shown for 20, 40, or 60,000 milliseconds. In order to prevent people from predicting the time and place for providing the target stimulus, as well as their distraction from the point of fixation, the target stimulus had to be presented at intervals of 2 to 7 seconds (Ruys & Staple, 2008). In the same vein, images of each set at intervals of 2, 8, 5, 3, and 4 seconds and at a distance of 40 cm were presented to the participates. The images were presented in a direct point of view and at a radius of 15 cm from the center of the image on the computers screens in random order (Hosni, & Amiri, 2015). Previous research in this area shows that the model used in this study is of high validity in preventing the awareness of individuals from the subliminal stimulus (Staple, Coman, & Ruys 2002; Ruys & Staple, 2008). For more certainty, a briefing was held at the end of the experiment, which showed that none of the subjects were aware of the test objectives and that they were not able to recognize the images. In the end, after subliminal induction, both groups responded to addiction potential, addiction acknowledgement, addiction craving scales. Finally, the subjects were fully told about the research, and the subject, objectives and stages of the research were explained to them.

Results The age range of the participants in the study was from 22 to 40 years old with an average (and standard deviations) of 15.28 (1.20) years. Also, 60% of them were single and 40% were married, of which 15% had primary education degree, 45% had below high school diploma degree, 30% had diplomas and 10% had university degrees. 70 percent of these people had jobs, and 30 percent did not have a good income. Regarding the number of drug abstinence attempts, 24 percent less than 5 times, 47 percent between 5 and 10 times, and 29 percent have withdrawn from drug use more than 10 times. Also, 43.5% were under treatment for less than one month and 46.5% were under treatment for more than one month. The descriptive statistics of the variables studied is presented in Table 1 based on group and test type.

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Table 1: Descriptive Statistics of the Variables Studied based on Group and Test Type Experimental group Control group Pre-test Post-test Pre-test Post-test Standard Standard Standard Standard Variables mean mean mean mean deviation deviation deviation deviation Craving 17.55 1.60 20.85 1.69 14.05 10.13 14.35 5.83 Acknowledgement 18.75 2.61 18.25 3.16 32.30 18.53 30.65 16.32 Potential 95.65 8.35 82.50 8.44 138.65 59.92 135.75 47.71 In order to determine the effectiveness of the intervention used in this study and due to the mismatch of the data with the normal distribution and meaningfulness of the Kolmogorov-Smirnov test, for all three variables of craving, acknowledgement and potential in both the experimental and control groups (P <0.05) , the non-parametric Mann-Whitney U was used. These data, even after statistical transformations known as logarithms based on 10, did not have normal distribution. Before determining the difference between the post- test scores of the groups, the difference between the scores of the post-test groups was calculated from the pre-test scores. Then, the differentiated scores were compared. The results of Mann-Whitney U test for comparing the ranked mean for craving, acknowledgement and potential variables experiments and control groups are presented in Table 2.

Table 2: Mann-Whitney U Test Results for Determining the Difference between the Scores in the Studied Variables Ranked Mann-Whitney U variables groups Z Sig. mean statistics Experimental 24.20 Craving 126.00 -2.028 0.403 Control 16.80 Experimental 20.75 Acknowledgement 195.00 -0.140 0.889 Control 20.25 Experimental 21.35 Potential 183.00 -0.466 0.641 Control 19.65

As is shown in Table 2, there is a significant difference between the average craving scores in the experimental group after the intervention (presentation of the subliminal presentation of smoking images) (P <0.05, Z = -2.28 ; that is, Compared with the control group, the rate of craving increased in the experimental group (24.24 vs. 16.80). The results of this non-parametric analysis for two variables of acknowledgement and potential were not significant (P> 0.05).Graph 1 shows the score change trend for craving, acknowledgement, and potential variables in both the experimental and control groups in the pre- test and post-test phases based on ranked mean.

Discussion and Conclusions The purpose of this study was to investigate the role of subliminal smoking images in addiction potential, addiction acknowledgement, and addiction craving in drug abusing men. That is, is there any possibility of a change in Reza Shabahang et al 123 addiction potential, addiction acknowledgement, and drug abuse craving through the presentation of the subliminal smoking images? According to the results, the presentation of subliminal smoking images led to increased drug abusing craving participants, but did not affect the addiction potential and addiction acknowledgement. This means that the participants in the experimental group who were presented with subliminal smoking images showed a significant increase in the post-test craving scores compared to the control group participants who were presented with neutralized subliminal color images. This is indicative of an increase in drug abuse craving due to the presentation of subliminal smoking images. The results of this study are in line with the results of studies done by Palmatier & Bornstein (1980), Schurtman, R., Palmatier, J. & Martin, E. (1982), Thornton, Igleheart, & Silverman (1987) and Lundal et al.. (2008) which confirm the effectiveness of subliminal interventions in addiction. In a study done by using subliminal symbiotic stimulation as adjunct treatment for addictive behavior, Palmatier & Bornstein (1980) used rapid smoking method to help smokers abandon their habits. After the completion of the 12-session treatment, all smokers in both the control group and the subliminal experimental group were reluctant to smoke. But after one month, participants in the experimental group who received the simultaneous subliminal messages kept the cigarette tendency (67% vs. 13%) more than the control group (quoted by Thornton, Igleheart, & Silverman, 1987). In a study conducted on 72 alcoholic people in a resident treatment program, Schurtman, R., Palmatier, J. & Martin, E. (1982) found that when the subliminal symbiotic stimulation was given to the participants in 6 sessions in a two-week period, the members of the subliminal experimental group participated more in the therapeutic program than those in the control group. Also, in a three-month follow-up test, among those who were initially more symptomatic, those who received the message "Mom and I were the one", showed decreased anxiety and depression, increased self- esteem, and decreased alcohol consumption compared to the control group. In their research on heroin addicts in New York's Methadone Clinic, Thornton, P., Igleheart, H., & Silverman, L. (1987) selected 47 addicts and placed them in experimental and control groups. In addition to the usual methadone treatment program, both experimental and control groups were presented with 24-hour verbal sublingual messages (4 times a week for 6 weeks). In the experimental group, the message "Mother and I are one" and to the control group, the message "People are walking" were presented. The results showed a significant reduction in the use of heroin and other prohibited drugs during the post-intervention period in the experimental group compared with the control group members. Also, the results of follow-up test showed that the experimental group experienced more control over habits, had better job performance and, of course, more positive dreams in relation to their spouse or child than the control group. Also, Lundal et al. (2008) note the existence of subliminal bias in addiction and addiction relapse. In Lundal et al.’s

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(2008) study, subliminal -images were presented to three groups: the non- smoker group, the smokers deprived for 12 hours group, and non-smokers group. The results showed that smokers showed an error in the processing of smoking- related stimuli, while this did not happen in the non-smokers group deprived of smoking as well as non-smokers group. In fact, tobacco deprivation led to increased subliminal processing of the smoking-related stimuli, while it had no effect on the processing of subliminal processing of emotional stimuli. The results of this study, as studies of Palmeriter and Burnstein (1980), Shartman, Palmter & Martin (1982), Thorenton, Ellhart & Silverman (1987), and Lundal et al. (2008), show the effect of subliminal induction on addiction. The presentation of subliminal smoking images to the experimental group in comparison with the control group (providing subliminal color images) led to increased addiction craving in them. Indeed, participants in the experimental group showed a significant increase in the post-test scores in comparison with the control group participants, indicating an increase in the potential of addiction craving due to the presentation of smoking images. According to the results of the present study as well as those of the previous studies, subliminal induction can be an effective factor in addiction. This means that using subclinical induction and programs can reduce addiction and related variables such as drug abuse craving in addicted people. Therefore, subliminal programs can be used as the main or complementary methods along with the main methods for preventing, treating and controlling addiction. Finally, it is important to note that the present study suffered from a number of limitations. In this research study only male participants participated and since gender can be considered a determining factor, it is suggested that in future studies, female participants be examined to measure gender difference in subliminal induction of smoking images and their effect on addiction potential, addiction acknowledgement, and addiction craving. Extraneous variables such as biological, social, cultural, and economic conditions of the participants in the present study were not completely controlled for. In the same vein, it is suggested that future research be done by controlling and evaluating the above variables. It is also suggested that other studies in the area but in different environments, and with larger number of participants be done so that the results become generalizable. Based on the results of the present as well as previous studies, it is recommended that research on the possibility of preventing, treating and controlling addiction through subliminal programs, either as a primary method or as a complementary method be done in order to provide more information and background regarding the effective impact of subliminal induction on addiction. Reference Akbari Zardkhan, Saeed & Zandi, Saeed. (2016). Anticipating student addiction acknowledgement based on their self-efficacy and social support. Knowledge & Research in Applied Psychology, 17 (2): 36-44. Reza Shabahang et al 125

Bashpour, Sajjad; Mohammadi, Nasim & Asadi Shishegaran, Asadi. (2017). The effectiveness of cognitive self-education in craving, the severity of cognitive dependence and cognitive flexibility of drug-dependent individuals. Clinical Psychology, 9 (3): 93-103. Bermeitinger, C., Goelz, R., Johr, N., Neumann, M., Ecker, U. K. H., Doerr, R. (2009). The hidden persuaders break into the tired brain. Journal of Experimental Social Psychology, 45(2): 320–326. Dehaene, S., Changeux, J. P. (2011). Experimental and theoretical approaches to conscious processing. Neuron, 70(2): 200-227. Dostkam, Mohsen; Pourheidari, Sepideh; Heydari, Mahmoud & Shahidi, Shahriar. (2010). Mood induction .)by using subliminal emotional faces. Applied Psychology, 4 (2): 7-19. Ferrè, E. R., Sahani, M., Haggard, P. (2016). Subliminal stimulation and somatosensory signal detection. Acta Psychologica, 170: 103-111. Ghadimi, Azade; Karami, Jahangir & Yazdanbakhsh, Kamran. (2014). The relationship between initial maladaptive schemata and metacognitive beliefs on addiction potential. Fundamentals of Mental Health, 17 (2); 67-73. Hassin, R. P. (2013). Yes It Can: On the Functional Abilities of the Human Unconscious. Perspectives on Psychological Science, 8(2); 195-207. Hosna, Jafar & Amiri, Sohrab. (2015). Performance in personal and non-personal moral judgments based on the dimensions of positive and negative subliminal emotional experiences. Quarterly Journal of Social Cognition, 4 (8): 48-61. Huang, L., Murnighan, K. (2010). What’s in a name? Subliminally activating trusting behavior. Organizational Behavior and Human Decision Processes, 111(1): 62-70. Kamkary, K., Shokrzadeh, S. (2012). Scale standardization tendency to addiction (with emphasis on MMPI-ARF) secondary school students and pre – university. Pelagia Research Library, 2(5): 1868-1879. Karremans, J. C., Stroebe, W. & Claus, J. (2006). Beyond Vicary’s fantasies: The impact of subliminal priming and brand choice. Journal of Experimental Social Psychology, 42(2006), 792-798. Kawakami, N., Yoshida, F. (2015). Perceiving a story outside of conscious awareness: When we infer narrative attributes from subliminal sequential stimuli. Consciousness and Cognition, 33: 53-66. Khazaal, Y., Zullino, D., Billieux, J. (2012). The Geneva Smoking Pictures: Development and Preliminary Validation. European Addiction Research, 18(3): 103- 109. Krosnick, J. A., Jussim, L. J., Lynn, A. R. (1992). Subliminal conditioning of attitudes. Society for Personality and Social Psychology, 18(2): 152-162. Le Bars, S., Hsu, Y. F., Waszak, F. (2016). The impact of subliminal effect images in voluntary vs. stimulus-driven actions. Cognition, 156: 6-15. Légal, J. B., Chappé, J., Coiffard, V., Villard-Forest, A. (2012). Don't you know that you want to trust me? Subliminal goal priming and persuasion. Journal of Experimental Social Psychology, 48(1): 358-360. Leventhal, A. M., Waters, A. J., Breitmeyer, B. G., Miller, E. K., Tapia, E., Yisheng, L. (2008). Subliminal processing of smoking-related and affective stimuli in tobacco addiction. Experimental and Clinical Psychopharmacology, 16(4): 301-312. Lu, Y., Zhang, W. N., Hu, W., Luo, Y. J. (2011). Understanding the subliminal affective priming effect of facial stimuli: an ERP study. Neuroscience Letters, 502(3): 182- 185. Miller, C. S., Shields, A. L, Campfield, D., Wallace, K. A., Weiss, R. D. (2007). Substance Use Scales of the Minnesota Multiphasic Personality Inventory: An

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Exploration of Score Reliability Via Meta-Analysis. Educational and Psychological Measurement, 67(6): 1052-1065. Minooie Mahmoud & Salehi Mahdiyeh. (2002). The validity, reliability, and standardization of AAS, APS, and MAC-R tests in order to identify exposed and susceptible drug abuse among high school male students in Tehran. Research on Addiction, 11 (3): 77-105. Montoro, P. R., Luna, D., Ortells, J. J. (2014). Subliminal Gestalt grouping: Evidence of perceptual grouping by proximity and similarity in absence of conscious perception. Consciousness and Cognition, 25: 1-8. Rosenberg, H. (2009). Clinical and Laboratory assessment of the subjective experience of drug craving. Clinical Psychology Review, 29(6): 519 – 534. Schurtman, R., Palmatier, J. R., Martin, E. S. (1982). On the Activation of Symbiotic Gratification Fantasies as an Aid in the Treatment of Alcoholics, International Journal of Addictions, 17(7): 1157-1174. Shabahang, Reza; Soltani Shal, Reza; Nikmatfar, Mansour & Hakim-Jewadi, Mansour. (2017). Effectiveness of subliminal induction of emotional effects of the face on the mood. Quarterly Journal of Social Psychology, 7 (27); 35-48. Smith, P. K., Dijksterhuis, A., Chaiken, S. (2008). Subliminal exposure to faces and racial attitudes: Exposure to Whites makes Whites like Blacks less. Journal of Experimental Social Psychology, 44(1): 50-64. Sussman, S., Lisha, N., Griffiths, M. (2011). Prevalence of the Addictions: A Problem of the Majority or the Minority?. Evaluation & the Health Professions, 34(1): 3-56. Thornton, P. I., Igleheart, H. C., Silverman, L. H. (1987). Subliminal Stimulation of Symbiotic Fantasies as an Aid in the Treatment of Drug Abusers. International Journal of Addictions, 22(8): 751-765. Van der Ploeg, M. M., Brosschot, J. F., Versluis, A., Verkuil, B. (2017). Peripheral physiological responses to subliminally presented negative affective stimuli: A systematic review. Biological Psychology, 129: 131-153. Verwijmeren, T., Karremans, J. C., Stroebe, W., Wigboldus, D. H. J. (2011). The workings and limits of subliminal advertising: The role of habits. Journal of Consumer Psychology, 21(2): 206–213. Weed, N. C., Butcher, J. N., McKenna, T., Ben-Porath, Y. S. (1992). New Measures for Assessing Alcohol and Drug Abuse With the MMPI-2: The APS and AAS, Journal of Personality Assessment, 58(2): 389-404. Zargar, Yadollah; Najarian; Bahman & Naiami, Abdul Zahra. (2008). Investigating the relationship between personality traits (excitement, assertiveness, psychological hardiness), religious attitude and marital satisfaction with drug addiction potential. Journal of Educational Sciences and Psychology, 1 (3): 99-120. Zeinali, Ali. (2013). Extending and validating the Student Addiction potential-Editing Inventory. Quarterly Journal of Educational Psychology, 4 (4); 1-11 Zilberman, N., Yadid, G., Efrati, Y., Neumark, Y., Rassovsky, Y. (2018). Pers onality profiles of substance and behavioral addictions. Addictive Behaviors, 82: 174-181. Rostami, Reza; Nasrat Abadi, Masoud & Mohammadi, Fatemeh. (2007). Preliminary evaluation of diagnostic accuracy of APS, MAC and AAS scales. Psychological Research, 10 (2): 32-41. Zeynali, Ali; Vahdat, Roghieh & Hamednia, Safar. (2017). Study of pre-addiction backgrounds of addicts and comparing them with non-addicted healthy people. Research on Addiction, 33 (9); 149-168.

Abstract Prediction of Retaining and Resigning from Objective: The present study aimed at the prediction of retaining and resigning Addiction Treatment from addiction treatment interventions Interventions based on based on personality disorders. Method: A descriptive-correlational research Personality Disorders design was employed for the conduct of this study. The statistical population of this study consisted of all addicts in Ardabil city who presented to one of the addiction treatment centers. From among this population, 349 participants were selected through multi-stage cluster sampling. Data were collected Ghamari Kivi, H. , Khoshnoodnia using Millon Clinical Multiaxial Chomachaei, B. Inventory (MCMI-III). Results: The results of discriminant function analysis showed that Schizoid, Avoidant, Depressive, Dependent, Histrionic, Narcissistic, Antisocial, Sadistic, Compulsive, Negativistic, Self- Defeating, and Schizotypal personality disorders had the predictive power of addicts' retaining and resigning from Ghamari Kivi, H. addiction treatment interventions; University Professor, Department of however, Borderline and Paranoid Counseling, University of Mohaghegh personality disorders could not predict Ardabili it. Conclusion: Therefore, it can be concluded that personality disorders Khoshnoodnia Chomachaei, B. predict addicts' retaining and resigning MA. in Psychology, University of from addiction treatment interventions. Mohaghegh Ardabili, Ardabil, Iran, These findings have important implications for camps and addiction Email: [email protected] treatment centers. Keywords: personality disorders, retaining and resigning from addiction treatment interventions, addiction Research on Addiction

Quarterly Journal of Drug Abuse

Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir

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Introduction Today, drug use is considered one of the major problems of human societies. Various pieces of evidence suggest that addiction is currently one of the most costly and biggest problems in our society, and young people, as the engine of the community, are the most vulnerable stratum in this regard (Rafi'ea, & Alipour, 2015). For this reason, human societies have been trying for many years to come up with rigorous legal measures to control, eliminate or mitigate the prevalence of drug abuse in the general population (Newton, 2011). According to the UN report in 2005, the highest proportion of heroin and opium addicts is in Iran and 20% of the 15-to-60-year-old population of Iran is engaged in drug abuse (Ekhtiari & Jillson, 2008). Addiction can occasion a variety of physical harm, including malnutrition, physical illness, mortality, and suicide (Schiffer, Pedersen, Broers, Widdershoven, & Denollet, 2008); family problems, such as divorce, separation, and family violence; and psychological problems like aggression, depression, stress, anxiety, and psychotic states (Alegría et al., 2011). Also, the problematic consumption of substances has extensive psychosocial consequences, including difficulty in achieving life goals and increased interpersonal conflicts (Sloan et al., 2011). Despite the widespread injuries of drug use, the examination of underlying mechanisms of chronic drug use is a consciousness-raising source that can develop appropriate interventions. Research in the field of etiology of substance use has directed us to such factors as personality and its strong role in interaction with other environmental factors in the onset and continuation of drug use (Dermody, Cheong, & Munuck, 2014). Personality has also a pivotal role in exploring the factors leading to addicts' departure from treatment. Some research findings suggest that personality and behavioral characteristics are among the possible barriers to the success of drug-dependent people's treatment (Myrsth, Pallesen, Molde, Johnsen, Lorvik, 2009; Doran, McChargue, & Cohen, 2006). Personality is an aspect of human life that allows for predicting how a person will behave in certain circumstances (French & Savred, 1992; as cited in Bahri, & Yousefi, 2013). According to a definition of personality, which has obtained almost an inclusive consensus among scholars, personality is regarded as certain behavioral and thinking patterns that determine how a person is adapted to the environment (Atkinson et al., 2002; as cited in by Yousefi, Chalbianlou, & Baghban Novin, 2015). Personality can be compatible or incompatible. Incompatibility arises when people are unable to adapt their thinking and behavior to the environment and its changes. Compatibility or lack of it is closely related to resilience and a healthy person has some degree of resilience along with stability. However, incompatible individuals exhibit non- resilient thoughts and behavior in dealing with situations where their reactions require new changes and decisions. Therefore, personality disorder refers to incompatible and non-resilient behaviors in dealing with the environment and Hossein Ghamari Kivi et al 129 situations (Skodol et al., 2011). Personality disorder is, in fact, the enduring intrinsic and behavioral experiences that are not in line with cultural criteria, have an inflexible penetration, begin with adolescence or youth, do not change over time, cause a person's dissatisfaction, and disrupt his/her functions (American Psychiatric Association, 2013). Research also emphasizes the role of personality disorders in drug abuse and the duration of drug use (Kimonis, Tatar, & Cauffman, 2012). Donnelan, Conger, & Bryant (2004) examined various addiction patterns and found that more than half of people with substance abuse suffered from at least one personality disorder and many of them suffered from more than one personality disorder. Rady, Salama, Elkholy, & Shawky (2013) investigated the dual diagnosis of personality disorder and substance abuse and found that 22% of the cases had a dual diagnosis. Moreover, 12% of the subjects suffered from personality disorder and 57.32% of patients with personality disorder were revealed to have a dual diagnosis with drug use disorder. Gaber & Abdelfattah (2016) studied personality disorders in substance abusers and showed that dependent, borderline, and antisocial personality disorders predict subjects' exit from therapeutic interventions and relapse into drug use. Brorson, Arnevik, Rand-Hendriksen, & Duckert (2013) also carried out a meta-analysis and examined 122 studies on the factors leading to exit from addiction treatment and reported the existence of a significant relationship between personality disorder and exit from addiction treatment. By examining retention in and resignation from psychological treatment of cocaine addiction, Fernandez- Montalvo & López-Goñi (2010) showed that those who exit the treatment significantly suffer from higher levels of antisocial and histrionic personality disorders. The results also showed that all patients with histrionic personality disorder resigned from cognitive therapy. However, some other studies have shown differing findings. For example, Krieger et al. (2016) compared the process of addiction treatment between individuals with and without personality disorder and indicated that there was no significant difference between the two groups in terms of adherence to and resignation from the treatment process. The etiology and prevention of substance abuse seem necessary (Denney & Connor, 2016) because drug treatment programs impose a heavy burden and costs on societies (Harrop & Catalano, 2016). A wealth of research has focused on the identification of preventive factors and the potential risks associated with drug use in the hope that the identification of the groups exposed to risk will lead to the development of effective strategies to prevent substance abuse (McConnell, Memetovic, & Richardson, 2014). In line with the research findings mentioned above, it can be argued that some personality disorders affect the process of treatment and drug use withdrawal in the phenomenon of retention in and resignation from addiction therapy. Therefore, considering the importance of the issue of addiction and its huge costs on society, the contradiction and the research gap in this realm, the present research seeks to explore which of the

130 Research on Addiction Quarterly Journal of Drug Abuse personality disorders is effective in the retention in and resignation from treatment interventions.

Method Population, sample, and sampling method A descriptive-correlational research design was employed for the conduct of this study. In this method, the individuals resigning from and adhering to addiction treatment interventions and personality disorder are considered as the criterion and predictor variables, respectively. The statistical population of this study consisted of all addicts in Ardabil city who had presented to one of the addiction treatment centers. According to the report released by the Ardabil Drug Control Headquarter in 2014, about 9,000 people were placed in the cycle of addiction treatment. Based on Krejcie and Morgan's table, the sample size was considered 368 people. The sampling method was multi-stage cluster sampling method where the list of all addiction treatment centers licensed by the Welfare Organization or Ardabil University of Medical Sciences in Ardabil city was obtained. Then, from all the addiction treatment centers available in the four municipal regions of Ardabil, 16 centers were selected. After reviewing the addicts' profiles, the ones who had received health interventions and were newly accepted for this program were selected. The entry criterion in this research was the receipt of at least two weeks of addiction treatment interventions. This period had been considered in order to ensure the entry of the client into the treatment cycle. Eventually, after six months which had been considered as the full duration of addiction withdrawal, the attachment to or resignation from treatment stages was specified. In the end, due to the faulty completion of some questionnaires; the research sample size was reduced to 349 participants.

Instrument Millon Clinical Multiaxial Inventory (MCMI-III): A self-assessment scale with 175 yes/no items, which measures 14 clinical patterns of personality and 10 clinical symptoms. This instrument is used for the adults above 18 years of age who presented to mental health centers for psychological treatment or assessment. According to Millon's test, people with a Br score of 85 and above are diagnosed with personality disorder, and people with a Br score of less than 85 are diagnosed without the disorder (Millon & Davis, 2000). MCMI-III was constructed on the basis of the three steps of test development and validation described by Loevinger (1957). In fact, these three steps were followed to refine the test from item selection to scale development, and for assessing its external validity by using Millon's theory as a criterion. Various studies have shown a relatively good reliability of MCMI-III. For personality disorder scales, moderate correlations have been obtained from 0.58 to 0.93 with an average of 0.78. In the case of clinical syndrome scales, moderate correlations from 0.44 (post-traumatic stress disorder) to 0.95 (major depression) with an average of Hossein Ghamari Kivi et al 131

0.80 have been obtained (Craig, 1999). In validation studies, the reliability of these scales has been reported from 0.82 (debasement scale) to 0.96 (somatoform disorder) with an average of 0.91 for all scales (Craig, & Olson, 1998). In Iran, Sharifi (2002) reported the correlation between the raw scores belonging to the first administration and the re-test in the range of 0.82 (delusional disorder) to 0.98 (schizoid personality disorder). In the present study, the reliability of the test was calculated through the internal consistency method and the alpha coefficients of the scales were obtained in the range of 0.85 (alcohol use) to 0.97 (post-traumatic stress disorder).

