Effect of group in reducing depression and increasing hope in drug addicts Mohamad Khaledian1, Masood Yarahmadi2, Hemn Mahmoudfakhe1

Journal of & Health Abstract Social Development & Research Center Today, addiction is a major problem in human society, threatens Vol. 6, No. 1, Mar & Apr 2016 health of the community, family, and individual, and leads to loss Pages: 167-174 Original Article of personal, occupational, family and social achievements. This experimental pretest-posttest study with control group aimed to 1. Department of , School of determine the effect of group logotherapy in reducing depression Psychology, Payame Noor University, Tehran, Iran and increasing hope in drug addicts. From a total of 70 addicts, 2. Department of Law, School of Law, 60 were selected by random sampling method, and finally 20 Kermanshah Islamic Azad University, were selected with the highest scores in Beck's depression Kermanshah, Iran inventory and the lowest scores in Snyder’s hope scale, Correspondence to: Mohamad Khaledian, Department of Psychology, School of who were then randomly divided into control and trial groups. Psychology, Payame Noor University, The trial group received 10 sessions of group logotherapy, and Tehran, Iran the control group received no intervention at all. Data were Email: Mohamad_khaledian22@yahoo. com analyzed using descriptive and inferential (covariance analysis) statistics. Results showed significantly lower mean depression Received: 16 Jan 2014 scores, and significantly higher mean hope scores in posttest in Accepted: 18 Mar 2014 trial group compared to control group. According to results, it How to cite this article: Khaledian M, can be concluded that group logotherapy is effective in reducing Yarahmadi M, Mahmoudfakhe H. Effect of group logotherapy in depression and hope in depression and increasing hope in drug addicts. drug addicts