Procedure In terms of data collection, it is noteworthy that, after sample selection in line with the entry criteria, the participants were asked to participate in the research. The request was given in such a way that they were given the right to choose. If willing, the consent form of the research participation was distributed among individuals to sign after reading it carefully. After that, the research was carried out. Data were analyzed using SPSS-23 by means of statistical method of diagnostic function.

Results The number of 188 drug addicts resigned from the treatment interventions and 161 ones remained permanently in treatment interventions. In terms of gender, 276 ones were male and 73 ones were female. In terms of marital status, 121 ones were single, 201 ones were married, and 27 ones were divorced.

Table 1: Descriptive Statistics of Social Support Scores in Resigning and Retaining Groups Resigning from the intervention Retaining in the intervention Variable Mean SD Mean SD Schizoid 55.01 20.98 49.69 22.83 Avoidant 60.95 20.30 50.05 19.10 Melancholic 58.03 19.39 53.06 17.27 Dependent 57.96 14.27 54.54 16.08 Histrionic 65.90 15.89 53.80 17.24 Narcissistic 76.53 14.72 68.14 14.66 Antisocial 65.38 21.18 56.66 24.40 Sadistic 76.92 14.26 68.79 14.07 Compulsive 74.34 15.94 67.00 14.16 Negativistic 73.63 15.54 66.50 14.31 Masochistic 73.47 13.03 67.09 13.92 Schizotypal 68.25 14.90 60.92 16.11 Borderline 70.77 14.88 68.61 13.87 Paranoid 66.11 18.75 66.24 18.22

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Before data analysis, the assumptions of the diagnostic function analysis were examined. The results of Kolmogorov-Smirnov test showed that the distribution of scores in the variables of dependent and sadistic personality disorders is not significant and it can be argued that the normality assumption of the data has been observed. Moreover, the results of M Box test show that the groups are not homogeneous in terms of the variance-covariance matrix. However, we can safely conduct the analysis due to the small difference in the sample size of the two groups as well as the high sample size of the groups. Table 2: Summary of Findings of Conventional Diagnostic Function and Some Important Information about Personality Disorder Important information pertaining to the discriminant Concurrent discriminant function analysis Eigenvalue 0.690 Percentage of variance 100 Canonical Correlation 0.639 Eta squared 0.408 Wilks' lambda 0.592 Chi square 196.796 Df 14 Significance of the discriminant function 0.001 Mean scores for the group retaining in treatment -0.915 Mean scores for the group resigning from treatment 0.750 Prediction of group membership %82.6

The results of discriminant analysis test in Table 2 showed that the eigenvalue enjoys the discrimination power of the diagnostic function between classes; in other words, Eta squared shows that 41% of the total dispersion is explained in the concurrent method, which is an acceptable percentage. On the other hand, the significance level indicates that the analysis of diagnostic function is significant in predicting the group resigning from addiction treatment (p <0.001). In other words, the diagnostic function has a significant diagnostic power in discriminating the two levels of the criterion variable. The mean scores of resigning group was obtained equal to 0.75 and it was obtained -0.915 for the group retaining in the addiction treatment. Therefore, the cut-off point for discriminating the two groups is equal to zero, which indicates that if the diagnostic function obtained a negative value for a person, then the individual is predicted to attach to the addiction treatment. The prediction of group membership shows that 82.6% of the sample units have been classified in the groups correctly.

Hossein Ghamari Kivi et al 133

Table 3: Evaluation of the Significance of Each Component of Personality Disorder Predictor variables Wilks' lambda F Df1 Df2 Sig. Schizoid 0.985 5.637 1 347 0.018 Avoidant 0.93 28.884 1 347 0.001 Melancholic 0.982 6.902 1 347 0.009 Dependent 0.987 4.853 1 347 0.028 Histrionic 0.882 50.970 1 347 0.001 Narcissistic 0.925 30.973 1 347 0.001 Antisocial 0.965 14.030 1 347 0.001 Sadistic 0.924 31.289 1 347 0.001 Compulsive 0.945 22.241 1 347 0.001 Negativistic 0.947 21.463 1 347 0.001 Masochistic 0.947 21.389 1 347 0.001 Schizotypal 0.947 21.345 1 347 0.001 Borderline 0.994 2.12 1 347 0.145 Paranoid 1.000 0.005 1 347 0.944 The levels of significance obtained in table 3 suggest that schizoid, avoidant, melancholic, dependent, histrionic, narcissistic, antisocial, sadistic, compulsive, negativistic, masochistic, and schizotypal personality disorders have a significant effect on diagnostic function analysis. Table 4: Power of Personality Disorder Components in Discrimination of Groups Standardized Unstandardized Structural Variable coefficients coefficients coefficients Schizoid 0.037 0.002 0.440 Avoidant 0.461 0.023 0.345 Melancholic 0.180 0.010 0.343 Dependent 0.270 0.018 0.331 Histrionic 0.509 0.031 0.290 Narcissistic 0.244 0.017 0.285 Antisocial 0.257 0.011 0.285 Sadistic 0.238 0.017 0.285 Compulsive 0.279 0.018 0.231 Negativistic 0.299 0.020 0.162 Masochistic 0.332 0.025 0.146 Schizotypal 0.221 0.014 0.136 Borderline 0.042 0.003 0.090 Paranoid -0.034 -0.002 -0.004 Constant - -13.405 - As it has been shown in Table 4, three sets of standardized, unstandardized, and structural coefficients have been presented for the concurrent discriminant functions. The standardized coefficients of the discriminant function are equivalent to the regression coefficients (beta) in regression analysis. These coefficients, in fact, show the discriminant weight of each variable in group differentiation. Using unstandardized coefficients of the equation, discriminant functions can be obtained. Therefore, respondents' scores are obtained placing each person's score in each of the variables pertaining to the functions.

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According to the column of unstandardized coefficients and the constant value of the concurrent discriminant function, the following prediction equation was obtained: D=13.405+0.002+0.023+0.010+0.018+0.031+0.017+0.011+0.017+0.01 8+0.020+0.025+0.014

Discussion and Conclusion Drug use disorder is one of the factors that directly and indirectly disrupts the order and discipline in the society, and has had a profound effect on legal, social, biological, and financial domain in the world both individually and socially. In addition to millions of people in the world who suffer from this social disorder, its effects and consequences also involve the lives of millions more indirectly (Kamarzarin, Zare, & Brookimilan, 2012). The aim of this study was to investigate the role of personality disorder in predicting retaining in and resigning from addiction treatment interventions. The results of discriminant function analysis showed that the eigenvalue enjoys the discrimination power of the diagnostic function between classes; in other words, Eta squared shows that 41% of the total dispersion is explained in the concurrent method, which is an acceptable percentage. On the other hand, the significance level indicates that the analysis of diagnostic function is significant in predicting the group resigning from addiction treatment in such a way that schizoid, avoidant, melancholic, dependent, histrionic, narcissistic, antisocial, sadistic, compulsive, negativistic, masochistic, and schizotypal personality disorders were revealed to have a significant effect on diagnostic function analysis. In other words, the diagnostic function has a significant diagnostic power in discriminating the two levels of the criterion variable. In addition, the prediction of group membership shows that 82.6% of the sample units have been classified in the groups correctly. This finding is consistent with the findings of the research conducted by Gaber, & Abdelfattah (2016), Brorson et al. (2013), Fernandez-Montalvo, & López-Goñi (2010); and is inconsistent with the findings of the research conducted by Krieger et al. (2016). To account for this finding, it should be acknowledged that substance abuse and addiction are among the most important problems of the present age, which have become global and have gone beyond the boundaries of health care and, thereby, they have become psychological, social, and family problems (Skiba, Monroe, & Wodarski, 2004). Research has shown that the first effective factor in high-risk behaviors is the psychological factor (Diclemente et al., 2013; as cited in Mokhtarnia, Zadeh Mohammadi, Habibi, & Mirzayifar, 2016). In addition, studies have shown that there are certain personality traits in drug-dependent individuals (Grana, Munoz, & Navas, 2008; as cited in Rahmanian, Zamani, & Alibazi, 2015). The presence of personality traits, such as dependency along with aggression towards others, lack of emotional development, ambivalence towards the individuals who have a role in personal life, lower threshold of tolerance, Hossein Ghamari Kivi et al 135 guilty feeling, and sexual role disturbance are considered as the characteristics that have has been observed in addicted people (Heidari Pahlavian, Amirzargar, Farhadinezab, & Mahjoub, 2003). However, in most cases, a number of factors and areas are involved in individuals' tendency to drug use while some factors play a more significant role in different cultural and individual-social conditions. Specific personality disorders and personality traits are among the most important factors in drug use tendency. Research also emphasizes the role of personality disorders in drug abuse and the duration of drug use (Kimonis, et al., 2012). In this regard, Donnelan, et al. (2004) have examined various addiction patterns and found that more than half of people with substance abuse suffered from at least one personality disorder and many of them suffered from more than one personality disorder. Therefore, personality disorder and drug use tendency can interfere with the treatment process and dissuade them from the completion of the treatment period. Generally, this trend occurs when people show impulsive behaviors and are intolerant and relentless (Mami, Ahadi, Naderi, Enayati, & Mazaheri, 2013). On the other hand, a positive and balanced image of the self, lack of determination, suggestibility, low resilience, and lack of personality development and growth, which are observed in personality disorders, predict individuals' resignation from treatment. Almost all the documents on addiction have referred to personality traits as a factor contributing to addiction tendency. In other words, personality failures and incompetence, and affinity with addicted individuals can be considered among the effective factors in the creation and continuation of addiction (Kaplan & Sadock, 2000) and, undoubtedly, inappropriate thoughts and emotions orient individuals to strange thoughts and causes the appearance of addiction. Therefore, one can emphasize the relationship between psychiatric pathology and drug use tendency (Shakerzadeh, 2013). Personality disorder clusters, especially cluster B, have the highest rate of comorbidity with substance abuse disorders (O,Connell, 1990), and the existence of destructive habits and self- control disruptions or the need for arousal and stimulus levels can be among the other reasons for the resignation from addicts' treatment process. On the other hand, when defense mechanisms are not effective and personality traits are impaired, it is difficult for people to adapt to the process of treatment. In addition, demotivation in, lack of interest in, and absence of collaboration in changing the conditions can also lead to individuals' resignation from the treatment process (Ball, Carroll, Canning-Ball, & Rounsaville 2006). The sample was limited to Ardabil city and no control was exerted on the way people asked for treatment (at their own request or under family pressure); thus, caution should be exercised in generalizing the results. The replication of this study in other cities and cultures while controlling the referral status of individuals to the addiction centers can produce more reliable results. It is also suggested that this study be conducted by differentiating among the types of drugs used by addicts. The current findings can be used in the pathology and

136 Research on Addiction Quarterly Journal of Drug Abuse treatment of people with addiction and in the design of therapeutic courses about personality disorders. Reference Alegría, A. A., Hasin, D, S., Nunes, E, V., Liu, S. M., Davies, C., & Grant, B. F. (2011). Comorbidity of generalized anxiety disorder and substance use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 71(9), 1187-95. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association, Washington, DC 5th Ed. Bahri, L., & Yousefi, F. (2013). Predictive role of personality traits in social skills, relationship with peers, and behavioral-emotional participation among students, Journal of Behavioral Sciences, 7 (3), 279-288. Ball, S. A., Carroll, K. M., Canning-Ball, M., & Rounsaville, B. J. (2006). Reasons for dropout from drug abuse treatment, symptoms, personality and motivation. Addictive Behaviors, 31, 320-330. Brorson, H. H., Arnevik, E. A., Rand-Hendriksen, K., & Duckert, F. (2013). Drop-out from addiction treatment: a systematic review of risk factors. Clinical Psychology Review, 33, 1010-1024. Craig, R. J. (1999). Overview and current status of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 72(3), 390-406. Craig, R. J., & Olson, R. (1998). Stability of the MCMI-III in substance abusing inpatient sample. Psychosocial Reports, 83, 1273-1274. Denney, A. S., & Connor, D. P. (2016). Serious juvenile offenders who have experienced emerging adulthood: Substance use and recidivism. Children and Youth Services Review, 67, 11-19. Dermody, S. S., Cheong, J., & Munuck, S. (2013). An evaluation of the stress negative affect model in explaining alcohol use. The role of components of negative affect and coping style. Substance use & Misuse. 48,297-308. Donnelan, M. B., Conger, R. D., & Bryant, C. M. (2004). The big five and enduring marriages. Journal of Research Personality, 38(5), 481-504. Doran, N., McChargue, D., & Cohen, L. (2006). Impulsivity and the reinforcing value of cigarette smoking. Addictive Behaviors, 32, 80-90. Ekhtiari, H., & Jillson, I. (2008). Prevention of opioid abuse in Iran. Quarterly journal of addiction, 2, 123-136. Fernandez-Montalvo, J., & López-Goñi, J. J. (2010). Comparison of completers and dropouts in psychological treatment for cocaine addiction. Addiction Research & Theory, 18(4), 433-441. Gaber, O. H., & Abdelfattah, M. E. (2016). Relationship between personality disorders and relapses among sample of substance abuse patients. Journal of Psychology and Clinical Psychiatry, 6(6), 00381. Harrop, E., & Catalano, R. F. (2016). Evidence-Based Prevention for Adolescent Substance Use. Child and Adolescent Psychiatric Clinics of North America, 25(3), 387-410. Heidari Pahlavian, A., Amirzargar, M., Farhadinezab, A., & Mahjoub, H. (2003). Comparative study of personality traits between drug addicts and non-addicts living Hossein Ghamari Kivi et al 137

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Abstract Prediction of Objective: The aim of this study was to Addiction Potential predict addiction potential based on the quality of work life and academic burnout based on Quality of among university students. Method: All Work Life and the employed students both in Azad and State universities of Tehran in the Academic Burnout academic year 2017-18 constituted the among University statistical population of this study. Using Cochran formula, 384 people were Students required to be selected as the sample units. The scales pertaining to Addiction Potential, Quality of Work Life, and Academic Burnout were employed for data collection. Results: The results Esmaeili Moghadam, F. , showed that addiction potential had a Mashayekh, M. , Eslami, S. negative relationship with the quality of work life but had a positive relationship with academic burnout. The results also indicated that active addiction potential is the best predictor of students' quality of Esmaeili Moghadam, F. life and academic burnout. However, M.A. Student, Rehabilitation passive addition potential did not Counseling, Islamic Azad University, contribute to the prediction of students' Tehran, Iran quality of work life dimensions. Mashayekh, M. Conclusion: The dimensions of students' Assistant Professor, Department of quality of work life and academic burnout Psychology, Islamic Azad University, have a decisive role in explaining the Karaj Branch, Karaj, Iran, e-mail: components of their addiction potential. [email protected] Keywords: addiction potential, quality of Eslami, S. work life, academic burnout, university Assistant Professor, Department of students Psychology, Islamic Azad University, Central Tehran Branch, Tehran, Iran

Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir 140 Research on Addiction Quarterly Journal of Drug Abuse

Introduction In the present age, the identification and control of the variety of natural and artificial forms of narcotic drugs, which are produced and distributed to underground markets, are highly difficult. According to US statistics, more than 250 types of psychotropic substances are trafficked and this rate is experiencing an increasing trend (Pickhardt, 2010; translated by Huoman, 2010). Drug use and its dependence have undesirable psychological, social, humanistic, etc. effects on the structure and functioning of the society, and the use of narcotic drugs damages cognitive processes and, then, addiction exacerbates psychosocial problems and increases the risk of unintentional injuries and death (Berg, 2007; translated by Seyyed Mohammadi, 2015). According to global reports, the age of onset of addiction is estimated to be between 16 and 20 years while it is still decreasing (Eiseman, 2017). According to the US National Drug Administration, 2.5 million people above the age of 12 years suffered from one substance-related disorder in 2004 (Sadock, Sadock & Ruiz, 2015). There are no accurate statistics on the number of drug addicts in Iran, but research findings indicate an alarming amount of addiction among young people. In a study carried out on 75,000 young people and adolescents aged 14 to 25 years old in different provinces of Iran in 2003, it was revealed that 27.5% of the population were drug addicts (Ahadi, & Dasht Bozorgi, 2017). Studies on young people's addiction also indicate the significant growth and even the critical status of this phenomenon in Iran. According to the report mentioned in Ahadi and Dasht Bozorgi's research (2017), 25% of university students in Tehran have drug use tendency and it is estimated that 5% of them have consumed narcotics. Also, due to the emergence of environmental stressors and job insecurity of employees in some industries, drug use tendency has witnessed an increasing trend among employees. The consumption of drugs has led to reduced productivity of employees in companies and institutions in the long run, which will impose irreparable losses on the country at large. Considering the above-mentioned points and due to the increasing use of narcotic drugs in Iran, the factors affecting this phenomenon in the society are felt more than ever among the youth population. Moreover, according to Article 80 of the Sixth Development Plan of the Republic of Iran, adopted in 2016, several responsibilities have been placed on the shoulder of the government in order to prevent and reduce social harm, especially addiction, which required the conduct of this research. Addiction is one of the most important health and psychosocial challenges that have become global (Eiseman, 2017). A large number of people get addicted every day and this results in the elimination of the cultural boundaries of the community and threatening of individuals' health (Galanter, 2006). Iran is also suffering from a critical situation for many cultural and geographical reasons (Mohammadkhani, 2017). Recent studies have shown that addiction in Iran is a serious and growing problem in such a way that there are three addicts out of Fatemeh Esmaeili Moghadam et al 141 every 1,000 people (Moazen et al., 2015). Increased addiction tendency of Iranian youth is very worrying as most individuals who start taking drugs in the younger ages continue its use in the coming years (Mohammadkhani, 2017). The results of some studies indicate that cigarette smoking, alcohol drinking, and the consumption of other substances have increased in recent decades (Moazen et al., 2015). In fact, university students will turn to addiction tendency in order to escape this pressure and these limitations since they undergo academic burnout, which is a state of mental and emotional exhaustion that arises from chronic stress, role overload, pressure, time constraints, and lack of resources to accomplish tasks and duties. In other words, academic burnout in educational situations is defined as a feeling of fatigue due to educational demands and requirements, a pessimistic and callous feeling without interest in university courses (indifference), as well as a feeling of poor personal development in educational affairs (Zhang, Gan & Cham, 2007). People with academic burnout usually have symptoms, such as indifference to course content, inability to attend classrooms, non- participation in classroom activities, a sense of meaninglessness in learning activities, and a sense of inability to learning course content. In recent years, the concept of burnout has also spread to students because studying is their core activity (Mansour Sepah, 2017). Similarly, various studies have focused on stress in students' practical life. However, there is still insufficient research into the extent and nature of academic burnout. In fact, it is assumed that academic burnout is composed of three distinct but related conceptual dimensions. Exhaustion due to compulsory studying, pessimistic attitude, a lack of interest in studying, the sense of insufficiency, emotional exhaustion indicating the lack of emotional resources are considered as essential components of individual stress. The second component refers to negative, pessimistic or excessive callous responses to other people, which represents the interpersonal component of burnout. Ultimately, reduced personal accomplishment refers to a feeling of diminished competence and productivity, and a sense of reduced self-efficacy, which represents self-assessment component (Bresó Esteve, 2008). It is assumed that the dimension of exhaustion adds to two other dimensions, namely response to others (pessimism) and response to the self (reduced personal accomplishment). Salmabadi, Salimi Bajestani, Abiz, & Javan (2015) investigated the contribution of academic burnout and resilience and perceived stress in predicting students' addiction tendency. The results indicated that academic burnout (excessive fatigue, indifference, and ineffectiveness) can predict 20% of addiction tendency. Molavi, & Rasoulzadeh (2004) showed that academic burnout is a predictor of drug use. Shafi'ea, Shamsi, & Ghaderi (2012) found that drug use had a negative effect on students' academic achievement. On the other hand, the quality of work life is one of the factors that can influence addiction potential. The concept of the quality of work life pertains to a philosophy in organizations that aims to increase employees' dignity and

142 Research on Addiction Quarterly Journal of Drug Abuse working status (Soleimani, 2013). This concept implies the existence of a specific set of organizational conditions and practices (Srivastava & Kanpur, 2014). In short, it is an attitude that seeks to improve people's quality of work life and tries to respond to job requirement as a productive factor, along with other factors (Taleghani et al., 2013). Any organization should pay attention to the quality of work life at least for the four following reasons: a) Quality of work life as a goal provides grounds for the improvement of organizational performance by creating a more challenging, satisfying, and effective working environment for individuals at all levels of the organization. b) The quality of work life as a culture that creates a high level of mutual commitment between individuals and the organization means that individuals are committed to the goals of the organization and its development, and the organization is committed to the needs of the individuals and their prosperity. c) Quality of work life as a process of achieving the goals through the active involvement and participation of all members of the organization. and d) The quality of work life is a phenomenon that goes beyond the boundaries of the organization and the company, and its effects can be observed in individuals' private life and outside the organization (Sirgy, Efraty, Siegel, & Lee, 2001). The quality of work life contains some dimensions as follows: a) Safe work environment: Safety is a condition that protects employees from those harmful factors that may endanger their health. The major responsibility for the safety of the work environment is on the shoulder of top managers (Abtahi, & Kazemi, 2004). b) Reward system: The most immediate and fastest way to improve the quality of work life is the assignment of external rewards, such as basic remuneration, facilities and loans, and side benefits like annual leave. Although the interests of the employer (client) and the employee (agent) may vary, reward system in the organization can be used as a tool to make it more effective (Aarabi, 2001, as cited in Sharifi, 2016). c) Flexible working hours: Work hours are among the most important factors in work issues. As previous studies have shown, the number of working hours is known as one of the sources of conflict within the working roles almost everywhere in the world, which has an objective representation (Aziz, 2011). d) Learning and growth: Each organization requires trained, skilled, and experienced individuals for the accomplishment of its mission and achievement of its goals (Mohajeri, & Sayadi, 2008). Research has shown that the individuals who do not have pleasurable experiences in the work environment are less satisfied with their life; and this affects their job commitment and their daily tasks (Noor, & Abdollah, 2012). Shabani & Talkhabi (2011) found that there is a significant relationship between work addiction and the quality of work life among managers. Also, various studies have examined the relationship between quality of work life and psychological well-being, mental health, and increased morale (Karadag, 2009). Mohammadkhani (2012) examined the predictive role of addiction tendency and substance-related disorders based on social anxiety disorder and quality of life Fatemeh Esmaeili Moghadam et al 143 in Payame Noor University students and showed that there is a direct relationship between social anxiety disorder and addiction potential. Also, there was an inverse relationship between the quality of life scores and addiction potential. Reid (2006) investigated the relationship between job burnout and addiction potential and showed that drug or alcohol addiction has a significant impact on employees' ability to do their jobs. Addiction can increase absenteeism, reduce productivity, and increase the rate of interests. According to what has been mentioned, domestic and external investigations have proved a dramatic increase in drug use among young people where different factors are involved in this phenomenon. Since youth is a period of psychological development, greater independence, and risk-taking; in this regard, job and work, and the quality of work life, and education of young people can play a role in satisfying the need for independence and the willingness to take a risk. Any deficiencies in this regard will cause many psychological problems, and it is believed that the quality of work life has a major role in predicting addiction tendency among young people. So far, little national and international research has been conducted in this area to devise useful political and security and treatment policies and take appropriate actions and measures if there is such a relationship. Therefore, this research sought to find out if addiction tendency was predicted on the basis of the quality of work life and the academic burnout among young people and whether dimensions of the quality of work life can predict university students' addiction potential.

Method Population, sample, and sampling method A descriptive-correlation with an applied research type was employed for the conduct of the current study. All the employed students both in Azad and State universities of Tehran in the academic year 2017-18 constituted the statistical population of this study. The sample size consisted of 384 students of Alzahra, Allameh Tabataba'i, Shahid Beheshti, Tehran University, and Islamic Azad University (Central Tehran Branch, South Tehran Branch, and North Tehran Branch) that included 150 males and 234 females who were selected via cluster random sampling. Following the provision of coordination with the authorities, the questionnaires Addiction Potential and Quality of Work Life were distributed among them. Using Cochran formula, the sample size was estimated at 95% confidence level according to the population size and variance.

Instruments 1. Iranian Scale of Addiction Potential: This questionnaire was developed by Zargar (2006) according to the social psychological characteristics of the Iranian society and its validity has been verified. This sale includes 36 items plus 5 lie detecting factors. The items numbered 6, 12, 15, 21, and 33 are scored in reverse and two factors of passive potential (8 items) and active potential (28 items). In

144 Research on Addiction Quarterly Journal of Drug Abuse the active factor, most of the items pertain to antisocial behavior, desire to drug use, positive attitude towards drug use, depression, and sensation seeking. In the passive factor, most of the items are related to the lack of self-assertiveness and depression. The items are scored on a Likert scale from strongly agree (5), agree (4), almost agree (3), disagree (2), and strongly disagree (1). The minimum and maximum scores of the whole scale are equal to 0 and 108, respectively. Zargar (2006) reported the reliability of the total scale, active factor, and passive factor using Cronbach's alpha method equal to 0.90, 0.91, and 0.75, respectively. The convergent validity of this scale was calculated by measuring its correlation with 25-item Scale of Clinical Symptoms and the value of 0.40 was obtained (Zargar et al., 2008). In this study, the Cronbach's alpha coefficient of the questionnaire was obtained equal to 0.87. 2. Quality Work Life Questionnaire: This questionnaire was developed by Walton (1973), which included 32 items in eight subscales, namely adequate and fair compensation, safe and healthy working conditions, opportunity for continued growth and security, constitutionalism in the work organization, social relevance of work life, work and total life space, social integration in the work organization, and immediate opportunity to use and develop human capacities. Questions are scored based on a 5-point Likert scale from very low (1) to very high (5). The items numbered 21, 22, and 23 are scored in reverse. The reliability coefficient of the questionnaire was reported equal to 0.92 after its administration to a 30-participant sample (Maleki, Khadivi, & Khanshakizadeh, 2012). Swamy, Nanjundeswaraswamy, & Rashmi (2015), Cronbach's alpha coefficient was reported 0.82 for the whole questionnaire. In the present study, Cronbach's alpha coefficient of 0.90 was obtained for the whole scale. 3. Academic Burnout Inventory: This questionnaire was developed by Bresó et al. In 1997. It measures three domains of academic burnout, including exhaustion, academic unwillingness, and academic deficiency. It has 15 items that are scored on a five-point scale. It is noteworthy that 5 items belong to exhaustion, 4 items pertain to academic unwillingness, and 6 items belong to academic deficiency. The reliability coefficients of the questionnaire were reported equal to 0.70, 0.82, and 0.75 for the subscales of exhaustion, academic unwillingness, and academic deficiency, respectively (Bresó, 1997, as cited in Azimi, Piri, & Zavar, 2014). Comparative Fit Index, incremental Fit Index, and root mean square error of approximation (RMSEA) were reported almost desirable. Na'ami (2009) reported the Cronbach's alpha reliability coefficients of 0.79, 0.82, and 0.75 for the subscales of exhaustion, academic unwillingness, and academic deficiency, respectively. Pouladi Riehshahri (1995) reported the convergent validity coefficients of 0.38, 0.42, and 0.45 for the subscales of exhaustion, academic unwillingness, and academic deficiency, respectively by measuring the correlation of the scores with the scores of Student Stress Questionnaire.

Fatemeh Esmaeili Moghadam et al 145

Results The descriptive statistics of respondents' demographic variables have been presented in Table 1.

Table 1: Descriptive Statistics of Respondents' Demographic variables Frequency Cumulative frequency Gender Frequency percentage percentage Male 150 39 39 Female 234 61 100 Frequency Cumulative frequency Age Frequency percentage percentage Less than 20 years 7 1.8 1.8 21 to 30 238 62 63.8 31 to 40 113 29.4 93.2 Above 40 years 26 6.8 100 Frequency Cumulative frequency Place of study Frequency percentage percentage 57 Allameh Tabataba'i University 14.8 14.8 Shahid Beheshti University 50 13 27.8 Alzahra University 45 11.7 39.5 176 Branches of Azad University 45.8 85.3 56 University of Tehran 14.7 100 384 Total 100 - The descriptive statistics of the research variables are presented in Table 2.

Table 2: Descriptive Statistics of the Research Variables in the Sample Group Variable Mean SD Variable Mean SD Active addiction potential 2.13 1.13 Constitutionalism 30.6 1.08 Passive addiction potential 1.95 1.08 Work and total life 30.6 1.14 space Total addiction potential 2.04 1.10 Social relevance of 3.13 1.07 work life Adequate and fair 2.70 1.08 Quality of work life 3.05 1.08 compensation Safe and healthy working 3.05 1.06 Emotional exhaustion 2.52 1.11 conditions Human capacities development 3.35 1.08 Pessimism 2.34 0.94 Opportunity for continued 2.91 1.07 Academic inefficiency 3.66 0.82 growth and security Social integration 3.02 1.10 Total academic 2.93 1.06 burnout

Before measuring the relationships between the variables, we need to examine the normal distribution of the variables. The results of Kolmogorov-

146 Research on Addiction Quarterly Journal of Drug Abuse

Smirnov test indicated a normal distribution in addiction potential (Z = 0.12, P >0.05), quality of work life (Z = 0.0.21, P >0.05), and academic burnout (Z = 1.21, P >0.05). Therefore, the results of Pearson correlation test between quality of work life and addiction potential (r = -0.35, p <0.001), passive potential (r = -0.38, p <0.001), active potential (r = -0.29, p <0.001), and academic burnout (r = 0.15, p <0.001) was significant. In addition, there was a significant relationship between academic burnout and active potential (r = 0.18, p <0.001) and passive potential (r = 0.10, p <0.001). The correlation matrix of addiction potential and academic burnout is presented in Table 3.

Table 3: Correlation Matrix of Quality of Work Life (Components) and Academic Burnout Variable 1 2 3 4 5 6 7 8 1. Adequate and fair 1 ------compensation 2. Safe and healthy **0.53 1 ------working conditions 3. Human capacities **0.64 **0.67 1 - - - - - development 4. Opportunity for continued growth and **0.44 **0.64 **0.60 1 - - - - security **0.43 **0.61 **0.61 **0.53 1 5. Social integration - - - **0.53 **0.61 **0.57 **0.55 **0.77 1 6. Constitutionalism - - 7. Work and total life **0.35 **0.68 **0.57 **0.59 **0.50 **0.52 1 - space 8. Social relevance of **0.44 **0.68 **0.61 **0.58 **0.58 **0.66 **0.60 1 work life -0.10 *-0.14 -0.05 -0.08 *-0.19 *-0.18 -0.08 *-0.13 9. Academic burnout *P<0.05; p<0.01

To investigate the role of quality of work life components in predicting addiction potential, multiple regression analysis was run via Enter method. A summary of the regression model is presented in Table 4.

Table 4: Summary of Regression Model of Addiction Potential based on Quality of Work Life Components Correlation Coefficient of determination Durbin-Watson statistic -0.45 0.21 1.98

The regression coefficients of addiction potential based on the quality of work life components are presented in Table 5.

Fatemeh Esmaeili Moghadam et al 147

Table 5: Regression Coefficients of Addiction Potential based on Quality of Work Life Components Standard Variable B β t Sig. error

Constant 131.10 5.54 - 23.600 0.0005 Adequate and fair compensation 0.043 0.44 0.006 -0.09 0.922 Safe and healthy working 0.784 0.48 0.14 -1.62 0.10 conditions Human capacities development -1.02 0.47 -0.158 -2.160 0.03 Opportunity for continued -0.234 0.53 -0.028 -0.42 0.67 growth and security Social integration -2.51 0.59 -0.366 -4.23 0.0005 Constitutionalism -0.928 0.61 -0.135 -1.530 0.13 Work and total life space -0.303 0.56 -0.037 -0.537 0.59 Social relevance of work life -0.223 0.46 -0.038 -0.488 0.63

To investigate the role of academic burnout components in predicting addiction potential, multiple regression analysis was run via Enter method. A summary of the regression model is presented in Table 6.

Table 6: Summary of Regression Model of Addiction Potential based on Academic Burnout Components Correlation Coefficient of determination Durbin-Watson statistic 0.50 0.25 1.92

The regression coefficients of addiction potential based on academic burnout components are presented in Table 7.

Table 7: Regression Coefficients of Addiction Potential based on Academic Burnout Variable B Standard error β t Sig. Constant 113.5 9.47 - 11.980 0.0005 Emotional exhaustion 0.46 0.41 0.07 1.120 0.26 Pessimism 1.06 0.15 0.15 2.380 0.019 Academic deficiency 2.53 0.36 0.36 2.530 0.0005

Discussion and Conclusion To explain these findings, one can argue that the weakness in the quality of work life in each organization and institution causes stress, anxiety, and despair among the organization's staff. Stress, in the form of a set of stressful occupational forces, requires significant energy from the staff in the psychological and physiological dimensions (Bariheh Barihi, Na'ami, Zargar, & Hashemi, 2016); therefore, employees may turn to narcotics in order to eliminate this stress. Addiction to drugs or alcohol has a significant impact on employees' ability to do their jobs. Addiction can increase absenteeism, reduce productivity, and

148 Research on Addiction Quarterly Journal of Drug Abuse increase the incidence rate (Reid, 2006). Addiction is the repetitive use of narcotics and leads to failure in work, education, family roles or sensitive situations, such as driving or creates legal problems related to narcotics (Khosroshahi, & Khanjani, 2013). Research has shown that stressful situations and conditions can increase the prevalence of drug abuse. In other words, working in unsuitable conditions can increase the tendency toward substance abuse (Drug Control Headquarters, 2013). Salm-Abadi et al. (2015) found that perceived stress and burnout have a significant positive correlation with addiction tendency. Also, a positive correlation was observed between academic burnout and perceived stress. Shafi'ea et al. (2012) investigated the correlation of drug use, alcohol drug use, cigarette smoking, and psychiatric drugs with academic achievement in university students of Bam city. The findings of their study showed that the frequency of substance use among students included psychiatric and psychosocial drugs (13.8%), alcohol (10.8%), narcotics (9.9%) and cigarettes (5.7%), respectively. In addition, academic achievement in students with a history of smoking, alcohol, narcotics, and psychiatric drugs was significantly lower than those who did not have a history of drug use. Molavi & Rasoulzadeh (2004) studied the effective factors in young people's tendency to use narcotics in Ardabil and showed that depression, parent divorce, affinity with bad friends, smoking, and educational failure with coefficients of 4.23, 3.23, 2.59, 2.17, and 1.57 have had the highest impact on young people' tendency to drug use. Therefore, academic failure in young people and students is one of the factors that increases the rate of addiction potential. According to a research study, it has been reported that young people and adolescents' perceptions of drug-related risk (for example, marijuana) are low (Johnson, O'Malley, Bachman, & Schulenberg, 2006). In addition, the rate of drug use in young people is relatively high (Wu, Liu, & Fan, 2010; Embleton, Ayuku, Atwoli, Vreeman, & Braitstein, 2012). For example, the study carried out by Johnston et al. (2006) showed that a fifth (20%) of the eighth grade students and about 50% of university in the university have experienced drug use. Also, 38 percent of adolescents in the 12th grade have consumed drugs. In 2004, nearly 1.4 million young people were reported to have experienced the consumption of amphetamines during the last year and nearly half a million Americans have experienced marijuana use for the first time. Research findings have indicated that the abuse of prescribed drugs and new psychotropic substances is on the rise in Europe, while it appears that heroin use is declining. While cocaine market in South America and in the growing Asian economy seems to be rising (Brunt et al., 2017), opioid use (heroin and opium) has remained constant (about 16 million or 0.4 percent of the 15-to-64-year-old population). On the other hand, the high prevalence of opiate use in Central and Southwest, Southeast, and Eastern Europe and the North American has been reported. Although pertaining Fatemeh Esmaeili Moghadam et al 149 data are scarce in this regard, Africa is becoming a target for smuggling and trafficking of illegal drugs (Loeffler, Delaney, & Hann, 2016). On the other hand, 8,800 kilos crystalline methamphetamine have been discovered, which is the highest figure in the last five years, indicating that this substance haunts an imminent danger. Mexico has reported its largest methamphetamine discovery which has been more than twice in one year from 13 to 31 tons (the largest discovered amount in the world). Cannabis is still the most consumed drug. While the consumption of cannabis has declined among young people in Europe over the last decade, a slight increase in the prevalence of cannabis users (180 million, or 3.9% of the 15-to-64-year-old population) has been reported in comparison with previous estimates in 2009 (Brunt & Niesink, 2011). Research has shown that access to substance and factors, such as the legal availability of drugs (like alcohol and cigarettes) and their costs are crucial determinants of the first attempt of drug use among young people (Davey, 2008). Today, substance use and its destructive effects are among the most challenging issues in terms of health and medicine. Drug use by adolescents and young people imposes a huge burden on the community, and its social, psychological, health-therapeutic, and economic burden on the society always heavy (Tavolacci, Ladner, Grigioni, Richard, Villet & Dechelotte, 2013;Isaacs, Jellinek, Martinez Garcel, Hunt & Bunch, 2013; Vetere & Henley, 2001). The prevalence of drug use in the world is growing dramatically, especially among young people. The assignment of attention to the factors contributing to the attractiveness of drug addiction among this stratum was essential. Research findings have shown that addiction potential is closely related to the quality of work life and academic burnout. Educational environments, such as universities are all of an academic nature and attitudes toward drugs are taught by peers and university professors. It is recommended that the rate of drug abuse will be measured when selecting students and all university staff so that healthy students will not be negatively affected in terms of mental health. In order to increase students' awareness of the consequences of drug use and the prevention and treatment methods, it is recommended that a curriculum course, titled Drug Use Addiction be included in the syllabus of all academic fields. It is suggested that future studies considering the setting of an academic grant for students, and the inclusion of optional courses for learning professional skills irrelevant to university degree programs, for example, carpet knitting for girls and similar professional skills and services for the boys who have a profession and do not need special university education so that they will not experience the economic pressure and can have a positive quality of work life. In addition, it is suggested that further research consider quality of life in terms of student dormitories and their places of living.

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Abstract Structural Equation Objective: The aim of this study was to assess the structural equation modeling Modeling of of the relationship of sensation seeking Sensation Seeking with addiction potential mediated by self-differentiation and cognitive with Addiction emotion regulation among male addicts under treatment in Sari. Method: A Potential Mediated by correlational research design based on Self-Differentiation Structural Equation Modeling (SEM) method was used for the conduct of this and Cognitive study. The statistical population of this Emotion Regulation research included all male addicts in the city of Sari that amounted to a number among Male Addicts of 500 addicts where a total of 350 sample units were selected via under Treatment in purposive sampling method. To Sari measure the variables, Differentiation of Self Inventory (DSI), Emotion Cognitive Regulation Questionnaire, Addiction Potential Scale, and Sensation Seeking Scale were used. Results: In general, significant correlations were found between the Babaei Holari, N. , research variables and the research Hasanzadeh, R. model was approved where the total of 17% of addiction potential variable was explained by the research variables. Conclusion: The current findings have Babaei Holari, N. positive implications in the intervention Department of Psychology, Islamic Azad centers of addiction. University, Sari, Sari, Iran Keywords: sensation seeking, Hasanzadeh, R. addiction potential, self-differentiation, Professor of Psychology, Islamic Azad cognitive emotion regulation, addictin University, Sari, Sari, Iran, Email: [email protected]

Research on Addiction Quarterly Journal of Drug Abuse

Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir 154 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction is a psychosocial phenomenon which is caused by a variety of factors, including family relations, social occasions, sociocultural conditions, and psychological characteristics of the addicted person (Faramini, 2008). Goldesmite (2009), in an experimental study, manipulated emotion and showed people tend to use alcohol as a coping strategy and emotion regulation strategy. Mohammadifar, Kafi Anaraki, & Najafi investigated negative emotions and showed that depression and anxiety can predict changes in substance abuse behavior. Mack DorMate Matwell, Gratez, & Vellzooz (2009) supported the pivotal role of emotion regulation difficulty in the prediction of post-traumatic stress disorder among crack- and cocaine-dependent individuals. Foxx, Bergootsit, Cass, & Hong Wasinha (2010) showed that cocaine-dependent individuals exhibit significant deficits in emotion regulation that increase with response to stressors and are reduced by impulse control. The main characteristic of high sensation seekers is that they tend to take new experiences and risk to gain them. In other words, unlike low sensation seekers, these people are constantly looking for new and novel stimuli in their living environment and are willing to put them at risk under heavy pretexts and gain their own social prestige and credibility and even their physical health and vitality (Ryoo, 2001). Zuckerman believes that sensation seeking structure is related to the amount of stimulation that the central nervous system (brain and spinal cord) require to obtain from external sources. According to Zuckerman, sensation seeking is a trait that is characterized by diverse, new, and complex experiences, and the desire to take physical and corporal risks through these experiences. A sensation seeker prefers permanent external stimulation of the brain; gets bored with ordinary chores; constantly looks for some ways to increase stimulation through exciting experiences. The less sensation seeking person prefers a less continuous invasion of brain stimulation and tolerates normal tasks (Ryoo, 2001). Lazarus, Sherer, and Wiener are three pioneers in cognitive perspective. To any of these theorists, cognitive activity will be eliminated, and emotion will disappear. In Lazarus's view, one's cognitive assessment from the meaning of an event (not that event alone) provides the grounds for experiencing an emotion (Reu, 2005). Moreover, in the acquisition of emotions, Lazarus lays emphasis on the information processing of the events that occur following the incidence of the consequences of a person's life. After achieving success, if we believe that we ourselves have gained it, there will be an emotion (pride), while if we believe that friends have made it, there will be a different emotion (thankfulness). Therefore, this is the attribution, rather than the event or outcome, that creates the emotion. The concept of differentiation is one of the basic concepts of Bowen's theory, which refers to one's ability to experience intimacy with others and, at the same time, the independence of others (Cloor, 2009). In Bowen's theory, all symptoms, such as mental illnesses, physical illnesses arising from Nafiseh Babaei Holari & Ramezan Hasanzadeh 155 substance abuse, and social problems are interrelated with failure to adapt to the system, low self-differentiation, and exaggeration in the emotional process (Heras, 2008). The four components of emotional reactivity, I-position, emotional cutoff, and fusion with others have been proposed for differentiation, as follows: Emotional reactivity: It refers to a state in which one's emotions overcome his/her rationale and logic, and his/her decisions are thus made only on the basis of emotional reactions. I-position: It means having personal beliefs and opinions in life. Differentiated individuals take advantage of a strong specific identity or I-position, and do not change their behavior or beliefs to obtain others' satisfaction. Bowen shows differentiation on a hypothetical continuum, on the one end of which differentiation is placed; and fusion with others is on the other end. Fused individuals are strongly in need of approval and support of the surrounding people, and their behaviors are shaped under the influence of the emotional system of the environment and the reactions of the surrounding people (Scoron, 2004). The aim of this study was to model the structural relations of sensation seeking with addiction potential through the mediation of self- differentiation and cognitive emotion regulation among male addicts in Sari in 2016. Considering the importance of this issue in this research, it is attempted to respond to the following fundamental question: Is there any causal relationship between sensation seeking and addiction potential with the mediating role of self-differentiation and cognitive emotion regulation among male addicts under recovery? The development of the model involves the use of related theories, research findings, and the available information in the theoretical model.

Self-differentiation

Sensation- Addiction Potential seeking Cognitive emotion regulation

Fig. 1: Proposed Conceptual Model based on Research Background

Method Population, sample, and sampling method A descriptive correlational research method (structural equation modeling, in particular, structural regression equations (a mixture of path analysis and factor analysis)) was employed for the conduct of this study. The statistical population of this study included all drug addicts recovering from opioid drugs from 1 to 24 months in mid-term care centers in Sari. The number of eligible candidates was about 500 people. This approach was based on covariance based in AMOS software. This approach estimates path coefficients and factor loadings by

156 Research on Addiction Quarterly Journal of Drug Abuse minimizing the difference between the sample-based covariance matrix and the model-based covariance matrix. The sample size was obtained equal to 350 by Klein method and the participants were selected via purposive sampling.

Instruments 1. Differentiation of Self Inventory: This questionnaire contains 43 items and 4 sub-scales, namely emotional reactivity, I-position, emotional cut-off, and fusion with others. The emotional reactivity component has 11 items and reflects the degree to which a person responds to an environmental stimulus with oversensitivity or emotional variability. I-position sub-scale consists of 11 items, and in addition to the clear definition of one's own sense, determines the degree of loyalty to personal beliefs when one has to do something contrary to his/her own beliefs. The emotional cut-off sub-scales contains 12 items and is indicative of a feeling of fear of intimacy and a feeling of extreme vulnerability in contact with others. The items pertaining to this sub-scale represent fear of intimate relationships, defensive behaviors such as excessive performance, distance, or denial. The component of fusion with others contains nine items and shows that one's involvement in an overly emotional relationship with others. To compute the total score, the scores of all the scores are summed (by considering reverse scores), and then the score is divided by 43. 2. Emotion Cognitive Regulation Questionnaire: This questionnaire was developed by Garnefski et al. (2001) and has 36 items that are scored based on a 5-point Likert scale (from all the time to never). Each of the four items evaluates one factor and, thereby, the whole scale consists of a total of nine factors, namely putting into perspective, self-blame, other-blame, catastrophizing, rumination, refocus on planning, acceptance, positive refocusing, and positive reappraisal. The Persian form of this scale has been validated by Samani and Jokar (2007). In this questionnaire, the respondent is asked to determine his/her reaction in the face of threatening experiences and stressful events that have just been experienced. This questionnaire has a special form for adults and a special form for children. The Cronbach's alpha coefficient for the scores of this questionnaire has been reported by Garnefski et al. (2002) in the range of 0.71 to 0.81. 3. Addiction Potential Scale: This scale was developed by Weed and Butcher (1992) and some attempts have been made to validate it in Iran. This scale is the Iranian version of the Addiction Potential Scale which was constructed by Zargar according to the psychosocial condition of Iranian society (Zargar, Najarian, & Na'ami, 2008). It consists of two factors and consists of 36 items plus 5 lie detecting items. Each question is scored on a spectrum from zero (I strongly disagree) to 3 (I strongly agree). Of course, this method of scoring is reverse in questions numbered 6, 12, 15, and 21. The items numbered 12, 13, 15, 21, and 33 are lie detectors. To obtain the total score, the scores of all items should be summed (other than the lie detecting items). Therefore, the total score Nafiseh Babaei Holari & Ramezan Hasanzadeh 157 ranges from 0 to 108. Higher scores represent the higher tendency of the person to addiction and vice versa. This questionnaire is a combination of active readiness and passive readiness. Active readiness is related to antisocial behaviors, desire for drug use, positive attitude to drugs, depression, and sensation seeking. In the second factor (passive readiness), most of the items pertain to a lack of self-assertiveness and depression. In the research carried out by Zargar et al. (2008), two methods were used to calculate the validity of this scale. In criterion validity, the scale discriminated between addicts and non- addicts very well. The construct validity of the scale was calculated by calculating its correlation with the 25-item index of clinical symptoms, which was significantly obtained equal to 0.45. The reliability of the scale was calculated using Cronbach's alpha (90/0) (Zargar et al., 2008). 4. Sensation Seeking Scale: This scale was developed by Jeffrey Arendt in 1992 and has 20 items and 2 subscales, namely novelty (items numbered 11, 1, 9, 7, 5, 3, 13, 17, 15, and 19) and intensity (items numbered 4, 2, 6, 8, 12, 10, 12, 14, 16, 18, and 20). Arendt's scale is characterized by the concept of sensation seeking with a need for novelty and the intensity of the stimulus as two sub-axes. Instead of focusing on any genetic and biological basis found in Zuckerman's fifth edition, this scale addresses the role of socialization and social interaction in the behavioral direction. Arendt's scale, in addition to enjoying a moderate reliability, has a high predictive validity and is well correlated with Zuckerman's sensation seeking scale. The psychometric properties of Arendt's Sensation Seeking Scale in Iran (Poorvafayi, 1997) have been reported acceptable and this scale has been introduced as a substitute instrument to be used by researchers interested in the scope of personality traits in sensation seeking.

Results The correlation matrix of the research variables is presented in Table 1. Table 1: Correlation Matrix of the Research Variables Variables 1 2 3 4 5 6 7 8 1 ------Novelty **0.62 1 ------Intensity *-0.11 *-0.18 1 - - - - - Emotional reactivity *0.11 0.09 *-0.20 1 - - - - I-position Emotional cut-off *-0.16 *0.22 **0.33 **-0.23 1 - - - *-0.11 *-0.15 **0.45 **-.032 **0.34 1 - - Fusion -0.02 *-0.12 0.09 0.08 0.08 *0.13 1 - Self-blame -0.01 -0.05 0.02 -0.07 -0.04 0.08 **0.20 1 Other blame *-0.11 *-0.15 -0.01 0.09 0.01 0.01 **0.38 **0.24 Rumination 0.06 -0.09 -0.01 -0.01 -0.04 0.01 **0.32 **0.24 Catastrophizing 0.01 0.04 -0.02 -0.04 -0.05 -0.06 **0.30 **0.62 Acceptance 0.01 *-0.11 0.03 -0.07 0.07 0.02 **0.33 **0.39 Positive focus 0.01 -0.09 0.06 *0.11 -0.03 -0.02 **0.29 **0.26 Positive reappraisal *0.12 **0.24 0.04 **-0.16 -0.04 0.10 0.02 *0.14 Addiction potential -0.02 *-0.15 0.04 -0.09 -0.03 0.02 **0.57 **0.52 Cognitive emotion regulation **0.89 **0.91 *-0.16 *0.11 **0.21 *-0.15 -0.08 -0.03 Sensation seeking *-0.12 **-0.21 **0.69 *0.12 **0.69**0.65 *0.11 0.08 Self-differentiation

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Table 1 (Cont.): Correlation Matrix of the Research Variables Variable 9 10 11 12 13 14 15 16 ------Novelty ------Intensity ------Emotional reactivity ------I-position ------Emotional cut-off ------Fusion ------Self-blame ------Other blame 1 ------Rumination **0.30 1 ------Catastrophizing **0.40 **0.40 1 - - - - - Acceptance **0.40 **0.32 **0.29 1 - - - - Positive focus **0.40 **0.42 **0.38 **0.34 1 - - - Positive reappraisal *0.16 0.07 0.04 0.07 *0.12 1 - - Addiction potential **0.68 **0.63 **0.63 **0.75 **0.72 *0.15 1 - Cognitive emotion regulation *0.14 -0.02 -0.02 -0.07 -0.06 **0.31 *-0.12 1 Sensation seeking Self-differentiation 0.01 -0.03 -0.09 -0.02 -0.04 *-0.19 0.08 **-0.19

After examining the obtained relationships, the statistical assumptions of the research, including skewness, kurtosis, and normality of data distribution were checked by box's test. Then, the outliers were corrected via Mahalanobis test. Finally, Kolmogorov-Smirnov test was run and the normality of data was confirmed. Afterwards, the model was designed and its fit indices were examined. The fitness indices of the model are presented in Table 2. Table 2: Fitness indices derived from the analysis of data and variables after three stages of correction Test Description Acceptable range Value 훘ퟐ/퐝퐟 Relative Chi-square <3 2.036 RMSEA Root Mean Square Error of Approximation <0.1 0.057 GFI Adjusted Fitness Index >0.9 0.936 NFI Normed Fit Index >0.9 0.828 CFI Comparative Fit Index >0.9 0.902

As it has been shown in Table 2, RMSEA value equals 0.015; which is less than 0.1 and it indicates that the RMSEA of the model is appropriate and that the model is acceptable. In the same way, the chi-square to freedom degree (1.088) is between 1 and 3, and the values of GFI, CFI, and NFI are greater than 0.9, which indicate that the model of research variables is appropriate. In Table 3, the model assumptions have been examined using a structural model. Table 3: Direct Estimation of the Model Variable Value Lower bound Upper bound Sig. 1.900 - 0.204 0.0005 Sensation seeking on addiction potential Self-differentiation on addiction 0.496 -0.77 1.208 0.13 potential Cognitive emotion regulation on -1.472 -3.996 -0.651 0.004 addiction potential Nafiseh Babaei Holari & Ramezan Hasanzadeh 159

According to the above table, only the direct effects of the two paths (cognitive emotion regulation on addiction potential) and (sensation seeking on addiction potential) are significant.

Table 4: Indirect Estimation of the Model Using the Bootstrap Estimation Method Lower Upper Variable Value Sig. bound bound Sensation seeking by mediating self- -0.569 -1.272 -0.120 0.012 differentiation and cognitive emotion regulation As it can be observed, the indirect path of sensation seeking is mediated by self-differentiation and the cognitive emotion regulation. However, with regard to the general acceptability of the model, a structural model of the relations between the covert and overt variables can be drawn. In general, all the research variables have the predictive power (R2 = 0.17) of addiction potential variable.

Fusion Emotional cut-off position Emotional reactivity

Self- differentiation Novelty

Emotion Addiction Potential

Intensity Regulation

Self-blame Other blame Rumination Catastrophiz Acceptance Positive focus Positive reappraisal ing

Fig. 1: Final Tested Model along with Non-standardized Statistics

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Fusion Emotional cut-off position Emotional reactivity

Self- differentiation Novelty

Emotion Addiction Potential

Intensity Regulation

Self-blame Other blame Rumination Catastrophiz Acceptance Positive focus Positive reappraisal ing

Fig. 2: Final Tested Model along with Standardized Statistics

Discussion and Conclusion To explain the results, it is possible to argue that the term addiction potential (addiction tendency) means to assess the readiness for or vulnerability to substance abuse, whether or not the person is currently undergoing substance abuse. New clinical findings have shown that unhealthy developmental areas and addiction potential play an essential role in the formation of addiction. Addiction potential theory states that some people are susceptible to addiction and if they are exposed to it, they will get entrapped into it. On the other hand, if they are not exposed to it, they will not get addicted (Ghadimi, Karami, & Yazdan- bakhsh, 2014). Many substance abuse clients have certain thought patterns that can lead to the continued disorder in them and may prevent any changes. These patterns of thought include one's beliefs associated with expectations and one's beliefs about substance use (Beck & Wright, 1993). The findings of this research confirm Yang's early maladaptive schema theory and the schema-based cognitive behavioral therapy model. In this theory, behaviors, such as addiction Nafiseh Babaei Holari & Ramezan Hasanzadeh 161 are formed to reduce the negative emotions resulting from the activity of maladaptive schemas. According to Yang's theory (1990), maladaptive behaviors are created in response to early maladaptive schemas and, then, are stimulated by the schemas themselves. When an inappropriate schema is triggered, people usually experience a high level of negative emotions, such as intense anger, anxiety, grief, and guilt. Therefore, people often use maladaptive behaviors to avoid the stimulation of the schemas so that they will not experience the affection associated with these schemas. Thus, they embark on showing maladaptive behaviors, such as opioid use, in order to reduce the unbearable pain caused by their initial schemas (Yang, translated by Sahebi and Hamidpour, 2005). Since the path pertaining to the cognitive emotion regulation schema and addiction potential is the most powerful route in this model, one can argue that emotion and its regulation have always been at play in the field of addiction. Even addiction has been referred to as a mechanism for emotion regulation (Wu, 2015). Moreover, cognitive emotion regulation strategies are among the most important determinants of individuals' responses to their personal emotions; in this regard, the increased use of maladaptive strategies is associated with pathology and the growth and continuity of disorders. A number of studies have shown that difficulty in emotion regulation is associated with a wide range of disorders, including drug abuse (Gratz, & Romer, 2004). In the area of addiction, various models and theories with biologic, social, and environmental tenets have been proposed to date (Ewasik & Summer, 2010). One of the theoretical approaches that addresses this issue psychologically is Hampson, Andows, & Barckley's self-care theory (2008). Khantzian believes that since substance users view negative emotions and restlessness as unbearable and distracting; and these individuals cannot manage these emotional states without drug use. Hence, they use the physiological and psychological properties of drugs to achieve emotional stability. According to this theory, drug addiction is considered as a means for regulating stressful emotions. This theory is stipulated based on the assumption that many people turn to addiction due to their low distress tolerance and emotion regulation disorder (Hampson et al., 2008). These findings are reminiscent of more recent psychiatric insights on addiction which introduce addiction as the essential deficiencies in the individual's growth and affection. Drugs are taken to reduce the bothersome emotional states or to act as a defense mechanism in relation to internal conflicts. In fact, drugs act as a temporary external aid to maintain a sense of well-being (Beirami, 2014). The employment of ineffective cognitive emotion regulation strategies also leads to an increase in negative emotions and these negative emotions increase the degree of addiction potential because they have found comorbidity with substance abuse over years. In fact, substance abuse is an ineffective mechanism to cope with emotional disturbance, which mutually reinforces and continues early maladaptive schemas. The other variable in the

162 Research on Addiction Quarterly Journal of Drug Abuse model is coping strategies whose mediating role with the schema in addiction potential was indirectly confirmed according to the findings of this research. As a result, it can be argued that one of the variables that plays an important role in the relationship between factors related to personality and psychological outcomes is coping strategies with stress. According to phenomenological theory, coping styles with stress refer to the cognitive-behavioral responses that individuals use in an attempt to manage the internal or external dimensions of stressful situations (Lazarus, & Folkman, 1984; as cited in Beigi, Mohammadifar, Farahani, & Mohammadkhani, 2011). These coping strategies are divided into two problem-focused and emotion-focused categories. The obtained results show that early maladaptive schemas are correlated with the processes in which people assess or respond to stressful and problematic events and, ultimately, predict addiction potential (Dehghani, Izadikhah, Mohammadtaghi-Nasab, & Rezaei, 2014). One of the other research variables that, as a mediator, predicts addiction potential in the path of schema and attachment is loneliness. From Yang's point of view, schemas are one's deep and firm beliefs about him/herself and are the result of the teachings of the early years of life. Schemes are our knowledge of ourselves and the world, and tell us how we are and how the world is (Reddy, Pickett, & Orcutt, 2006). Therefore, it is suggested that transdiagnostic and supportive treatments be employed by specialists in these centers in order to save time since addiction has usually comorbidity with other disorders and there is an increasing incidence of addiction in Iran. Reference Beebe, R., & Frisch, N. (2009). Development of the Differentiation of Self and Role Inventory for Nurses (DSRI-RN): A tool to measure internal dimensions of workplace stress. Nursing outlook, 57(5), 240-245. Chicago Beck, Wright, (1993). Incorporating emotion regulation. Into concoptu Alizade and treatment so anxiety and mood disorders in J, J Gress (ED), Handbook of emotion regulation New York: Guilford pros 542-559 on line. Beigi, A., Mohammadifar, M., Farahani, M., & Mohammadkhani, S. (2011). Comparison of Stress Tolerance Styles and Hope Levels among Members of the Association of Anonymous Addicts and Addicts under Methadone Maintenance, Quarterly Journal of Research on Addiction, 5 (20), 55-72. Beirami, M., Fahimi, S., Akbari, E., & Amiri Pichaklayi, A. (2012). Prediction of Marital Satisfaction based on Attachment Styles and Differentiation Components. Journal of Fundamentals of Mental Health, 14, 67-77. Beirami, M., Movahedi, Ya. & Movahedi, M. (2014). The relationship between perceived social support and the feeling of social- emotional loneliness with internet addiction in university students, Journal of Social Cognition, 2, 3 (6), 109-122. Dehghani, S., Izadikhah, Z., Mohammadtaghi-nasnab, M., & Rezaei, E. (2013). A Path Analysis of Early Maladaptive Schemas, Stress Coping Strategies, and Psychological Quality of Life, Journal of Research in Behavioural Sciences, 1, 1, 8-12. Nafiseh Babaei Holari & Ramezan Hasanzadeh 163

Eskian, S., Sana'i Zaker, S., & Nevayinejad, S. (2008). The study of the effect of psycho- drama on increasing self-differentiation of the original family among female high school students in the fifth municipal district of Tehran, Journal of Counseling Research & Developments, 7, 25, 27-42. Ewasik K, Summer H (2010). Cognitive emotion regulation strategies. Gender differences and association to worry. Personality and individual differences 108 – 413. Fox, taco Bergius, K. locasey, J hong, K.A Shinar (2011). Selective cocaine related difficulties in emotional intelligence. Or latainshipt. Stress and impulse contvel. American journal Adictive, pp.175 – 100. Ghadimi, A., Karami, J., & Yazdanbakhsh, K. (2014). Relationship of early maladaptive schemas and metacognitive beliefs with addiction potential, Journal of Fundamentals of Mental Health, 17 (2), 67-73. Granefeskin, K Rajiv (2006). Cognitive emotion regulation juestionnaire development of s short 18 – item (CEBRA – short) personality and individual difference. 4101045.1053. Hampson, S.E Andows JA. Barckley m. (2008). Childhood predict or saf a dolessent mariguana use Early sensation seeking adrelant peeraffiliation. And social images Addictive behaviors. 33, (9), 1140- 1147 Mohammadifar, M., Kffi Anaraki, M., & Najafi, M. (2014). The role of meta-cognition and negative emotions in predicting substance abus e behavior, Quarterly Journal of Research on Addiction, 8 (29), 65-76. Reddy, M.K., Pickett, S.M., Orcutt, H.K. (2006). Experiential avoidance as a mediator in the relationship between childhood psychological abuse and current mental health symptoms in college students. J Emotional Abuse; 6(1): 67-84. Riso, L. P., Toit, P. L. D., Stein, D.J & Young, J. E. (2003). Cognitive schemas and core beliefs in psychological problems. American psychological association Washington, DC. Safari Hajat Aghaei, S., Kamali, A., Dehghani Firoozabadi, S., & Isfahani, M. (2014). A meta-analysis of the comparison of individual and environmental factors affecting addiction relapse after drug use abstinence. Quarterly Journal of Research on Addiction, 8, 52, 30-35. Schultze, D., & Schultz, S.A. (2002). Theories of Personality, Translated by Yahya Mohammadi, Fourth Edition of Tehran: Virayesh Publications. Yang, J. (2005). Cognitive Therapy of Personality Disorders, Translated by Ali Sahebi and Hasan Hamidpour, First Edition. Tehran: Agah Publications. Zuckermanm, M. (1990). The psychology siologo of sensutien. Seeking tournal of personality 58,313- 341.

Comparison of Abstract Learning Ability and Objective: The present study aimed at comparing the learning and memory Memory between ability between methamphetamine- ant Opiate- and opiate-dependent patients and healthy people. Method: A causal-comparative Methamphetamine- research method was employed in this study. The statistical population of the Dependent Patients study included the men with and Healthy People methamphetamine and opioid dependence and healthy men in Tehran. The sample consisted of 20 men with methamphetamine, 17 opioid dependent men, and 20 healthy men who were Akhani, A. , Birashk, B. , Habibi, selected via convenience sampling M. , Ashouri, A. method. In this research, Rey Auditory Verbal Learning Test and Depression Anxiety Stress Scales (DASS) were used for data collection. Results: The results Akhani, A. of this study showed that drug dependent Iran University of Medical Sciences, persons had lower scores in learning Tehran, Iran ability and memory than the healthy Birashk, B. , group. The opioid group was weaker in Department of ..., Iran University of the recall ability and recognition of Medical Sciences, Tehran, Iran, Email: information. The methamphetamine [email protected] group showed more repetition in the Habibi, M. , recall and interference in the recognition Assistant Professor, Department of of the words. Conclusion: The drug- Addiction Psychology, Iran University dependent group undergone a higher of Medical Sciences, Tehran, Iran degree of harm to learning and memory Ashouri, A. ability. Further study of the vulnerability Assistant Professor, Department of of these groups provides constructive tips Addiction Psychology, Iran University for the arrangement of appropriate of Medical Sciences, Tehran, Iran interventions in the realm of rehabilitation. Keywords: cognitive ability, learning, memory, opioid dependence, Research on Addiction methamphetamine dependence Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir

166 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Drug disorder has a high prevalence in the world population (UNODC, 2014). Iran has a long history of opioid consumption and these substances are still the most common abusive substances in Iran (Shari'ati-Rad, Mo'arefvand, & Ekhtiari, 2013). Although opioid dependence is highly prevalent, drug use has seen a significant and increasing trend (World Health Organization, 2004). Stimulants primarily affect the young population (American Psychiatric Association, 2013). The population of Iran is mostly composed of young people aged between 20 and 40 years. Young people's less awareness about the signs and symptoms of prolonged use of stimulants, especially methamphetamine, has prevailed the use of these substances in Iran in such a way that the abuse of stimulants today has become one of the most serious social concerns (Shari'ati- Rad et al., 2013). Findings show that the chronic use of psychoactive substances is associated with many defects in the nervous system (Verdejo-Garcia, Lopez-Torrecillas, Gimenez, & Perez-Garcia, 2004). Addiction to substances affects various cortical and subcortical systems of the brain and causes long-term structural changes in the brain (Meilandt, Barea-Rodriguez, Harvey, & Martinez, 2004). One of the functions that is affected by brain changes is individuals' decision- making ability and executive functions (Rapeli et al., 2006), working memory (Lundqvist, 2005), and spatial memory and learning (Ersche, Clark, London, Robbins, & Sahakian, 2006). Learning refers to changes pertaining to the experiences that are caused by changes in brain connections. If we regard learning as some changes resulting from experience, memory will be the continuation of these changes (Byrne, Eichenbaum, Menzel, Roediger, & Sweatt, 2008). Learning is a mechanism that makes the organism adaptable, and memory contributes to the continuity of behavior change, but both of them are aspects of the same system for gathering information about experiences (Lieberman, 2011). Several findings have shown that different brain regions, especially hippocampus and prefrontal cortex contribute to learning ability and memory function (Byrne et al., 2008). Also, many transmitters, such as glutamate, norepinephrine, endogenous opioids, GABA, and dopamine play a role in the process of data encoding and retrieval from memory (Hyman, 2014; Johansen, Cain, Ostroff, & LeDoux, 2011). Since the above-mentioned structures and transmitters are also involved in the process of drug use dependence, memory and learning in drug users undergo changes with the change of these substances and structures (Koob & Moal, 1977). Previous research has also focused on exploring simple learning mechanisms, such as learning based on responses like conditioning, sensitivity, and silence in animal studies in laboratory designs (Recinto et al., 2012; Parsegian & See, 2014). Human research has also mainly focused on conditioning and the impact of reinforcement on attention to drug-related stimuli (Hyman, 2014; Robbins & Afsaneh Akhani et al 167

Everitt, 2002) and has shown that substance users have weaker performance in cognitive abilities, especially learning and memory, whereas no mention of the memory capability to learn complex issues has been made. A number of studies have investigated memory and learning in substance dependent individuals according to their performance in cognitive tasks. These tasks have mainly compared spatial memory (Ersche et al., 2006) or work memory (Landkvist, 2005) between drug-dependent and normal groups but have not compared verbal memory between drug-dependent people and normal people. Despite these findings, it can be expected that the memory and ability to learn verbal information will be influenced by substance use and will be different from those in the normal group. On the other hand, narcotics and stimulants have a different effect on the central nervous system in such a way that they weaken and stimulate it, respectively. These substances influence different types of neurotransmitters in various brain structures (Meilandt et al., 2004). It is expected that memory changes vary in these two groups. Considering the importance of memory and learning in doing routine actions and adapting to the environment, this study compares methamphetamine-dependent men, opioid men, and normal people together in terms of memory and learning.

Method Population, sample, and sampling method The statistical population of the study consisted of methamphetamine-dependent men, opioid-dependent men, and ordinary people in Tehran. The sample consisted of 20 men with methamphetamine, 17 opioid-dependent men, and 20 healthy men who were selected via convenience sampling method. The three groups were matched with each other in terms of the intervention characteristics in such a way that the results of analysis of variance and chi-square test did not show any significant difference between the three groups in terms of the level of education (P> 0.05, χ2 = 1.72), age (F = 1.48, P>0.05), anxiety (F=1.06, P> 0.05), depression (F = 1.01, P > 0.05), and stress (F = 0.99, P>0.05). Similarly, there was no difference between the two groups of methamphetamine-dependent and opioid-dependent men in terms of the duration of drug use (t = 0.93, p> 0.05) and the duration of withdrawal (t = 1.41, p> 0.05). Consumption in the clinical groups was in the smoking format and these groups were placed in the middle socioeconomic class. These individuals were under treatment according to the 60th Congress of the Human Revival Program, which was based on the use of opioid tincture for both methamphetamine and opioid users. In the protocol of the 60th Congress, the gradual reduction of opioid tincture is used where the decrease is accomplished by the coefficient of 0.8, and the treatment duration according to this protocol is 10 months, which is taken during twenty-one-day steps. To investigate the drug use withdrawal, some tests and experiments are performed that lasts up to one year after the withdrawal where morphine, amphetamine, hashish,

168 Research on Addiction Quarterly Journal of Drug Abuse benzodiazepine, and methadone tests are performed at each run (Dejakam, 2009). Due to the matching problems, three candidates were excluded from the sample because of their non-compliance with the entry criteria of the research. The sampling method was convenience one. The entry criteria of the research were: 1. The age range of 18 to 50 years; 2. Having a minimum of secondary education degree; 3. Individuals' willingness to participate in the test; and 4. The history of methamphetamine and opioid use in the two drug-dependent groups (without simultaneous consumption of other substances) for at least 12 months. The exit criterion was physical and psychological inability to participate in the test. The participants were introduced to the researcher by the authorities of the 60th Congress. At first, the research process was explained to them, informed consent was obtained from them, then, participants were evaluated based on the entry and exit criteria, and their characteristics were compared for homogeneity with members of other groups. Thereafter, Rey Auditory Verbal Learning Test was conducted under standard conditions.

Instruments 1. Rey Auditory Verbal Learning Test: This test is one of the most valid ones for the measurement of learning ability, immediate memory, and false memory. It consists of three lists, namely a 15-word list (the first list), another 15-word list in the name of the intervention list (the second list) whose terms are phonetically and semantically very similar to the first one, and a recognition list that includes 50 words composed from those of the first and second lists, along with thirty new words that are phonetically and semantically similar to the presented lists and are used to examine incorrect recognition (Lezak, 2004). In this test, the lists have been prepared according to the common words available in the Persian language. Studies have shown that the Persian version of this test enjoys the desired reliability in such a way that the reliability of this test has been reported at a moderate level, i.e. 0.55 during a one-year interval. The re-test reliability of this test has been reported to equal 0.65 during a one-month interval (Jafari, Moritz, Zandi, Akbari, & Malayeri, 2009). In this research, the first list was performed for participants 5 times according to standards and, after each run, the participants reminded the words and wrote them on a sheet. Then, the second list was distributed and the words were reminded and recorded. The participants were then asked to recall the first list of words without replaying and, finally, the recognition sheet was given to the participants. The test scores were as follows: The number of words mentioned in each of the 5 first list attempts, the words recalled from the second list, the number of words recalled from the first list with delay and without replay (also titled recall of the first list with delay 1) (immediately after the second playlist) and recall of the first list with delay 2 (fifteen minutes after the second playlist), the number of duplicate recalled words, the number of incorrect recalled words, the number of false recognition, Afsaneh Akhani et al 169 and the learning ability (improved recall of words) were obtained in the first five attempts. 2. Depression Anxiety Stress Scales (DASS): This questionnaire contains 42 items that measure each of the constructs of stress, anxiety, and depression (14 different questions for each construct). Early evidence suggests that this questionnaire has appropriate divergent and convergent validity (Lovibond & Lovibond, 1995). In Iran, Afzali, Delavar, Borajali, & Mirzamani (2007) administered it to a sample of 400 students and obtained the Cronbach's Alpha coefficients of 0.94, 0.85, and 0.87 for depression scale, anxiety scale, and stress scale, respectively. Cronbach's alpha coefficients of these scales in this study were obtained higher than 0.7.

Results The descriptive statistics of the variables related to recalls in the 5 attempts of the first list, the second list, as well as the delayed recalls, incorrect recalls, repetition in the recall of words, and incorrect recognition have been presented in Table 1 for each group. Table 1: Descriptive Statistics of Recall, Recognition, and Learning Variables Group Variable Mean SD Variable Mean SD Stimulants First recall 6.40 1.79 Delayed 10.50 1.91 Opiate 5.71 1.69 recall 10.17 1.74 Control 7.32 2.00 11.84 1.96 Stimulants Second 8.90 1.97 Delayed 8.75 2.01 Opiate recall 8.65 2.45 recall 2 8.71 2.33 Control 10.42 2.31 11.32 2.11 Stimulants Third 10.60 1.60 Incorrect 1.65 1.49 Opiate recall 9.41 3.22 recall 0.88 1.97 Control 11.89 2.08 0.63 0.86 Stimulants Fourth 10.95 2.19 Repetition 1.15 1.59 Opiate recall 10.18 3.97 of recalled 0.88 1.11 Control 12.63 1.38 words 0.21 0.43 Stimulants Fifth recall 11.65 1.84 Incorrect 3.85 2.43 Opiate 11.76 2.56 recognition 2.35 1.97 Control 13.47 1.84 1.95 2.30 Stimulants Recall of 4.80 1.96

second list Opiate 5.00 1.12

Control 7.53 2.89

For data analysis, repeated measures analysis of variance was used. Box's test was used to assess the equality covariance matrix, which was not significant (F = 0.51, P> 0.05). Mauchly's Test of Sphericity (P≤0.089, P <0.001) was significant, which indicates the non-homogeneity of the covariance matrix of the dependent variable. In this way, the modified F value of Greenhouse- Geisser statistic was used. The investigation of the main effect of the within-

170 Research on Addiction Quarterly Journal of Drug Abuse group variable, i.e. learning during 5 attempts and the interaction effects of learning and group were calculated using the F-Greenhouse-Geisser test. The results show a significant change in learning over time (F = 106.03, p<0.001, ŋ2 = 0.667). As ETA shows, nearly 67% of the within- group variance is explained by the effect of time. Also, the findings do not indicate any interactive effect of time in the three groups (F = 0.939, P> 0.05). Thus, the learning process does not interact with membership in the drug- dependent groups and does not vary in different groups. Considering that the main effect of the within-group variable of learning is significant over time, it is possible to compare the mean values of within-group variables at this stage (Table 2). Table 2: Means of Within-group Variables Attempt Mean SD Attempt Mean SD First 6.47 0.25 Fifth 12.29 0.28 Second 9.32 0.30 List 2 5.77 0.29 Third 10.64 0.31 Recall 1 10.84 0.36 Fourth 11.25 0.36 Recall 2 9.59 0.43 The comparison of the mean of the groups showed that the participants have had the maximum recalls in the fifth attempt of the first list and the minimum recalls in the second list. The Levene's test was also used to examine the homogeneity assumption of variances for between-group effects. The result showed that Levene's test was not significant (P≥0.05). In this way, the between- group effects were examined. The findings were indicative of the significant between-group effects (F=6.68, P<0.01, ŋ2 = 0.20). This finding shows that 20 percent of between- group variances is accounted for by the effect of membership in groups. The mean values (standard deviations) of the methamphetamine group, opioid group, and the healthy group were equal to 9.07 (0.42), 8.99 (0.45), and 10.80 (0.43), respectively. The findings of the between-group mean values show that the healthy group has experienced the highest levels of learning, and the methamphetamine group has experienced greater learning than the opioid group. Pairwise comparisons of between-group mean values were made using Bonferroni posthoc test and the methamphetamine group (P< 0.05, mean difference = -1.73) and opioid group (P <0.01, mean difference= -2.10) were significantly different from the normal group. However, there was no significant difference between the opioid and methamphetamine groups (P> 0.05, mean difference = 0.37). Figure 1 shows learning paths in the three groups of methamphetamine users, opioid users, and healthy people. Afsaneh Akhani et al 171

Fig. 1: Learning Path in the Methamphetamine, Opioid, and Healthy Groups in terms of the Number of Recalled Words

Based on what the diagram displays, the mean of word recall has increased in all three groups during 5 attempts. All three groups have acted more weakly in recalling the information of the second list and have reminded fewer words in delayed recalls. One-way ANOVA was used to compare the groups based on the three variables of repetition of recalls, incorrect recalls, and incorrect recognition of the words. The findings showed a significant difference between the three groups in terms of repetition in recalls (F = 3.34, P <0.05) and incorrect recognition (F = 3.89, P <0.05); however, no significant difference was observed between the three groups in terms of incorrect recalls (F = 2.83, P >0.05). Post-hoc test for the pairwise comparison of the groups based on repetition of recalls (MD=0.94, p <0.05) and incorrect recognition (MD = -1.9, P <0.05) showed a significant difference between the methamphetamine and healthy groups where the methamphetamine group showed a weaker performance.

Discussion and Conclusion The aim of this study was to investigate learning and memory differences in opioid-dependent, methamphetamine-dependent, and healthy subjects. The findings were indicative of the weaker performance of substance users than healthy subjects in all memory and learning tasks. These findings are in line with prior research findings where opioid users and methamphetamine users obtained lower scores in brain functions pertaining to learning and memory (Mohammadzadegan et al., 2015). One of the factors that causes both drug-dependent groups to have a weaker memory and learning performance than the healthy group is that drug use brings about the destruction of neurons. Opioids affect cognitive function through

172 Research on Addiction Quarterly Journal of Drug Abuse processes, such as planned cell death (apoptosis) and inhibition of new neuronal formation (neurogenesis) (Nyberg, 2012). This effectiveness was also studied by Arguello et al. (2008) and the findings showed that opioid use results in some deficiency in memory by contributing to the reduced reconstruction of nerve tissues in the hippocampal gyrus. On the other hand, recent studies have shown that methamphetamine use influences glutamate transmitter in such a way that this transmitter is reduced after withdrawal from the chronic consumption of methamphetamine (Crocker et al., 2014; Parsegian & See, 2014). Glutamate plays a role in the synaptic deformity arising from learning (Lovinger, 2010). The findings also show that the damage caused by methamphetamine poisoning occurs as a result of glutamate hyperactivity during methamphetamine use. Research carried out on mice has shown that a high dose of methamphetamine can cause the death of cells even months after the withdrawal (Gururajan, Manning, Klug, & Van den Buuse, 2012). Considering the role of glutamate in learning and information maintenance in memory structures (Meilandt et al., 2004), learning and information retrieval are also disturbed when there is a problem in regulating this transmitter. Thus, with regard to the effect of drug use on the increased mortality of cells in the brain structures effective in memory activity, it can be concluded that individuals with opioid and methamphetamine use suffer from similar lesions in memory and learning. In this study, the comparison between two groups of opioid-dependent and methamphetamine-dependent subjects showed a different performance of these two groups in memory tasks where the opioid-dependent group obtained lower scores in recall and recognition abilities. However, repetition of recalled words and incorrect recognition in the methamphetamine-dependent group have been observed more frequently. These findings are consistent with the studies that have shown that hippocampal structure and forehead play an important role in the coding and stabilization of new information in memory (Schacter & Slotnick, 2004). The dorsal hippocampus is related to the ability to create and retrieve memory (Bannerman et al., 2014). This area covers the mu-opioid receptor. Opioid receptors are among the most recognizable opioid receptors involved in memory creation and retrieval (Meilandt et al., 2004). Opioid sigma receptors, which are frequently found in the hippocampus, amygdala, corpus striatum, and other basal core structures, are involved in learning and memory (Klenowski, Morgan, & Bartlett, 2015). The withdrawal from opioid use is accompanied by impaired opioid production (Sadock, Kaplan, & Sadock, 2007), which is associated with memory disorder. Considering the other effects of opioids on the central nervous system, the long-term use of opioids can affect memory performance, which disrupts the ability to recognize and recall information. The findings of the study also showed that methamphetamine-dependent subjects had a lower accuracy in recalling and recognizing information. This finding was in line with the research done by Ballard et al. who showed that disruption in the encoding of information among methamphetamine consumers Afsaneh Akhani et al 173 leads to incorrect recognition (Ballard, Gallo, & De Wit, 2012). These findings have shown that avoiding interference of irrelevant information, accuracy in coding, and accuracy in the recognition of information are mainly derived from executive functions (Shimamura, 2014). Executive functions are a set of executions that are responsible for the management and control of other cognitive systems and also direct goal-oriented behaviors. In other words, it is a kind of intelligent control mechanism that enables information processing in a top-down approach (Shimamura, 2000). Prior studies have shown that executive functions undergo impairment in methamphetamine users (Eghtedari, Shari'at, & Farhani, 2010). One of the explanations for the cause of this defect is that methamphetamine mainly affects dopaminergic pathways and leads to the higher release and reduction of dopamine reuptake in the synapses (Mendez & Fras, 2011; Miller, 2011). Dopamine plays a major role in the processes of executive function in the lobes of prefrontal cortex and corpus striatum (Stuss & Knight, 2013). The results of the current study indicated a significant difference in learning and memory ability between drug-dependent individuals and healthy people where drug-dependent individuals showed a weaker performance. These findings show the vulnerabilities and weaknesses of the two groups of opioid- dependent and methamphetamine-dependent individuals in learning and memory ability. With a better understanding of these patients, it is possible to take effective steps to improve their quality of life and go for their rehabilitation more effectively. Some of the limitations of this study were the lack of objective measures for evaluating drug use, ensuring the treatment of these patients by opioid tincture, and the absence of women in the sample. The replication of this research in two groups of women and men is strongly recommended for future research. Reference Afzali, A., Delavar, A., Borjali, A., & MIRZAMANI, M. (2007). Psychometric properties of DASS-42 as assessed in a sample of Kermanshah High School students . AmericanPsychiatiricAssociation. (2013). Diagnostic and Statistical Manual of Mental Disorders. United States. Arguello, A. A., Harburg, G. C., Schonborn, J. R., Mandyam, C. 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Mohammadzadeghan, R., Bayrami, m., Movahedi, Y., Gasem baklo, Y., Mohammadyari, G., & Tahmaseb poor, M. (2015). On the Comparison of Cognitive Function in Substance Abusers and Addicts under Methadone Treatment with Normal Individuals. Research on Addiction, 9(34), 23-36 . Nyberg, F. (2012). Cognitive impairments in drug addicts: INTECH Open Access Publisher. Parsegian, A., & See, R .E. (2014). Dysregulation of dopamine and glutamate release in the prefrontal cortex and nucleus accumbens following methamphetamine self- administration and during reinstatement in rats. Neuropsychopharmacology, 39(4), 811-822 . Recinto, P., Samant, A. R. H., Chavez, G., Kim, A., Yuan, C. J., Soleiman, M., . . . Koob, G. F. (2012). Levels of neural progenitors in the hippocampus predict memory impairment and relapse to drug seeking as a function of excessive methamphetamine self-administration. Neuropsychopharmacology, 37(5), 1275-1287 . Rapeli, P., Kivisaari, R., Autti, T., Kähkönen, S., Puuskari, V., Jokela, O., & Kalska, H. (2006). Cognitive function during early abstinence from opioid dependence: a comparison to age, gender, and verbal intelligence matched controls. BMC Psychiatry, 6(1), 9. doi: 10.1186/1471-244x-6-9 Robbins, T. W., & Everitt, B. (2002). Limbic-striatal memory systems and drug addiction. Neurobiology of learning and memory, 78(3), 625-636 . Sadock, B. J., Kaplan, H. I., & Sadock, V. A. (2007). Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry: Lippincott Williams & Wilkins. Schacter, D. L., & Slotnick, S. D. (2004). The cognitive neuroscience of memory distortion. Neuron, 44(1), 149-160 . Shariatirad, S., Maarefvand, M., & Ekhtiari, H. (2013). Emergence of a methamphetamine crisis in Iran. Drug and alcohol review, 32(2), 223-224 . Shimamura, A. P. (2000). The role of the prefrontal cortex in dynamic filtering. Psychobiology, 28(2), 207-218 . Shimamura, A. P. (2014). Remembering the Past Neural Substrates Underlying Episodic Encoding and Retrieval. Current Directions in Psychological Science, 23(4), 257- 263 . Stuss, D .T., & Knight, R. T. (2013). Principles of frontal lobe function: Oxford University Press. Tomkins, D. M., & Sellers, E. M. (2001). Addiction and the brain: the role of neurotransmitters in the cause and treatment of drug dependence. Canadian Medical Association Journal, 164(6), 817-821 . UNODC. (2014). world drug report. New York: Vienna: united nations. .(A., Lopez-Torrecillas, F., Gimenez, CO., Perez-Garcia, M. (2004 وVerdejo-Garcia Clinical implications and methodological challenges in the study of the neuropsychological correlates of cannabis, stimulant, and opioid abuse. Neuropsychology review, 14(1):1-41.

Abstract Structural Equations of Emotional Self- Objective: The aim of this study was to determine the contribution of emotional Regulation, Behavioral self-regulation and behavioral Activation/Inhibition activation/inhibition systems in addicted patients' psychological well- Systems by Mediating being under the mediating role of Thinking Styles in thinking styles. Method: The current research employed a descriptive Addicted Patients' correlational method. Hofmann & Psychological Well- Kashdan's Affective Styles Questionnaire, Behavioral Inhibition being Activation Inventory, Sternberg &

Wagner's Thinking Styles Inventory, and Psychological Well-Being Alipour, Z., Ahadi, H., Hatami, H., Questionnaire were used for data Malihi-al-Zakerini, S. collection. A sample of 100 addicts in Nazarbad was selected by random Alipour, Z. sampling. The collected data were Ph.D. Student, Department of Health analyzed using PLS Software. Results: Psychology, Kish International Branch, The results showed that self-regulation Islamic Azad University, Kish, Iran, e- has a positive effect on thinking styles mail: [email protected] and well-being; and thinking styles Ahadi, H. have a positive impact on psychological Assistant Professor, Department of well-being. Moreover, behavioral Psychology, Islamic Azad University, activation/ inhibition systems have a Kish International Branch, Kish, Iran positive effect on thinking styles and on Hatami, H. psychological well-being. Conclusion: Assistant Professor, Department of The role of emotional self-regulation Psychology, Islamic Azad University, and behavioral/inhibition activation Kish International Branch, Kish, Iran systems with the mediation of thinking Malihi-al-Zakerini, S. styles is predictable in addicted Assistant Professor, Department of patients' psychological well-being. Psychology, Islamic Azad University, Keywords: emotional self-regulation, Kish International Branch, Kish, Iran behavioral activation/ inhibition, thinking styles, psychological well- being Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 12, No. 47, Autumn 2018 http://www.etiadpajohi.ir 178 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Drug addiction is one of the important issues of the present age, which has become a global issue. In the study of human history, few countries can be found that has not been dealing with drug issues. According to the United Nations Office on Drugs and Crime (UNODC), 200 million people in the world suffer from drug abuse (Ebrahimi and Agahi, 2011). One of the factors that is closely associated with drug use is emotional self-regulation. Emotion regulation is a basic principle in initiating, evaluating, and organizing the adaptive behavior and also in preventing the negative emotions and maladaptive behaviors. This structure is a complex concept that covers a wide range of biological, social, behavioral, and conscious and unconscious cognitive processes (Garnefski, 2001). Since emotion regulation plays a central role in normal evolution and weakness, it is considered as an important factor in creating mental disorders. Thus, theorists believe that the individuals who are not able to manage their emotions against everyday events in a proper way show the diagnostic symptoms, and the internalization disorders such as depression and anxiety (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). Gray explains how brain-related personality traits make people susceptible to the psychological disorders and harms. In Gray’s theory, there are two major brain systems that control the behavior and emotions (Gray, 1990). The Behavioral Inhibition System which is activated by a conditional stimulus that is related to the punishment or elimination of the rewards, and the Behavioral Activation System which is activated by a stimulus that is associated with the reward or the termination of the punishment in order to direct the organism to the stimulus. Those who have a high sensitivity in the behavioral activation system are more likely to experience the tendency behavior and positive affection in the stimulating conditions that are accompanied with rewards. (Carver & White, 1994; Dawe & loxton, 2004; & Fowles, 2000). Some studies conducted in the area of the relationship between the behavioral activation/inhibition systems and alcohol abuse problems have shown that there is a positive relationship between the high sensitivity of the behavioral activation system and alcohol abuse (Franken & Muris, 2006; Hundt, Kimbrel, Nelson, & Mitchell, 2008; & O’Connor, Stewart, & Watt, 2009). The behavioral inhibition system is activated by the conditional stimuli that are associated with the punishment or removing the reward and also by the new stimuli or the stimuli that inherently involve fear (Gray, 1994). It is predicted that people whose behavioral activation system is higher than the activity level of this system in normal people and the activity of their inhibition system is lower than that of the normal people are exposed to the highest risk of problems of substances and alcohol (Nathan et al., 2007). Rose and Musyler (2013) concluded that there was a positive correlation between the behavioral activation system and the tendency toward addiction (quoted by Sheikh-al-Eslami et al., 2016). Among the various Zahra Alipour et al 179 variables that play a significant role in explaining and predicting the tendency toward addiction, thinking styles can be mentioned. Being placed in the particular situations that direct a person to drug use can create a particular way of thinking that is specific to the life in these situations. The results of the research show that the addicted people have different thinking styles in comparison with non-addicted people. Soto (2007) and Lacy (2000) investigated whether prisoners with substance abuse problems have different thinking styles than prisoners without substance abuse problems. And also explored what specific thoughts and thinking styles are predominant in these individuals? The results of the research indicated that the prisoners with substance abuse problems use the confusing criminal thinking styles more than the prisoners without substance abuse problems. The thinking style is not an ability by itself, rather it refers to how the capabilities are used (Sternberg, 1997; quoted by Emamipourr, 2001). By introducing the theory of mental autonomy, Sternberg proposed thinking in the form of 13 styles which are categorized into five dimensions of function, form, level, scope, and learning. In brief, in the dimension of function, the individual with legislative style tends to develop inventions and designs and performs the works in his own way. A person with an executive style performs what is said to him, and the person with the judicial style tends to judge and evaluate people and things. In the tendency dimension, a person with a liberal thinking style tends to do things in new ways and also disagrees with the customs. A person with a conservative thinking style tends to do things in the predetermined and proper ways (Emamipour, 2001). One of the important factors in explaining the individuals’ mental health is paying attention to their psychological well-being; if it is at a low level, it can predict several psychological and social harms. Ryff (1998), inspired by Aristotle, states that some of the aspects of the optimal activity such as the realization of the individual’s goals involve a lot of legitimacy and effort, and this may even be in complete conflict with short-term happiness. She believes that well-being should not be considered as an equivalent to more experience of pleasure against pain, but well-being includes efforts toward perfection and the realization of the individual’s potential forces. King & Hinds (1998) in the development of the psychological well-being structure, focused on the individual’s experiences and on the six aspects of the psychological performance associated with flourishing including autonomy, mastery, personal growth, positive relatedness, life purpose, and self-acceptance. Psychological well-being reflects how people feel about themselves and includes the individuals’ emotional responses, satisfaction with life, and judgment about quality of life. Psychological well-being is an important structure that at the low levels leads to depression and social isolation and cause the lack of satisfaction, self- confidence, and feeling and also leads to the reduced mental and physical health (King and Hinds, 1998). Psychological well-being has been defined as the individuals’ understanding of their own lives in the context of the emotional

180 Research on Addiction Quarterly Journal of Drug Abuse behaviors and mental performances and the dimensions of mental health. Research on the psychological well-being has shown the areas of personality, motivation, and cognitive factors (perception, self-confidence, optimism), all of which contribute to the individuals’ satisfaction with life (Diner, 2006). There is a wealth of research evidence that indicate the unpleasant events of life can affect and distort the psychological well-being and lead to the psychological problems such as depression and anxiety. On the other hand, the relationship between the psychological well-being and the other factors such as emotion regulation and personality traits should be considered. The role of affective styles has been discussed in a range of mental disorders including substance abuse (Hayes & Wilson, 1996) anxiety and mood disorders. Moreover, the individual differences in affective styles have shown to be associated with the biological correlates (Drabant, 2009). Such differences in affective styles and emotional regulation might predict the successful coping with the emotional challenges and also initiate the emotional disorders. Therefore, the question proposed regarding the emotion regulation is the difference between people in their habitual tendencies to use some affective and self-regulation styles more than others and also its relationship with the psychological well-being; especially if the preferred strategy have bad results. On the one hand, personality traits are among the factors affecting the individuals’ vulnerability or well-being (Cooper, 2000). Therefore, the other question is the role played by the personality dimensions based on brain- behavioral systems in the psychological well-being. Therefore, the purpose of the present study was to identify the role of the psychosocial factors such as emotional self-regulation and also the personality biological components in predicting the psychological well-being with the consideration of the mediating role of thinking styles in the addicted patients. On the other hand, with regard to the local conditions of the city of Nazarabad in terms of the extent of substance use especially in adolescents and young people, the existing economic and cultural problems in this area and the lack of sufficient skills regarding the immunity of young people and adolescents from drug use, it seems necessary and important to carry out studies especially regarding the identification of the biological and psychosocial factors making the background for drug use as an important factor in the prevention of addiction, as well as the necessary trainings to change each of the above mentioned factors in relation to the addiction treatment in the addicted. Accordingly, the present study seeks to investigate each of the hypotheses of the extent of the contribution of the psychological well-being based on the emotional self-regulation by mediating thinking styles in the addicted patients referring to the addiction treatment clinics. Furthermore, the extent of the contribution of the psychological well-being based on the behavioral activation/inhibition systems by mediating thinking styles in the addicted patients referring to the addiction treatment clinics is predictable. Zahra Alipour et al 181

Method Population, sample, and sampling method The method of this research is correlational through the structural equation modeling. Structural equation modeling, which is known as path analysis with the latent variables, is a commonly used method in behavioral and social sciences to illustrate the causal relationships in the multivariate data. By this method, we can study the fitting of the hypothesized model and the direct and indirect effects of the variables in that model. This method measures the estimations of the model parameters (path coefficients and error terms) and some goodness-fit indicators (Ebrahimi & Rahimi, 2013). The population of the present study is the complex of Medical Clinics of Nazarabad in 2016; the number of patients was estimated by the Healthcare Network of the city to be 700 people. With regard to the size and spread of the population, random cluster sampling was used and 3 clinics were selected as clusters, and 35 people from each clinic participated in the research. Finally, according to the sampling method of partial least squares, 100 people participated in the research correctly. An important feature of the partial least squares approach is to minimize the sensitivity to the sample size (N <100) and there is no need to use sample size methods; moreover, the normal distribution of the data is not an obstacle to use this software (Barklay et al. 2015). Therefore, with regard to the proposed principle in PLS (Barklay et al., 2015), it is equal to the largest value obtained from two principles (Davari and Rezazadeh, 2016): 1- Multiplied by the number of indicators of the measurement model that has the highest index among the measuring models. 2- Multiplied by the highest relationships existing in the structural part of the model that end with a variable. According to the first principle, the highest index is related to the variable of thinking styles with 11 indicators, so the minimum sample is 110. And according to the second principle, the existing relations in the structural part that end with the dependent variable are 3; therefore, the minimum sample is 30. Thus, the first principle with 110 samples is considered for the current study. It should be noted that 150 questionnaires were distributed; however, due to the limited participation, 50 questionnaires were completed incorrectly, which was discarded. Instruments 1. Affective Styles Questionnaire: This questionnaire was developed by Hofmann and Kashdan (2010) and consisted of 20 items. Answering the items is based on the 5-point Likert scale ranging from "It's not true about me at all (1)" to "It's completely true about me" (5) ( Hofmann & Kashdan, 2010) . In addition to the subscales, this scale has a minimum score of 20 and a maximum score of 100 (that is, the subscales measure the concept together). The questionnaire consists of three components or subscales of secrecy, compromise, and tolerance, which have 8, 7, and 5 items respectively. In Karshaki’s (2013) study, the above-mentioned questionnaire was translated and retranslated. Then,

182 Research on Addiction Quarterly Journal of Drug Abuse it was given to the psychological experts to investigate its content validity. The content validity was confirmed. After collecting the data, factor analysis was used to verify the construct validity. The results of factor analysis showed that sample size is sufficient and the factors are interpretable. The value of 17.8% of the variance is explained by the first factor (compromise), 14.97% of the variance is determined by the second factor (secrecy), and 8.43% is explained by the third factor (tolerance). Of course, the items 18 and 20 of the secrecy component and the items 3 and 14 of the tolerance component were removed due to the factor loading of weaker than 0.30. The Cronbach's alpha for the subscales of secrecy, compromise, and tolerance were 0.70, 0.75, and 0.50 respectively, and it was 0.81 for the total scale. In sum, the validity and reliability indices were satisfactory (Karshaki, 2013). In the present study, the Cronbach's alpha and composite reliability were 0.65 and 0.75 respectively. 2. The Behavioral Inhibition Activation Inventory: This scale was developed by Carver and White (1994), and includes 24 self-report items and two subscales: 1. the subscale of behavioral inhibition (BIS) and 2. the behavioral activation subscale (BAS). The subscale of the BIS in this questionnaire consists of seven items that measure the sensitivity of the behavioral inhibition system or the responding to the threat and anxiety when confronted with the signs of threat. This subscale includes questions 2, 8, 13, 16, 19, 22, and 24. The subscale of BAS also includes 13 items and measures the sensitivity of the behavioral activation system; it includes three other subscales which are: Drive (BAS-DR consists of 4 items including the questions 3, 9, 12, and 21), the responding to reward (BAS-RR consists of 5 items including questions 5, 7, 14, 18, and 23), fun search (BAS-FS consists of 4 items including the questions of 5, 10, 15, and 20). In this scale, the responses are calculated on the basis of the 4-point Likert scale (4 = completely agree, 3 = somewhat agree, 2 = somewhat disagree, 1 = completely disagree). To obtain the score of each dimension, we should add up the total score of the questions related to that dimension. Of course, it should be noted that items 1, 6, 11, and 17 do not affect the scoring and are only added to the questionnaire in order to be consistent with the other items. Carver and White reported the internal consistency of the BIS scale and the subscales of drive, search for happiness, and responding to rewards to be 0.74, 0.73, 0.76, and 0.66, respectively. In a study conducted by Amiri and Hasani on 103 university students from Urmia and Kharazmi University, the internal consistency of the BIS questionnaire was 0.78 and the internal consistency of BAS subscales reported to be 0.82, 0.75, and 0.86, respectively. In that study, the Cronbach's alpha and composite reliability were 0.61 and 0.70 respectively. 3. Psychological Well-being Questionnaire: Short version (18 items). This questionnaire was designed by Ryff in 1989 and was revised in 2002. The short version including 18 items is used in the present study. This test is a self- assessment tool that is completed in a 6-point Likert scale of completely agree to completely disagree; a higher score indicates that the psychological well- Zahra Alipour et al 183 being is better. This version consists of 6 factors. The total score of these factors is calculated as the total score of the psychological well-being, with the minimum total score of 18 and the maximum of 108. The correlation of Ryff’s short version of the psychological well-being questionnaire with the main scale ranges from 0.70 to 0.89 (Ryff, 2006). In the research conducted by Khanjani et al., the results of the reliability coefficients for the subscales of self-acceptance, environmental mastery, positive relationship with others, having a goal in life, personal growth, and independence were 0.51, 0.76, 0.75, 0.52, and 0.73; it was 0.72 for the total scale. In this study, the Cronbach's alpha and composite reliability were 0.69 and 0.81, respectively. 4. Thinking Styles Inventory: This questionnaire was designed by Sternberg & Wagner in 1991. It includes 104 items and 13 subscales. Each sub-scale has 8 items and measures one thinking style. Thirteen thinking styles are: Function (legislative, executive, judicial), forms (monarchic, hierarchic, oligarchic, and anarchic), levels (global and local), scope (internal and external) and leaning of government (liberal and conservative) (Matin Nejad, Mousavi, & Shams Esfandabad, 2010). A higher score in each of the styles reflects the individual’s dominant thinking style. The afore-mentioned scale has a minimum total score of 104 and a maximum score of 728 (that is, the subscales measure the concept together). Fathollahi (2005) employed this scale for 276 managers of higher education institutions of Tehran including 169 men and 98 women. Cronbach's alpha for the total questionnaire was reported to be 0.927. Emami worked on the standardization of the questionnaire in Iran. The reliability coefficient of the sub- scales was 0.57 to 0.84. In this study, the Cronbach's alpha and the composite reliability were 0.80 and 0.83, respectively.

Results The reasons for choosing the partial least squares approach in this study are as follows. Contrary to the first-generation approach, the second-generation approach based on the variance instead of reproducing the empirical covariance matrix, focuses on the maximization of the variance of the dependent variables that are predicted by the independent variables. And the reasons for using the PLS method in the present study is the small sample size and the lack of need for the assumptions of normal distribution of the data and solving the problem of the similarity of the measurement model. Furthermore, lack of sensitivity to the measurement scale, the range of variation, missed data, outliers, non-linearity of the data, and consequently the need to check the data is not through the graphical techniques and statistical tests to ensure that there is no problem in the data or to find a solution for it. (Mohsenin & Esfidani, 2014). The model of measuring the role of emotional self-regulation on the psychological well-being by mediating thinking styles The mutual factor loadings and the reliability coefficients of the self- regulation model are presented in Table 1.

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Table 1: Mutual Factor Loadings and Reliability Coefficients of the Self-regulation Model Self- Thinking Well- Cronbach's composite Variables Dimensions regulation styles being alpha reliability Secrecy 0.538 -0.033 0.000 Self- compromise 0.853 0.025 0.117 0.65 0.75 regulation Tolerance 0.858 0.068 0.091 Liberal thinking 0.000 0.764 0.587 Outward looking -0.104 0.410 0.273 Inward looking 0.064 0.395 0.163 Monarchic 0.116 0.618 0.343 Legislative 0.088 0.708 0.370 Thinking Judicial -0.025 0.365 0.132 0.80 0.84 styles Oligarchic 0.024 0.658 0.302 Local 0.174 0.531 0.166 Global 0.064 0.457 0.015 Conservative -0.015 0.438 0.110 Hierarchic 0.026 0.750 0.417 Autonomy 0.021 0.323 0.589 Self-acceptance 0.117 0.369 0.780 Well-being 0.69 0.81 Self-mastery 0.143 0.467 0.827 Personal growth 0.065 0.446 0.674 According to the results of the above table, the correlation between the questions of a construct was compared with other constructs. As shown in the table, the correlation among the questions with their related structures (colorful numbers) is greater than the correlation between the questions and other constructs; it indicates the appropriate divergent validity in this model (Tabatabaei, Motahari Nejad, & Tirgar, 2016). According to the obtained results of the above table, Cronbach's alpha of higher than 0.7 represents the acceptable reliability. Of course, Moss et al. (1998) have introduced the value of 0.6 as the coefficient threshold for the variables with a small number of questions (Tabatabaei & Jahangard, 2016). Therefore, by removing the dimension of the purposeful life and positive relationships from the component of the psychological well-being, the Cronbach's alpha value reached to above 0.6. As a result, all variables have a coefficient of above 0.6, which is an acceptable coefficient for the variables with few questions. As a result, the coefficient of all the latent variables in Table 1 is above 0.75. According to the results obtained in Table 1, the convergent validity of higher than 0.5 is acceptable, and the value of 0.4 is also sufficient for the variables with a small number of questions (Davari & Rezazadeh, 2014). Therefore, by removing the executive and non-affective dimension from the component of thinking styles and the dimension of life and by removing the relationships from the well-being component the convergent validity reached to above 0.4. As a result, all variables have a coefficient of above 0.4, which is an acceptable coefficient. The correlational matrix and the Zahra Alipour et al 185 convergence and divergent validity of Fornell and Larcher are presented in Table2. Table 2: Correlational Matrix and the Convergent and Divergent Validity of Fornell and Larcher Components Convergent validity 1 2 3 1. Self-regulation 0.529 0.73 - - 2.Thinking styles 0.391 0.057 0.62 - 3.Well-being 0.523 0.126 0.565 0.72 According to the contents of the table, based on Fornell and Larker’s view (1981), examining the divergent validity is done through a matrix. A component, in comparison to the other components, should have a higher differentiation and separation among its observed variables (questions) so that it can be stated that the given component has a high divergent validity. The listed numbers show an acceptable divergent validity in the Fornell and Larker’s method. The measurement model for the role of behavioral/inhibition activation systems in the psychological well-being by mediating thinking styles Table 3: Mutual Factor Loadings and Reliability Coefficients of the Behavioral Inhibition Model Behavioral Thinking Well- Cronbach's Composite Variables Dimensions inhibition styles being alpha reliability BIS 0.852 0.361 0.268 Behavioral BAS_DR 0.554 0.117 0.147 0.61 0.71 inhibition BAS_FS 0.580 0.163 0.170 Liberal 0.202 0.721 0.582 Outward 0.267 0.462 0.275 looking Inward looking 0.300 0.433 0.169 Monarchic 0.169 0.587 0.337 Thinking Legislative 0.260 0.732 0.372 0.69 0.81 styles Judicial 0.139 0.378 0.126 Oligarchic 0.119 0.657 0.304 Local 0.082 0.529 0.164 Global 0.336 0.531 0.016 Conservative 0.080 0.450 0.108 Hierarchic 0.269 0.732 0.416 Autonomy 0.265 0.314 0.612 Well-being Self- 0.228 0.364 0.786 acceptance 0.80 0.84 Personal 0.196 0.415 0.662 growth Environmental 0.195 0.435 0.816 mastery According to the results of the above table, the correlation between the questions of a construct was compared with the other constructs. As shown in Table 3, the correlation among the questions with their related constructs

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(colorful numbers) is higher than the correlation among the questions with other constructs; it indicates the appropriate divergent validity in this model. The correlational matrix and the convergent and divergent validity of Fornell and Larcher are presented in Table 4. Table 4: Correlational Matrix and the Convergent and Divergent Validity of Fornell and Larcher Components Convergent validity 1 2 3 1. Behavioral inhibition 0.456 0.67 - - 2. Thinking styles 0.524 0.358 0.72 - 3. Psychological well-being 0.434 0.302 0.534 0.66 The numbers listed in the above table show the appropriate divergent validity in the Fornelland Larcker method. In this step, using the structural model, the relationship between the constructs is examined causally. In fact, considering the results of investigating the relationships between the independent and dependent constructs using the relevant coefficient, we can examine the significant effects among the research constructs. Moreover, the Bootstrap test (with 500 sub- samples) was used to calculate the values of T to determine the significance of the path coefficients; the construct level changes that was recommended in the partial least squares method was used in order to correct the errors (Esfidani & Mohsenin, 2014). The structural model of the role of the emotional self-regulation on the psychological well-being by mediating the thinking styles Table 5: Quality Indicators of the Structural Model Dependent latent variables Prediction Power Goodness of fit Thinking styles 0.016 0.28 Psychological well-being 0.078 According to Table 5, the prediction power is not an appropriate coefficient. However, the goodness of fit is desirable; the obtained values represent the overall desirability of the model. Table 6: The Structural Model of Mediating Thinking Styles in the Relationship between Emotional Self-regulation and Psychological Well-being Factor Coefficient of Hypotheses Significance Level Hypothesis loading determination Emotional self- regulation→ thinking 0.357 3.232 0.003 P<0.01 Accepted styles Emotional self- regulation→ 0.294 2.739 P<0.01 Accepted 0.328 psychological well-being thinking styles→ 0.559 4.218 P<0.01 Accepted psychological well-being In the following, we examine the indirect effect and the significance of the Sobel test for the mediating effect of thinking styles in the relationship between self-regulation and well-being. Zahra Alipour et al 187

Table 7: Fitness of the Structural Model for the Mediation of Thinking Styles Indirect Coefficient of Hypotheses Sobel t-value Level effect determination Mediation of thinking styles in the relationship between emotional 0.199 2.225 0.328 P<0.05 self-regulation and psychological well-being As shown in Table 5, thinking styles have a positive and significant effect in the relationship between self-regulation and well-being (indirect = 0.199 and t = 2.255) (p <0.05). The factor load and the coefficient of determination of the structural model for the role of emotional self-regulation in psychological well- being by mediating the thinking styles are presented in Fig.

Outward Inward Liberal looking looking Monarchic Legislati Judicial Oligarchic Local Global Conservative Hierarchic

0.410 0.438 0.764

Thinking Styles

Autonomy

Self- 0.689 acceptance Secrecy

Compromis Personal e growth Tolerance 0. 827 Welfare Behavioral Environmental Inhibition mastery

Figure 1: Factor Load and Coefficient of Determination of the Structural Model for the Role of Emotional Self-regulation in Psychological Well-being by Mediating Thinking Styles

Structural Model for the Role of Behavioral Inhibition System in Psychological Well-being by Mediating of Thinking Styles

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The significance coefficient of the structural model for the role of emotional self-regulation in psychological well-being by mediating the thinking styles is presented in Fig. 2.

Liberal Outward Inward looking looking Monarchic Legislati Judicial Oligarchic Local Global Conservative Hierarchic

Thinking Styles

Autonomy

4.354 Self- acceptance secrecy

compromise Personal growth 3.053 tolerance Welfare Behavioral Environmental Inhibition mastery

Figure 2: The Significance Coefficient of the Structural Model for the Role of Emotional Self-regulation in Psychological Well-being by Mediating of Thinking Styles

The quality indicators of the structural model for the behavioral inhibition model are presented in Table 8. Table 8: Quality Indicators of the Structural Model for the Behavioral Inhibition Model Dependent latent variables Prediction power Goodness of fit Thinking styles 0.042 0.13 Cognitive well-being 0.031 As can be seen, the obtained prediction power is not a suitable coefficient. However, the value of goodness of fit is a desirable coefficient that reflects the overall desirability of the model. The structural model of the mediation of thinking styles in the relationship between the behavioral inhibition and cognitive well-being is presented in Table 9. Zahra Alipour et al 189

Table 9: Structural Model of the Mediation of Thinking Styles in the Relationship between the Behavioral Inhibition and Cognitive Well-being Factor Coefficient of Hypotheses Significance Level Hypothesis load determination Behavioral inhibition→ 0.358 3.24 0.128 P<0.001 Accepted thinking styles Behavioral inhibition→ 0.227 2.826 P<0.01 Accepted psychological well-being 0.299 Thinking styles→ 0.489 3.58 P<0.001 Accepted psychological well-being

The fitness of the structural model for the mediation of thinking styles is presented in Table 10.

Table 10: Fitness of the Structural Model for the Mediation of Thinking Styles Indirect Sobel t- Coefficient of Hypotheses Level Hypothesis effect value determination The mediation of thinking styles in the relationship between 0.175 2.36 0.299 P<0.05 Accepted behavioral activation/inhibition and the psychological well-being

Considering the investigation of the indirect effect and the significance of Sobel for the mediating effect of thinking styles on the relationship between behavioral inhibition and well-being. According to the table, the thinking styles have a positive and significant effect in the relationship between the behavioral inhibition and well-being (indirect =0.175 and t =2.36). Factor load and coefficient of determination of the structural model for the role of the behavioral inhibition/activation system in psychological well-being by mediating thinking styles is presented in Fig. 3.

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Oligarc Inward Liberal Outward Local Monarchic Legislati Judicial Conservative Hierarchic Global looking hic looking

2.354 2.541

Thinking Styles

Autonomy

Self- 0.612 secrecy acceptance

fun

Personal growth 0.816 Welfare Behavioral Environmental Inhibition behavioral mastery inhibition

Fig. 3: Factor Load and Coefficient of Determination of the Structural Model for the Role of the Behavioral Inhibition/Activation System in Psychological Well-being by Mediating thinking styles

The significance coefficient of the structural model for the role of the behavioral inhibition/activation system in psychological well-being by mediating thinking styles is presented in Fig. 4.

Zahra Alipour et al 191

Inward Hierarchic Liberal Outward OligarchicLocal Monarchic Legislati Judicial Conservative Global looking looking

2.354 2.541

Autonomy

3.940 Self- secrecy acceptance

fun

Personal growth 7.302 Environmental behavioral mastery inhibition

Fig. 4: Structural Model's Significant Coefficient for the Role of the Behavioral Inhibition/Activation System in Psychological Well-being by Mediating Thinking Styles

Discussion and Conclusion The purpose of the present study was to determine the contribution of the psychological well-being on the basis of the emotional self-regulation by mediating thinking styles and to determine the contribution of the psychological well-being on the basis of the behavioral inhibition/activation systems by mediating thinking styles in the psychological well-being of the addicted patients. The findings of this study are consistent with the previous studies that show that the addicted people use drug abuse as a generalized coping method due to the deficiencies, lack of the adaptive skills, and positive expectations from the effects of psychedelic drug (incorrect beliefs about the effects of drugs) (Matin Nejad, Mousavi, & Shams Esfandabad, 2010). Emotional processes interact with the aspects of cognition in such a way that the capabilities of the emotional stimuli influence a wide range of cognitive operations, and also the human ability is influential to apply the cognitive mechanisms in regulating the emotional responses (Ray and Zald, 2012; quoted by Motamedi & Amirpour, 2012). The majority of the previous studies have investigated the effects of the emotional stimuli on the cognitive functions such as working memory, conflict processing, and response inhibition (Shokri et al., 2006; quoted by Motamedi &

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Amirpour, 2012). In the research conducted by Motamedi and Amirpour about the effect of thinking styles on the patterns of anger expression and control in university students, the obtained data of the research showed a significant difference between the liberal thinking style and the style of outward looking thinking in girls and boys. Therefore, based on the results of this study as well as the previous studies, it can be concluded that considering the two-way relationship between cognition and emotion and the effect of each on the other, thinking as one of the components of cognition can influence the qualitative and quantitative domains of the emotions; meanwhile, the type of person's thinking has been a determinant of the way of emotional processing, expression and management of emotions. In addicts, both sides of this relationship are faced with problem because these individuals have developed a particular type of thinking due to their inability to manage emotions, and in another direction, the type of the developed thinking influences the way of expressing and regulating the emotions. . Therefore, these people have always been exposed to the mutual effect of these two elements in relation to themselves and the surrounding world and always struggle with numerous psychosocial-social damages. This mutual relationship between emotional regulation and thinking in relation to the psychological well-being can also be explained. Akhlaghi Yazdinejad and Hossein Sabet in their study showed that emotional regulation training can be effective in increasing the self-efficacy and psychological well-being of drug dependent individuals. In Esmaeili and Azadparvar's researches about the effectiveness of the emotional adjustment intervention in self-acceptance, the purposeful life, and positive relationships with others in veterans’ children, it was shown that the two groups of experiment and control differ in their self-acceptance rates and the positive relationships with others. The findings of this study suggest the intervention based on emotion regulation in order to increase the self-acceptance and positive relationships with others in veterans’ adolescent children. In Amiri and Sepehrian Azar's research, there was a positive correlation between the affective styles and psychological well-being in the affective styles such as compatibility and tolerance. Johnson, Turner, and Iwata (2003) showed that high scores of the behavioral activation predict substance abuse and dependency to it. Moreover, with respect to the behavioral inhibition activation systems, Abdollahzadeh Jeddi, Hashemi, Moradi, and Farzad (2010) showed that there is a relationship between brain/ behavioral systems and substance abuse. In explaining the relationship between the behavioral inhibition activation systems, emotional regulation, and thinking styles, we can refer to the results of Masoumi's (2013) study that indicated that there is a relationship between brain / behavioral systems, emotional regulation, and maladaptive schemas in the temptation toward drug use in the addicted people. Furthermore, Atadokht, Ranjbar, Gholami, and Nazari in their study on the tendency of university students to high-risk behaviors and its relationship with the individual-social variables and psychological well-being revealed that Zahra Alipour et al 193 psychological well-being had a negative relationship with high-risk behaviors and also with almost all aspects of the high-risk behavior dimensions. That is, the levels of psychological well-being decreases with increasing the level of tendency towards a variety of high-risk behaviors. The results of Amiri and Sepehrian Azar’s research indicated that affective styles, personality traits based on brain-behavioral systems, and emotional regulation have a significant role in predicting psychological well-being. In Gross and John's research, it is stated that people who use re-evaluation as a regulatory strategy show better social performance and higher well-being. In addition, investigating the relationship between personality traits based on brain-behavioral activation and behavioral inhibition with psychological well-being generally indicates a positive correlation between the behavioral inhibition system and psychological well- being. Nikzad's research, the effectiveness of the psychodrama theater therapy on psychological well-being and false beliefs of addicts (Case Study: Addiction treatment Center of Persian Gulf, Bushehr), showed that the psychological psychodrama could significantly increase the psychological well-being of the experimental group in establishing positive relationships with others, autonomy, self-acceptance, environmental domination, personal growth, and purposeful life; it reduced the irrational beliefs such as emotional irresponsibility, avoidance to deal with problems, helplessness against change, and the expectation of confirmation from others. One of the limitations of the present study was that it was a correlation research and thus the inference about the causal relationships between variables is based on probability, i.e., in addition to the relationships obtained in this study, the interventional variables such as social and cultural issues as well as other psychological variables might influence the results. Furthermore, another limitation was the lack of concentration and consciousness of the addict population in the participation and completion of the questionnaires, which resulted in the loss of a large number of questionnaires. Thus, the sample was small and the PLS software was used for the analysis with a small sample. Regarding the fact that the sample consisted of the male addicts, not using the both genders is another limitation of the present study. It is suggested that future studies use both genders, men and women, since there might be a difference between the two genders in each of the variables studied in this study. It is suggested that addiction therapists and healthcare administrators in the area of addiction hold programs and training workshops about the avoidance of drug use for drug addicts and other community members in order to change their thinking styles and also with regard to the trainability of emotional self- regulation. Especially considering the context of the current study and addiction in low ages, as well as lack of adequate information and skills in the family in preventing and confronting with the addiction, the proposed trainings are more necessary.

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Reference Abdollahi Majarishen, R. (2006). The Relationship between Behavioral Inhibition and Activation Systems and Invisible Memory Bias in Depressed People. Master’s Thesis, Tabriz University. Abdollahzadeh Jeddi, A., Hashemi, T., Moradi, A., & Farzad, V. (2010). The Role of Brain-behavioral Systems in Predicting Substance Abuse. Journal of Clinical Psychology, 2 (47), 37-45. Akhlaghi Yazdinejad, F., & Hossein Sabet, F. (2016). Effectiveness of the Emotional Regulation Training in Self-efficacy and Psychological Well-being of Drug Addicts. Master’s Thesis, Allameh Tabatabaei University. Aldao, A. Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30, 217-237. Amiri S, Hassani J. Assessment of Psychometric properties of Behavioral activation and Behavioral inhibition systems scale associated with impulsivity and anxiety. Razi J Med Sci. 2016; 23 (144):68-80. Atadokht, A., Ranjbar, M., Gholami, F., & Nazari, T. (2013). The Tendency of University Students towards High-risk Behaviors and Its Relationship with Individual- Social Variables and Psychological Well-Being. Journal of Health and Care, 15 (4). Campbell-Sills L, Barlow D. Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In: Gross J, editor. Handbook of emotion regulation 542-559. New York: Guilford; 2007 Carver CS, White TL. Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment: The BIS/BAS Scales. Journal of Personality and Social Psychology. 1994;67(2):319-33. Cooper CL. Theories of organizational stress. USA: Oxford University; 2000. Davari, A., & Rezazadeh, A. (2014). Structural Equation Modeling with PLS Software. Master's Thesis of Psychology. Kharazmi University, Publication Organization of Jihad Daneshgahi. Drabant EM, McRae K, Manuck SB, Hariri AR, Gross JJ. Individual differences in typical reappraisal use predict amygdala and prefrontal responses. Biol Psychiatry. 2009;65(5):367-73 Ebrahimi, A., & Aqahi, B. (2011). Collection of the Selected Articles of 30 Provincial Congresses on the Primary Prevention of Addiction, Cultural and Prevention Office of the Drug Control Headquarters. Esmaeili, L., & Azadparvar, V. (2016). Effectiveness of the Intervention of Emotion Regulation on Self-acceptance, Purposeful Life, and Positive Relationships with Others in veterans’ children. Second National Conference of Knowledge and Technology of Educational Sciences of Social Studies and Psychology of Iran. Sam Iranian Institute of Organizing the Development-based Seminars of Knowledge and Technology. Fathollahi, A., & Hooman, H. (2005). Investigating the Practicality, Reliability, Validity, and Standardization of the Sternberg-Wagner Thinking Styles for Managers of Institutions. Master’s Thesis, Azad University, Central Tehran. Fornell, C., & Larcker, D. F. (1981). Evaluating Structural Equation Models with Unobservable Variables and Measurement Error. Journal of Marketing Research, 18(1), 39-50. Doi: 10.2307/3151312 Zahra Alipour et al 195

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Sadock, B., & Sadock, V. (2010). Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry, Translated by Mohsen Arjmand, Farzin Rezaee, and Nadiya Faghani Jadid (2011). Arjmand Publications. Sheikh-al-Eslami, A., Kiani, A., Ahmadi, Sh, & Soleimani, E. (2016). On the Prediction of Tendency to Drug Use Based on Behavioral Activation and Inhibition Systems, Cognitive Flexibility, and Distress Tolerance among Students. Quarterly Journal Research on Addiction, 10 (39). Soto, R. D. (2007). Criminogenic personality and behavioral characteristics in substance abusers: An examination of the Lifestyle Model of Substance Abuse. The University of Nebraska – Lincoln.123-201. Tabataba'ei, S., & Jahangard, H. (2016). Structural Analysis of Self-efficacy of Occupational Decision Making on the Assurance of Occupational Decision Making by Mediating the Dimensions of Professional Opportunity Seeking. Scientific and Research Quarterly Journal of Educational Research, 11 (47), 85-112. Tabataba'ei, S., Motaharinejad, H., & Tirgar, H. (2016). The Validation of an Instrument to Measure Teacher Identity in Physicians Based on the Partial Least Squares (PLS) Approach. Developmental Steps in Medical Education, 13 (6), 553-567.

The Effect of Eight Abstract Weeks of Combined Objective: The present study aimed at Exercise With and investigating the effect of eight weeks of combined exercise with and without the Without supplementation of cinnamon on Supplementation of hematological factors of liver enzymes in female amphetamine addicts. Cinnamon on Method: In this quasi-experimental Hematological and Liver study, 48 women addicted to Enzymes AST, ALT, and amphetamine were divided into four groups. The exercise program was ALP in Female performed for eight weeks (three days a Amphetamine Addicts week). Cinnamon supplement was taken as a 500-mg capsule twice a day after breakfast and lunch. Blood samples were taken to measure hematological factors and liver enzymes. To compare the Moradi, M. , Ali-Akbari Bidokhti, groups, MANOVA test was used and M. , Ghofrani, M. paired t-tests were run for measuring intra-group changes. Results: The results of this study showed no significant difference in hematological Moradi, M. , variables and liver enzymes between the Master's Holder of Sports Physiology, groups (P≥0.05). However, t-test Sistan and Baluchestan University, showed a significant reduction of white Zahedan, Iran blood cells in all groups, while the Ali-Akbari Bidokhti, M. , reduction of hematocrit and red blood Ph.D. Student, Department of Sports cells was observed only in the Physiology, Birjand University, Birjand, supplement group (P <0.05). Iran, Email: Conclusion: The combined exercise [email protected] along with the supplementation of Ghofrani, M. cinnamon can be effective in the Assistant Professor, Department of hematologic factors of addicts. Physical Education, Sistan and Keywords: combined exercise, Baluchestan University, Zahedan, Iran cinnamon supplement, hematologic, liver enzymes, female amphetamine addicts Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

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Introduction Drug use is a major dilemma in many human societies, which, in addition to social and behavioral disorders, affect different aspects of one's physical health and imposes huge financial damage on the individual, the community, and the family (Karam et al, 2004). Currently, the pattern of drug use is changing throughout the world in that the use of traditional substances, such as opium is being replaced by the use of new industrial substances, including amphetamines. Amphetamine-type stimulants takes the second rank after cannabis in the world with about 38 million consumers in the world (Bamdad, Fallahi Khoshkanab, Dalvandi, & Khoda'ei Ardakani, 2013). The main position of the effect of amphetamines is the central nervous system, especially the serotonin neurons. For this reason, this substance belongs to the group of neurotoxin compounds. Amphetamines produce side effects on various body tissues, including heart, kidneys, and liver, and lead to the stimulation of the body's endocrine system, the pituitary-hypothalamic-thyroid axis, and the adrenal gland. Its consumption also increases body temperature and ACTH and cortisol secretion (Bagheri Haghighi, Fattahi, Forouzanfar, & Hemayatkhahi Jahromi, 2012). Drug dependence and abuse in women are growing more than those in men. The factors effective in the prevalence of substance use in women include stress, negative mood in relationships, disturbed and conflicting family environment, violence against them, addicted spouses, mental illnesses, and sexual violence (Vafamand, 2012). Addiction is a chronic disease that requires long-term treatment, and the use of medication has not been a successful method to prevent addiction relapse and reduce the desire to consume substance (Hosseini, Ala'ea, Naderi, Sharifi, & Zahed, 2009). Blood is a heterogeneous connective tissue that has numerous elements and compounds being influenced by the internal factors of the body and the outside environment (Mousavizadeh, Ebrahimi, & Nikbakht, 2009). Physical activity generally increases the power to do physical work and causes changes in the body, including the peripheral blood erythrocyte system. On the other hand, inactivity reduces plasma volume and the total volume of red blood cells, which ultimately results in lowering blood volume and decreasing the body's efficiency (Dubnov & Constantine, 2004). Research on various hematological indices reveals contradictory findings. The effect of physical activity on the level of hemoglobin and red blood cells, the percentage of transferrin concentration, serum iron, and hematocrit indicates the decrease, increase, or constancy of these factors (Mousavizadeh et al., 2009). The enzymes of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), and Alkaline Phosphatase (ALP) are considered as the most important indicators of liver health function (Vozarova et al., 2002; Larson et al., 2008). Studies have shown that drug use, alcohol drinking, obesity, overweight, and exercise may increase liver enzymes activity (Giannini, Testa & Savarino, 2005; Suzuki et al., 2005; Mahsa Moradi et al 199

Lawlar et al., 2005). Lawlar et al. (2005) conducted a study on the effect of exercise on liver enzymes. The results of this study indicated that regular exercises from light to moderate levels lead to the reduced activity of liver enzymes and reduced disease symptoms in people. Long-term exercises have been proved able to increase liver enzymes (Skenderi, Kavouras, Anastasiou, Yiannakouris, & Matalas, 2006). Suzuki et al. (2005) have shown that weight loss and regular exercise significantly reduce serum alanine aminotransferase, while drug use increases this enzyme. Cinnamon is a plant with the scientific name of zeylanicum. Cinnamon is also considered one of the medicinal plants in traditional medicine. The study of books on Iranian ancient medicine, such as The Canon of Medicine by Avicenna and "Kitab al-saydala fi al-tibb" (Book on the Pharmacopoeia of Medicine by Abū Rayḥān Muḥammad ibn Aḥmad Al-Bīrūnī shows that this plant is used to treat many disorders, including digestion and diarrhea, removal of halitosis, dyspnea, accelerated blood flow, menstrual and postpartum births, sleeplessness, and poor eyesight (Vahidi, Dashti, Mojdeh, & Soltani, 2012). The medicinal effects of this plant are indebted to the compounds available in the essential oil (ester oil) or the extract of cinnamon. These substances include cinnamaldehyde, eugenol, candenyl, coumarin and other compounds (Paranagama et al., 2001). Askari, Rashidkhani, & Hekmatdoost (2014) reported a decrease in plasma levels of liver enzymes after taking 1500 milligrams of cinnamon daily in patients with fatty liver. Cinnamon facilitates blood circulation; accordingly, the proper bloodstream provides oxygenation to the body cells and also eliminates blood contamination (Wainstein, Stern, Heller & Boaz, 2011). Moreover, cinnamon consumption is very useful for the treatment of anemia. The combination of cinnamic aldehyde available in cinnamon stimulates the immune system and helps this system in attacking infectious agents (Rose, 1999). Additionally, cinnamon prevents the non-enzymatic sugar metabolism of hemoglobin and low-density lipoprotein (LDL) oxidation due to its anti-oxidant activity (Baker, 2008). Sport activities will lead to a serious reduction of drug use tendency by eliminating temptation and craving, interest in diversity, and curiosity. Meanwhile, considering easy access to drugs, one of the most important ways of preventing people from drug use is their inclination towards exercise (Fontes- Ribeiro, 2011). Drug use among women has serious consequences, such as rejection, addicted generations, the decrease of communication with ordinary people, and the increase of communication with drug addicts. In addition, women have the motherhood responsibility and bringing up of the future generation and, thereby, the presence of the addicted mother in the family can seriously harm the spouse and children and, consequently, society. Therefore, we need to accept women's addiction as a major problem and seek methods of addiction prevention and treatment in women.

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The aim of this study was to investigate the effect of eight weeks of combined exercise with and without the supplementation of cinnamon on hematological factors of liver enzymes in female amphetamine addicts.

Method Population, sample, and sampling method The present study is a quasi-experimental one with four groups of random substitution, which has obtained ethics approval in research (IR.SSRI. REC.1395.111 code) from the Institute of Physical Education and Sports Sciences. The statistical population of this study consisted of female patients who had enrolled in Zahedan addiction treatment clinics in 2016. A sample of 48 people was selected from among those willing to participate in the study via convenience sampling method. The entry criteria of this study were lack of regular exercise, no history of blood diseases or diseases affecting hematological factors, and a seven-year period of addiction. The sample was randomly divided into four 12-person groups, namely practice-placebo, practice-supplement, supplement, and placebo. Participants signed a consent form after they were aware of their training goals and practices, and they were assured about the confidentiality of information.

Procedure After grouping, participants received oral 500-gram placebo capsules (starch) and cinnamon twice a day after breakfast and lunch. The prepared cinnamon and starch were sent to the Herbarium section of the Faculty of Pharmacy, University of Tehran, and its purity was determined and each of them was prepared in the form of powders. Then, they were sent to a herbal pharmacy in Karaj and 500- mg capsules of cinnamon and starch were prepared over there. The capsules were similar to each other in color, shape, material, and size (Mirfeizi et al., 2014). The supplement and practice-supplement groups took 500-mg cinnamon capsules, and the practice-placebo and placebo groups took 500-mg starch capsules for eight weeks. In terms of physical training, participants were first familiarized with the work environment and, then, referred to the training site to do the desired movements. An anaerobic circle training of six stations with the following features was conducted: each station took 15 seconds (sit-up, Swedish swim, butterfly, pair jump, scissors, walking on the paw) where 45 seconds of rest between each station was considered in three turns, and at the end of the circle training, the four-meter route was walked via kickback for three minutes, and the knee-high back was opted for with an intensity of 60-80% of the maximum heart rate with an increasing rate of 5% per week, 15 minutes of aerobic training (jugging) at five minutes of rest between the two exercises. A 10-minute warm- up at the start and a 5-minute cool-down at the end of the training for eight weeks (three days at 10 am each week) (Farzad et al., 2011). To determine Mahsa Moradi et al 201 cardiovascular fitness, the participants performed the average Rockport Walk Test at the beginning and end of the course (Arazi, Jourbonian, & Asghari, 2012). Oxygen consumption was considered as VO2max. Then, 24 hours before and after the training program, 10 cc blood from the venous vein was taken in the sitting position. The participants were also asked to come there while fasting for at least 12 hours. From seven to eight, blood sampling was carried out. Blood samples were poured into test tubes containing Ethylenediaminetetraacetic acid (EDTA). Three cc of blood was transferred to the laboratory for CBC and the remainder was separated in terms of centrifugation and plasma for 10 minutes at a rate of 3000 rpm and was stored at -70 ° C in the freezer (Mir, Attarzadeh Hosseini, Mirsa'eadi, & Hejazi, 2016). For the analysis of hematological factors and liver enzymes of blood cells, they were counted via cell counter XL22 device (made in Switzerland). In addition, the blood plasma volume was calculated using the Dill-Costill equation (Dill & Costill, 1974). PVb = (1-HCTb/100) × 100 BVb = 100 ml BVa = BVb × (HGBb/HGBa) RCVa = BVa × HCTa PVa = BVa × RCVa In this formula, BV represents blood volume, RCV indicates red blood cell volume, a denotes after exercise, and b shows before exercise. The measurement of liver enzymes of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase was performed using kits of the Iranian Biosystem Company and the 3000-BTT auto analyst device (jointly made in Japan-Germany). Results The descriptive statistics of the study pertaining to participants' physiological characteristics are presented in Table 1. Table 1: Descriptive Statistics Pertaining to Physiological Characteristics of Participants Practice- Practice- Variable Test type Supplement Placebo Placebo Supplement Age (years) - 23.25±5.13 26.41±3.77 26.72±2.74 33.18±3.09 Height (cm) - 153±0.08 156±0.07 159±0.04 155±0.08 Pretest 45.06±6.27 47.83±6.05 47.45±9.35 5.58±11.58 Weight (kg) Posttest 45.23±7.41 48.93±5.52 47.7±9.8 51.32±10.98 Body mass index (kg Pretest 19.17±2.28 19.43±2.51 19.45±3.18 20.99±4.96 / m 2) Posttest 19.32±2.91 2.10±5.52 18.86±20.68 21.36±5.02 Pretest 0.89±0.05 0.86±0.05 0.85±0.08 0.91±0.13 Waist to hip (m) Posttest 0.85±0.17 0.88±0.06 0.82±0.16 0.85±0.09 Maximum oxygen Pretest 51.13±5.80 56.01±7.92 46.6±7.34 58.82±9.52 consumption (ml / kg / Posttest 56.44±10.39 57.60±8.67 50.36±9.11 53.93±10.74 min)

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After assuring about the normal distribution of the data via Kolmogorov- Smirnov test; paired sample t-test, MANOVA test, and Tukey's post hoc test were run to investigate the variation in the post-test. The significance level was considered as P <0.05. Data were analyzed by SPSS20. The magnitudes of changes in hematological factors and liver enzymes of the study groups in the pre-test and post-test phases have been presented in Tables 2 and 3.

Table 2: Hematological Factors and Plasma Volume for Each Group Practice- Practice- Variable Test type Supplement Placebo Sig. Placebo Supplement Pretest 9.34±2.03 8.78±2.26 7.1±1.12 7.5±2.47 White blood Posttest 7.04±1.75 7.11±1.58 6.07±1.03 5.82±1.54 3 cell (10 per Within- 0.08 micro liters) 0.001 0.003 0.007 0.033 group Sig. Pretest 4.59±0.422 4.92±0.552 5.05±0.506 4.96±0.657 Red blood Posttest 4.46±0.591 4.82±0.366 4.63±0.515 5.1±1.04 0.13 cell (106 per Within- micro liters) 0.196 0.884 0.001 0.705 group Sig. Pretest 13.6±0.899 13.63±0.891 13.15±1.2 13.71±1.77 Hemoglobin Posttest 13.77±0.898 13.84±1.27 13.26±0.937 13.82±1.2 0.52 (g / dl) Within- 0.554 0.4446 0.587 0.766 group Sig. 41.9±2.06 41.83±2.04 41.2±2.84 43.58±4.06 Pretest 41.37±2.38 41.76±2.75 39.85±2.78 41.55±1.42 Hematocrit Posttest 0.21 (percent) Within- 0.505 0.933 0.022 0.104 group Sig. Pretest 106.41±3.34 74.23±3.35 64.25±3.27 95.67±3.4 3 Platelet (10 Posttest 104.23±3.28 80.92±3.34 62.36±3.25 77.58±3.63 0.66 per μl) Within- 0.753 0.958 0.877 0.148 group Sig. Pretest 58.10±2.06 58.16±2.04 58.79±2.84 56.41±4.06 Plasma Posttest 58.13±5.75 57.57±5.55 59.78±5.06 57.95±5.20 0.75 volume Within- (percent) 0.987 0.747 0.503 0.499 group Sig.

As it has been shown in Table 2, paired sample t-test showed a significant reduction after training compared to pre-training in white blood cell values in the practice-supplement group (P <0.01), placebo group (P <0.001) ), supplement group (P <0.01), and placebo group (P <0.05). Also, there was a significant decrease between the pretest and posttest in the values of red blood Mahsa Moradi et al 203 cells (P <0.001) and in hematocrit values in the supplement group (P <0.05). In other groups, there was no significant difference before and after training in red blood cells and hematocrit values (P≥0.05). There was no significant difference in the pre- and post-training phases in hemoglobin, platelet, and plasma volume of the groups (P≥0.05). The values of liver enzymes are presented in Table 3.

Table 3: Hepatic Enzyme Values for Each Group Practice- Practice- Variable Test type Supplement Placebo Sig. Placebo Supplement Aspartate Pretest 19.83±6.72 23.91±12.08 22.16±7.25 25.75±10.34 Aminotransfera Posttest 20.66±8.79 17.83±4.04 15.83±2.94 14.83±2.75 se Between- 0.46 (International 0.801 0.091 0.005 0.003 group Sig. Unit) Alanine Pretest 22.91±12.37 23.83±22.24 23.66±6.3 23.33±7.67 Aminotransfera Posttest 25.66±9.86 27.91±18.09 19.5±10.6 13.83±3.66 0.99 se Between- (International 0.586 0.493 0.207 0.005 group Sig. Unit) 373.25±183. Alkaline Pretest 337.91±101 369.41±211.18 298.41±81.64 12 phosphatase 0.67 Posttest 282.25±97.15 238.66±127.91 203.41±84.77259.5 ±270.2 (International Between- Unit) 0.046 0.001 0.002 0.007 group Sig.

As it can be observed, paired sample t-test showed a significant reduction after training compared to pre-training in aspartate aminotransferase values in the supplement group (P <0.01) and placebo group (P <0.01); however, no significant difference was observed in the practice-supplement and practice- placebo groups (P≥0.05). A significant decrease in the levels of alanine aminotransferase was observed after training in the placebo group (P <0.01); however, there was no significant difference in the levels of alanine aminotransferase in other groups (P≥0.05). On the other hand, paired sample t- test showed a significant decrease after training compared to pre-training in alkaline phosphatase values in all groups, i.e. practice-supplement (P <0.001), practice-placebo (P <0.05), supplement (P <0.01), and placebo groups (P <0.01).

Discussion and Conclusion This study was conducted on 48 amphetamine addicts who were on the verge of abstinence in order to examine hematological factors and hepatic enzymes after eight weeks of combined exercise with and without cinnamon supplementation. The results of the study showed no significant difference in the hematologic factors among the groups. However, the white blood cells showed a significant

204 Research on Addiction Quarterly Journal of Drug Abuse decrease after the training and exercise in the placebo, supplement, practice- supplement, and practice-placebo groups. Also, red blood cells and hematocrit showed a significant decrease in the supplement group. The research findings indicate that the proposed training did not create any change in the hematologic factors except in white blood cells. Patlar & Keskin stated that exercise and training under the maximum level did not significantly change the average corpuscular volume, the concentration of hemoglobin, and red blood cells, which is consistent with the findings of the present study (Patallar & Kaskin, 2007). Mousavizadeh et al. (2009) observed a significant decrease in hemoglobin, red blood cells, and hematocrit in studying the effect of aerobic training on hematological indices of students. Ghanbari Niaki & Mohammadi (2010) reported that the anaerobic RAST activity increases the hemoglobin and red blood cells, which is not consistent with the findings of the present study. Ahmadizad, & Besami (2010) also observed a significant increase in the number of platelets and plasma volume and a significant reduction in hematocrit after three types of resistance activities, which is not consistent with the results of the present study. Decreased hemoglobin and hematocrit concentrations due to exercise is associated with increased plasma volume. This condition causes the blood to be diluted and improves blood flow properties (Szygula, 1990). The destruction of red blood cells and hemoglobin is known as hemoglobin trauma where the following factors speed up its degradation: 1. RBC life, 2. Physical and body pressure, 3. Red blood cell deformation, 4. Red blood cell concentration, 5. Increased temperature, 6. Decreased blood glucose (Requena, 2017). Based on the findings of this study, the plasma volume in the exercise group increased by 1.65%. The factors contributing to the increase of plasma volume include exercise intensity, exercise duration, repetition of exercises, and level of individuals' readiness (Bejder, Andersen, Goetze, Aachmann‐Andersen, & Nordsborg, 2017; Afolabi et al., 2016). Exercise intensity is likely to be the main driver of increased plasma volume arising from exercise. The increase in plasma volume occurs mainly due to two mechanisms. First, exercise and practice increase the secretion of antidiuretic hormone (ADH) and aldosterone, which causes water retention by the kidneys and results in increased blood plasma levels. Second, exercise increases the amount of plasma protein, especially albumin, and whenever plasma protein concentrations increase, osmotic pressure increases and, thereby, the binding of water molecules to them occurs late in the recovery period. As a result, more liquid remains in the blood and these two mechanisms together increase blood plasma levels. Due to increased plasma volume and reduced hemoglobin and hematocrit, blood viscosity level decreases. The reduction of blood viscosity is beneficial because the blood performs the responsibility of its own transfusion well due to the ease of flow in the vessel (Bejder et al., 2017; Afolabi et al., 2016). On the other hand, the intake of some foods and medicine, such as cinnamon can facilitate blood circulation Mahsa Moradi et al 205

(Vahidi et al., 2012). According to the findings of this study, this influence can be due to increased plasma volume and hematocrit, which requires doing more research to achieve definite results on the mechanism of the effect of cinnamon on blood circulation facilitation. The results of the present study showed no significant difference between the groups in terms of liver enzymes, i.e. aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. However, the alkaline phosphatase enzyme significantly decreased in all groups. Liver tissue is one of the organs that is constantly in contact with toxic compounds because of its ability to neutralize toxic substances or to change their biological form. It should be kept in mind that the liver's ability in metabolic changes is limited; thus, if the encounter of liver tissues with different toxins is more than a certain amount that cannot excrete it in some way, it will inevitably cause abnormalities in the structure and function of the liver (Valente et al., 2016). Amphetamines appear to lower cells, including hepatocytes. This combination damages DNA and leads to a decrease in energy production due to a defect in the function of mitochondrial enzymes, the increased activity of lysozyme enzymes, and the oxidation of cytoplasmic proteins. Therefore, it can lead hepatocyte cells to death (Valente et al., 2016; Montiel-Duarte et al., 2002). Aminotransferases are normally present in liver cells; therefore, they are released with the membrane damage and cell death, which can be a sign of liver tissue damage (Fatahi, Forouzanfar, & Bagheri Haghighi, 2012). In this regard, Bagheri Haghighi, Fattahi, Forouzanfar, & Reza'ea Jahromi (2012) examined the effect of different doses of amphetamines on liver cells of Wistar rats for two weeks and showed that hepatocyte cells in the experimental group underwent damage and reduction. Accordingly, in the present study, participants have probably experienced damage hepatic cells and a decrease in the hepatic enzymes during the study period since they were on the verge of withdrawal from drug use. In the present study, in the practice-placebo group, the levels of aspartate aminotransferase and alanine aminotransferase increased significantly. In this regard, Asad et al. investigated the effect of eight weeks of endurance training on liver enzymes in female addicts under methadone maintenance treatment and showed that endurance training had no significant effect on the levels of aspartate aminotransferase and alanine aminotransferase (Asad, Haddadi, Nejad, & Soukhteh Zari, 2013). However, Davoudi, Mousavi, & Nikbakht (2012) concluded that eight weeks of aerobic and endurance exercise training could reduce liver enzymes and liver parenchymal density and could prevent the malignancy while these findings are not consistent with those of the present research. Also, in the present study, liver enzymes of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase in the supplement group were reduced by 28%, 17%, and 31%, respectively; in addition, aspartate

206 Research on Addiction Quarterly Journal of Drug Abuse aminotransferase and alkaline phosphatase decreased significantly in this group. The results of this study are consistent with those of the study carried out by Askari et al. (2014) where the reduction of plasma levels of liver enzymes after the daily intake of 1500 milligrams of cinnamon in patients with fatty liver. Cinnamon supplement has phenolic and non-phenolic compounds, such as cinnamic acid derivatives and coumarins, and it also has antioxidant properties. These compounds act as regenerative agents, or as potent inhibitors of peroxide radicals, and prevent oxidative reactions. Cinnamon has an inhibitory effect on the hepatocyte oxidation system and prevents the destruction of liver cells and reduces the release of liver enzymes into the circulation (Kemali Rousta, Ghavami, Elhami Rad, & Azizinejad, 2014). This research suffered from some limitations, such as no control of participants' stress, mental conditions, and the rate of smoking. It is suggested that future research employ groups with different doses of cinnamon supplementation and various sports exercises (endurance and resistance). Regarding the findings of this study, it can generally be concluded that combined exercise with cinnamon supplementation can reduce the white blood cells and liver enzymes of aspartate aminotransferase and alkaline phosphatase in amphetamine addicted women. Reference Afolabi, B. B., Oladipo, O. O., Akanmu, A. S., Abudu, O. O., Sofola, O. A., & Broughton Pipkin, F. (2016). Volume regulatory hormones and plasma volume in pregnant women with sickle cell disorder. Journal of the Renin-Angiotensin-Aldosterone System, 17(3), 1470320316670444. Ahmadizad, S., & Bassami, M. (2010). Interaction effects of time of day and sub- maximal treadmill exercise on the main determinants of blood fluidity. Clinical hemorheology and microcirculation, 45(2-4), 177-184. Arazi, H., Jourbonian, A., & Asghari, E. (2012). Comparison of Concurrent (Resistance- Aerobic) and Aerobic Training on VO2max Lipid Profile, Blood Glucose and Blood Pressure in Middle Aged Men at Risk for Cardiovascular Disease, Journal of Shahid Sadoughi University of Medical Sciences, 20 (5), 627-638. Asad, M. R., Haddadi, F., Nejad, M. R., & Sokhtehzari, S. (2013). Effect of eight weeks endurance exercise on liver enzymes in stopping drug women with methadone. Journal of Paramedical Sciences, 4(2), 68-71. Askari, F., Rashidkhani, B., & Hekmatdoost, A. (2014). Cinnamon may have therapeutic benefits on lipid profile, liver enzymes, insulin resistance, and high-sensitivity C- reactive protein in nonalcoholic fatty liver disease patients. Nutrition research, 34(2), 143-148. Bagheri Haghighi, A., Fattahi, E., Foruzanfar, M., & Hemayatkhah Jahromi, V. (2012). Evaluation of the Effect of 3.4-Methylindiax-Amphetamine (Ecstasy) on the Hepatic Textural Structure in Rats, Journal of Semnan Medical Sciences University, 13 (3), 368-375. Baker, W. L., Gutierrez-Williams, G., White, C. M., Kluger, J., & Coleman, C. I. (2008). Effect of cinnamon on glucose control and lipid parameters. Diabetes care, 31(1), 41-43. Mahsa Moradi et al 207

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Mirfeizi, M., Mehdizadeh Tourzani, Z., Mirfeizi, Z., Asghari Jafar-Abadi, M., Rezvani, H., & Shoghi, M. (2014). The Effect of Cinnamon on Blood Glucose and Blood Flow Control in Patients with Type 2 Diabetes: a Double-Blind Clinical Trial, Journal of Mashhad University of Medical Sciences, 57 (3), 533-541. Montiel-Duarte, C., Varela-Rey, M., Osés-Prieto, J. A., López-Zabalza, M. J., Beitia, G., Cenarruzabeitia, E., & Iraburu, M. J. (2002). 3, 4-Methylenedioxymethamphetamine (“Ecstasy”) induces apoptosis of cultured rat liver cells. Biochimica et Biophysica Acta (BBA)-Molecular Basis of Disease, 1588(1), 26-32. Mousavizadeh, M., Ebrahimi, K., & Nikbakht, H. (2009). Effect of an Aerobic Exercise Course on Hematological Indices of Female Students, Scientific Journal of Iranian Blood Transfusion Organization, 6 (3), 227-231. Paranagama, P. A., Wimalasena, S., Jayatilake, G. S., Jayawardena, A. L., Senanayake, U. M., & Mubarak, A. M. (2001). A comparison of essential oil constituents of bark, leaf, root and fruit of cinnamon (Cinnamomum zeylanicum Blum) grown in Sri Lanka. Journal of the National Science Foundation of Sri Lanka, 29(3-4). Patlar, S., & Keskin, E. (2007). The effects of glycerol supplement on various hematologic parameters in sedentariness and the athletes who exercise regularly. Exercise, 1, 23-35. Requena, B., García, I., Suárez-Arrones, L., de Villarreal, E. S., Orellana, J. N., & Santalla, A. (2017). Off-season effects on functional performance, body composition, and blood parameters in top-level professional soccer players. The Journal of Strength & Conditioning Research, 31(4), 939-946. Rose, J. O. H. A. N. N. E. (1999). Herbal and nutritional support for the immune system. Clinical Nutrition Insight, 6(2), 1-4. Skenderi, K. P., Kavouras, S. A., Anastasiou, C. A., Yiannakouris, N., & Matalas, A. L. (2006). Exertional rhabdomyolysis during a 246-km continuous running race. Medicine & Science in Sports & Exercise, 38(6), 1054-1057. Suzuki, A., Lindor, K., St Saver, J., Lymp, J., Mendes, F., Muto, A., & Angulo, P. (2005). Effect of changes on body weight and lifestyle in nonalcoholic fatty liver disease. Journal of hematology, 43(6), 1060-1066. Szygula, Z. (1990). Erythrocytic system under the influence of physical exercise and training. Sports Medicine, 10(3), 181-197. Vafamand, E., Kargarfard, M., & Marandi, M. (2012). Effect of eight-week aerobic training on serotonin and dopamine levels in addicted women in Isfahan Central Prison, Journal of Isfahan Medical School, 30 (204), 1336-1347. Vahidi, A., Dashti, M. H., Mojdeh, M., & Soltani, H. R. (2012). Effects of cinnamon on learning and short memory in mice. Medical Science Journal of Islamic Azad University-Tehran Medical Branch, 22(2), 105-109. Valente, M. J., Araújo, A. M., Silva, R., de Lourdes Bastos, M., Carvalho, F., De Pinho, P. G., & Carvalho, M. (2016). 3, 4-Methylenedioxypyrovalerone (MDPV): in vitro mechanisms of hepatotoxicity under normothermic and hyperthermic conditions. Archives of toxicology, 90(8), 1959-1973. Vozarova, B., Stefan, N., Lindsay, R. S., Saremi, A., Pratley, R. E., Bogardus, C., & Tataranni, P. A. (2002). High alanine aminotransferase is associated with decreased hepatic insulin sensitivity and predicts the development of type 2 diabetes. Diabetes, 51(6), 1889-1895. Wainstein, J., Stern, N., Heller, S., & Boaz, M. (2011). Dietary cinnamon supplementation and changes in systolic blood pressure in subjects with type 2 diabetes. Journal of medicinal food, 14(12), 1505-1510.

Abstract Effectiveness of Objective: The aim of this study was to determine the effectiveness of behavioral Behavioral activation therapy in action resilience and meta-cognitive beliefs among opiate Activation Therapy dependent patients. Method: A quasi- in Opiate-Dependent experimental research design along with pretest-posttest-follow-up and control Patients' Action group was employed for the conduct of this study. The statistical population of Resilience and this study consisted of all outpatient men who were on the verge of addiction Metacognitive withdrawal in Ahvaz city in 2016. From Beliefs among them, 30 subjects were selected through convenience sampling and were randomly assigned to two experimental (15 subjects) and control (15 People) groups. Connor-Davidson Resilience Scale and Wells Metacognitions Questionnaire were the data collection Dasht-Bozorgi, Z. tools in this study. The experimental group received eight 90-minute sessions of group behavioral activation therapy. After the end of the treatment program, both groups took post-test; and the follow-up stage was also conducted after Dasht-Bozorgi, Z. one month. For data analysis, Assistant Professor, Department of multivariate analysis of covariance was Psychology, Islamic Azad University, used. Results: The results showed that Ahvaz Branch, Ahvaz, Iran, E-mail: group behavioral activation therapy [email protected] enhanced action resilience and decreased metacognitive beliefs of uncontrollability, positive beliefs about cognition, low cognitive confidence, need to control thoughts, and self- consciousness in opiate dependent patients of the experimental group compared to the control group. The Research on Addiction results remained constant after one Quarterly Journal of month. Conclusion: Behavioral activation therapy intervention can be a Drug Abuse Presidency of the I. R. of Iran suitable treatment for reducing the Drug Control Headquarters cognitive problems of opiate dependent Department for Research and Education people. Keywords: behavioral activation Vol. 12, No. 47, Autumn 2018 therapy, action resilience, metacognitive http://www.etiadpajohi.ir beliefs, opiate-dependent patients

210 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Opioid dependence is a chronic disease that is associated with severe motivational disorders and loss of behavioral domination and leads to personality destruction. Millions of people suffer from this disorder, which often co-occurs with other mental illnesses and imposes various social and economic costs on the community (Dallas, 2013). Opioid dependence refers to a set of physiological, behavioral, and cognitive symptoms, which generally indicates the continuation of opioid use despite severe drug-related problems (American Psychiatric Association, 2013). Research has shown that addicts have low resilience to tensions and adverse events (Anderson, 2015). Resilience helps with individuals' adaptability in the face of disasters or stresses. This attribute is supported, developed, and presented as a positive feature with the person's inner ability as well as social skills and interaction with the environment (Diener, 2013). Action resilience is one of the most important cognitive dimensions for people on the verge of withdrawal (Scragg, 2014). The identification and increase of this construct create a promising insight into drug use withdrawal. On the other hand, meta-cognitive beliefs predict the experience of negative feelings, such as anxiety and depression in these individuals due to their thinking styles and incompatibility; in addition, the positive and negative meta-cognitive beliefs may cause continued anxiety (Pourmanadarian, Birashk, & Asgharnejad, 2012). Giyung (2014) carried out a study on substance-dependent people and found that substance-dependent people had higher meta-cognitive beliefs than normal people. Metacognitive beliefs are among the effective factors in the mental health situation. The status of mental health is threatened by changing the meta- cognition that intensifies maladaptive practices of negative thoughts or increases general negative beliefs. Metacognitive beliefs are the ones that relate to the uncontrollability, importance, and perilousness of cognitive thoughts and experiences (Zamanzadeh, 2013). On the other hand, people with opioid dependence undergo disruption and chaos in their beliefs. Negative metacognitive beliefs about uncontrollability are significantly predictive of depression, stress, and anxiety in substance abusers (Yelmaz, Gencoze, & Wells, 2014). Also positive and negative meta-cognitive beliefs have a direct relationship with the ability of individuals to cope with pathological anxiety (Cartwright & Hatton, 2011). I this regard, Mohammadifar, Kafi Anaraki & Najafi (2014) showed that two subscales of uncontrollability and the risk of cognitive thoughts and reliability could predict the changes in substance abuse behavior. Rumination is one of the problems of people with negative meta-cognitive beliefs. Mental or intellectual rumination is known as permanent employment of a thought or subject and thinking about it, and is referred to as a class of Zahra Dasht-Bozorgi 211 conscious thoughts that are characterized around a specific axis. These thoughts are repeated. These involuntary thoughts go into consciousness, distract attention and goals, and distort people's beliefs (Hamamci, 2013). To reduce such negative beliefs and increase resilience among addicts, non- pharmacological treatments can have tremendous effects on their problems (Fartousi, Talebi, & Karami, 2013). One of the therapeutic approaches is the third wave of behavioral activation therapy that focuses on behaviors and activities (Dimidjian, Brrera, Martell, Munoz, & Lewinshon, 2011). Behavioral activation therapy has a special focus on mood disorders and other disorders, and assigns attention to most of the activities of an individual, whether related and unrelated to disease, lifestyle change, and consequences of the disease (Kanter, Bush, & Rush, 2005; translated by Mirza'ea and Fereidouni, 2012). In this type of therapy, the patient is helped to be able to recover in the first possible step and the patient is activated behaviorally and socially. By increasing the constructive interaction between the patient and healthy people and reducing the symptoms of depression, anxiety, psychological stress, and negative beliefs, the patient is engaged fully in the treatment process over a long period of time in order to maintain recovery (Dawe, & Loxton, 2014). The aim of cognition in this type of therapy is the establishment of a relationship between actions and emotional outcomes and also the systematic substitution of dysfunctional behavioral patterns with adaptive behavioral patterns. In addition, in this type of treatment, attention is paid to the quality and improvement of social function (American Psychological Association, 2013). In general, this therapy is a behavioral therapy that offers objective and simple techniques for implementation and is economically feasible due to its short duration (Kanter et al., 2012). Many studies have examined the effectiveness of this treatment. Research findings suggest that this treatment can be effective in modifying some behavioral characteristics of addicts. Khalaf Beigi (2012) investigated the effect of behavioral activation therapy on perceived stress and anxiety in subjects with substance abuse and showed that behavioral activation therapy reduces perceived stress and anxiety in substance abusers. Also, Riazi (2012) concluded that behavioral activation therapy reduces stress and increases resilience among opiate-dependent patients. In the same way, Miles & Ander (2015) indicated that behavioral activation therapy reduces positive metacognitive beliefs about worry, uncontrollability, low cognitive confidence, and the need for thought control, cognitive awareness of substance abuse addicts. Anderson (2015) also concluded that behavioral activation therapy would increase action resilience and quality of life and would reduce perceived stress in substance abusers. Jan (2014) showed that behavioral activation therapy reduces the level of stress and anxiety in opiate-dependent addicts. Rasel (2013) showed that behavioral activation therapy reduces positive beliefs about worry, controllability, low cognitive confidence, and the need for control of the thoughts, and cognition among opioid-dependent persons.

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Similarly, behavioral activation therapy has a significant effect on the reduction of metacognitive beliefs in opiate-dependent people. Finally, Patric (2012) showed that group therapy based on behavioral activation model leads to reduced mental rumination and ruminative responses among substance abusers. In the end, it is noteworthy that it is possible to exert a positive impact on the cognitive constructs of these individuals by providing them with appropriate treatment protocols. With regard to what has mentioned, many physical, social, and economic problems are perceived in opiate-dependent people that have a negative effect on their action resilience and type of beliefs. Therefore, it should be attempted to provide a suitable treatment approach for the cure for cognitive disorders in opiate-dependent people. In the present study, it is sought to see whether behavioral activation therapy is effective in opiate-dependent patients' action resilience and metacognitive beliefs.

Method Population, sample, and sampling method A quasi-experimental research design along with pretest, post-test, and control group was employed for the conduct of this study. The statistical population of the study consisted of all addicts presenting to the outpatient addiction center of Ahvaz (affiliated to Welfare Organization) in 2016. In this study, 30 opiate addicts were selected via non-random sampling method and were randomly divided into two equal groups. The entry criteria of the present study included informed consent for participation in the research, 20 to 45 years of age, a minimum education of secondary school degree, the availability of criteria for the diagnosis of opioid dependence based on the criteria of the fifth edition of the Practical and Diagnostic Manual for Mental Disorders, the non-receipt of other non-medical treatment methods, and no experience of any stressful events, such as divorce or the death of loved ones in the past six months. The exit criteria were absenteeism of more than one meeting and incomplete completion of questionnaires. After expressing the research objective for sample members, the informed consent was received from the participants in the research.

Instruments 1. Connor-Davidson Resilience Scale: This questionnaire was developed by Connor & Davidson (2003) and contains 25 items that are scored on a Likert scale from zero (always false) to five (always true). The Cronbach's alpha reliability coefficient of this scale was reported equal to 0.91 and the convergent validity of this questionnaire was obtained by correlating it with Ahvaz's Psychological Hardiness Scale (r = 0.64) (Hosseini, 2012). In the present study, Cronbach's alpha coefficient of this scale was obtained equal to 0.78. 2. Wells Metacognitions Questionnaire: This questionnaire is a 30-item self- report tool that has been developed by Wells et al. (2004). It measures Zahra Dasht-Bozorgi 213 individuals' beliefs about their thinking. Responses in this scale are based on a four-point Likert scale: 1 = disagree to 4 = strongly agree. It consists of five subscales, namely positive beliefs about worries, negative beliefs about uncontrollability of thoughts and danger, cognitive confidence, beliefs about need to control thoughts, and cognitive self-consciousness. Zamanzadeh (2013) obtained Cronbach's alpha reliability of 0.81 for the whole questionnaire and the coefficients of 0.60, 0.74, 0.72, 0.71, and 0.77 for positive beliefs about worries, negative beliefs about uncontrollability of thoughts and danger, cognitive confidence, beliefs about need to control thoughts, and cognitive self- consciousness, respectively (Zamanzadeh, 2013). In the present study, Cronbach's alpha coefficients were obtained equal to 0.78, 0.81, 0.83, 0.80, and 0.79 for positive beliefs about worries, negative beliefs about uncontrollability of thoughts and danger, cognitive confidence, beliefs about need to control thoughts, and cognitive self-consciousness, respectively.

Procedure Following the referral to the drug addiction center, the researcher prepared a list of opiate dependent addicts. After consultation with the center's psychologist and according to a specialist interview conducted by the psychiatrist and psychologist of the center, opiate addicts who were in the maintenance phase were identified. Then they were interviewed individually and 30 volunteers who were willing to attend the sessions and the research process were selected. In the next step, 15 subjects were randomly assigned to the experimental group and 15 ones were assigned to the control group. Before the implementation of the intervention in the experimental and control groups, pretest on action resilience and meta-cognitive beliefs was performed. Group therapy program based on behavioral activation therapy model (Kanter, Bush, & Rush, 2005; translated by Mirza'ea and Fereidouni, 2012) was performed on the experimental group during eight 90-minute sessions. The therapeutic plan was held once every two weeks. At the end of the intervention, a posttest was performed on both groups and a follow-up test was conducted one month later. Meanwhile, with the coordination provided with the control group, it was decided to hold behavioral activation group therapy for opioid-dependent persons after the effectiveness of the therapy was proved. Then the results were analyzed. In this research, the intervention sessions of the activation behavioral group therapy (Kanter, Bush, & Rush, 2005; translated by Mirza'ea and Fereidouni, 2012) have been presented in Table 1.

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Table 1: Summary of the Sessions of the Behavioral Activation Group Therapy (Kanter, Bush, & Rush, 2005; translated by Mirza'ea and Fereidouni, 2012) Session Content First The administration of the pretest, establishment of a therapeutic relationship with addicts, and teaching of behavioral contracts in the form of written or verbal agreement between the therapist and the patients, and examining the barriers to achieving these goals. Second Training and focusing on the activation of behavior, the individual's interaction with the environment, and the training of appropriate strategies: Concentration on the interaction between the individual and the environment by changing the obvious behaviors. Behavioral activation strategies were based on principles of silence, formation, deletion, mental review, periodic distraction, procedural skills training, and observational thinking. Third Psychological training about group healing processes: Briefings were held on the general field of the disease, selection of appropriate therapeutic approaches, individuals' status, motivational issues regarding the interaction with other people (family and treatment staff), and the use of others' experiences . Fourth Concentration on aspects of stress and anxiety; using positive verbal reinforcement through hope therapy; using positive verbal reinforcement by expressing positive statements to each other; and stating promising ideas on the patient's small improvements. Fifth Concentration on resilience and changing mental and emotional states through the use of allegory in the course of psychological training; explaining processes, such as teaching resilience, improvement of tolerance, and acceptance of mental states in the form of allegories and group discussions . Sixth Concentration on cognitive beliefs, cognitive judgments, and their control, and management of patients' stress. Lifestyle, stress, and negative thoughts were identified. Personality; control, adaptation, and prediction of stress; identification and prevention of negative consequences and irrational and metacognitive attitudes were examined. Seventh Teaching about the psychosocial components of the present situation, coping skills training, behavioral rehabilitation training, determination and therapy skills training; and access to and optimal use of psychologists and caregivers . Eighth A wrap-up of the sessions was made, the group members were asked about the sessions, in the end, follow-up perspectives were presented, and the posttest was performed.

Results The descriptive statistics of the variables of action resilience and metacognitive beliefs for both groups and test type are presented in Table 2.

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Table 2: Descriptive statistics of action resilience and metacognitive beliefs for each group and test type Experimental group Control group Variable Pretest Posttest Pretest Posttest Mean (SD) Mean (SD) Mean (SD) Mean (SD) Action resilience (6.31)99.18 (6.86)114.95 (5.75)97.40 6.29(97.60) Positive beliefs about worry (6.71)34.61 (5.32)19.81 (6.51)23.89 (7.06)33.34 Beliefs about uncontrollability (7.32)20.94 (6.2)17.87 (6.51)21.93 (6.86)22.04 Low cognitive confidence (6.37)19.77 (5.42)18.12 (7.51)19.11 (7.27)19.41 Need to control thoughts (6.77)18.77 (5.81)17.34 (5.51)19.83 (5.73)19.92 Cognitive self-consciousness (5.37)21.24 (7.29)20.67 (5.51)22.38 (7.59)22.83

For data analysis and control of the effect of pretest and posttest, multivariate covariance analysis was used. One of the assumptions of multivariate covariance analysis is the homogeneity of variance-covariance matrix. The results of Box's test showed that this assumption has been met (P> 0.05, F=0.82, M Box=20.25). Another assumption of this analysis is the equation of error variances. The results of Levene's test showed that the assumption of the homogeneity of error variances has been met in components of action resilience (F = 0.01, p> 0.05) and meta-cognitive beliefs (F = 1.80, P >0.05). Another important assumption is the homogeneity of regression coefficients. It should be noted that the homogeneity test of regression coefficients was examined through the interaction of action resilience and the independent variable (treatment method) in the posttest (F = 1.19, p> 0.05) and metacognitive beliefs and the independent variable (treatment method) in the posttest (F = 1.45, p> 0.05). The results indicated that this assumption has also been met. Kolmogorov-Smirnov test was used to assess the normal distribution of the population. The results indicated that the distribution was normal. Therefore, multivariate covariance analysis was conducted to examine the effectiveness of the intervention in meta-cognitive beliefs and the results showed that there was a significant difference between the two groups in the linear composition of the variables (Eta squared = 0.72, P<0.001, F=45.39, Wilks' lambda = 0.91). In order to examine the patterns of difference, univariate covariance analysis was used, as described in table 3.

Table 3: Results of Univariate Covariance Analysis on Action Resilience and Meta- cognitive Beliefs Components in the Posttest Effect Statistical Variables Mean Square F Sig. size power Action resilience 5150.13 45.39 0.0005 0.83 1 Positive beliefs about worry 401.43 176.42 0.0005 0.91 1 Beliefs about uncontrollability 201.77 49.94 0.0005 0.74 1 Low cognitive confidence 255.80 64.10 0.0005 0.79 1 Need to control thoughts 222.47 91.29 0.0005 0.90 1 Cognitive self-consciousness 237.18 68.34 0.0005 0.89 1

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As it has been shown in Table 3, the results show that behavioral activation therapy is effective in all the components of action resilience and metacognitive beliefs. To evaluate the effectiveness of this treatment, multivariate covariance analysis was used in the follow up data. The results indicated the existence of a significant difference between the two groups in the linear composition of the variables (Eta squared = 0.48, P<0.001, F=31.12, Wilks' lambda = 0.82). In order to examine the patterns of difference, univariate covariance analysis was used, as described in 4. Table 4: Univariate covariance analysis examining action resilience and metacognitive beliefs in follow-up Mean F Effect Statistical Variables Sig. Square size power Action resilience 110.33 39.01 0.0005 0.60 1 Positive beliefs about worry 387.40 167.72 0.0005 0.87 1 Beliefs about uncontrollability 198.92 68.39 0.0005 0.66 1 Low cognitive confidence 249.65 94.87 0.0005 0.76 1 Need to control thoughts 201.10 86.87 0.0005 0.70 1 Cognitive self-consciousness 197.54 65.09 0.0005 0.69 1

As it has been shown in Table 4, the results show that behavioral activation therapy has had a lasting effect on all the components of action resilience and meta-cognitive beliefs. In other words, behavioral activation therapy has led to a continued increase in action resilience and reduction of metacognitive beliefs of the experimental group in the follow-up stage.

Discussion and Conclusion The findings showed that behavioral activation group therapy had an impact on action resilience and metacognitive beliefs among opiate-dependent addicts. This finding is consistent with the research findings obtained by Jan (2015), Anderson (2015), Riazi (2012), Moradi et al. (2013), and Khalf Beigi (2012). To explain these findings, it can be argued that opioid addicts can have a low level of resilience in coping with life challenges due to their perceived psychological challenges, conflicts, and stressful conditions. Opiate-dependent people are emotionally immature, rebellious, and uncontrollable and have strong hostility and stress. The intervention of behavioral activation therapy in opioid-dependent addicts causes them to actively participate in the recovery process with more flexibility and hardiness due to the fact that this therapy leads to the cessation of the old pattern of inability in resilience and action resilience and to the provision of motivation for individual changes. Due to the fact that small changes in resilience were rewarded and strengthened in this therapy, the level of internal resistance increased. As this treatment protocol was executed in a group format, participants received desired feedback on their problems. They also learned that they can be responsible for their actions and show a deep reconstruction of action resilience in coping with their problems. Moreover, effective communication Zahra Dasht-Bozorgi 217 and effective rejection techniques caused opioid-dependent addicts to recognize behavioral symptoms of non-resilience. With the dominance of their active role in adjusting the problems and stressors during the addiction period, their internal and active resistance to their problems experiences an increase. Then, the spirit of perseverance, the sense of responsibility, and purposefulness increase in them, and the states of isolation and helplessness were reduced in them. As a result, it can be argued that group therapy based on behavioral activation in opiate-dependent addicts can identify the behavioral characteristic of action resilience problems and challenges. In this therapy, these addicts started reconstructing and restoring themselves behaviorally and motivationally. In addition, they enhanced the practical program of internal rewards based on high endurance by means of the development technique and, thereby, their action resilience increased. In conclusion, behavioral activation therapy is effective in increasing the opioid-dependent individuals' resilience (Rasel, 2013). Moreover, behavioral activation group therapy was effective in metacognitive beliefs of opiate-dependent addicts. This research finding is in the same line with the research findings reported by Miles, & Andr (2015), Patric (2012), and Rasel (2013). To interpret this finding, one may argue that opioid- dependent addicts hold ineffective beliefs and negative metacognitive beliefs about recovery due to their inappropriate psychological and physical conditions. Based on self-regulation theory of executive action, psychological disorders continue when irrational beliefs arise from one's metacognitive knowledge and are activated and processed in difficult situations. However, in this study, it was revealed that behavioral activation therapy group is effective in reducing the metacognitive beliefs, including positive beliefs about worry, beliefs about uncontrollability, low cognitive confidence, need to control thoughts, and cognitive self-consciousness among opiate-dependent addicts. It can be concluded that behavioral activation group therapy reduces negative consequences of the inability in complete recovery by providing techniques pertaining to the control of disturbing thoughts and providing problem-solving behavioral-motivational techniques among the addicts in the maintenance phase. Group therapy based on behavioral activation in these individuals leads to increased behavioral efficiency, positive reinforcement, and a strong sense of self-control of behaviors and, thereby, has changed addicts' addiction to their minds and negative behaviors and has made it possible to relax the individuals in such a way that these people can have positive behavior towards and a high awareness of their relatively healthy condition considering their physical and mental status. Due to the group administration of the therapy and similar patient feedback, patients are more likely to perceive more appropriate enabling beliefs and activate their behaviors based on receiving internal rewards. Since opioid- dependent addicts receive appropriate behavioral activation exercises and, thereby, they show the metacognitive beliefs that cause the persistence of concerns and worries to a lesser extent. In addition, addicts experience lower

218 Research on Addiction Quarterly Journal of Drug Abuse degrees of negative self-assessment, negative emotions, such as anxiety and depression, uncontrollable conditions, and negative beliefs. Moreover, they develop self-esteem beliefs and goals and show increased personal growth. This therapy led to a decrease in obsessions with fear of self-criticism based on the creation and enhancement of motivation. It can also be maintained that behavioral activation group therapy in opioid-dependent group, based on the provision of techniques, makes it possible for a person to discover his/her innate capacity for behavioral change, and this leads this individual finds him/herself to be in charge of changing his/her state of mind by means of intrinsic motivation and to reduce the intensity of beliefs about the loss of his/her recovery time, severe worry about thoughts, negative and relatively uncontrollable imaginations, low cognitive confidence, and need to control thoughts, and cognitive self-consciousness. Among the research limitations, we can refer to the individual and intrinsic differences in the effect of the therapy as well as mental and psychological conditions of the sample units during the completion of the questionnaire, which might have affected their posttest scores. This was beyond the researcher's control. In addition, the limited intervention duration and no comparison with other therapies were among the research limitations. Finally, considering that behavioral activation therapy leads to reduced metacognitive beliefs in opiate- dependent addicts, this therapeutic approach is effective in reducing addicts' psychological trauma and can be applied at the same time with detoxification methods to reduce the metacognitive beliefs of opiate-dependent addicts. Considering the low action resilience and emotional, behavioral, and physical problems in addicts, activation interventions can be a good therapeutic alternative to mitigate their problems. It is suggested that researchers and therapists consider the strategies of spiritual therapy as a protective method in preventive and therapeutic interventions in addiction treatment centers. Reference American psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed, Text Revision, DSM-5). Washington DC. Author. Anderson, L.H. (2015). The effect of behavioral activation group therapy on the resilience, quality of life and perceived stress in abusing in drug abuser patient. American journal of Orthodontics Orthodontics .131(5).571-572. Cartwright, D., Hatton, S. & Wells, A. (2011). Beliefs about worry and intrusion: The Meta cognitions questionnaire. Journal Anxiety Disorder; 11: 279-315. Dallas, T.X., & David, W. (2013). Staley behavioral neuroscience of drug addiction. Biosocieties, 39: 22-6. Dawe, S., & Loxton, N.J. (2014). Abuse and dysfunctional eating in adolescent girls: The influence of individual differences in sensitivity to reward and punishment. Int J Eat Disord. 29: 455-62. Diener, E. J. (2013). Wellbeing for policy. New York: Oxford University Press. Zahra Dasht-Bozorgi 219

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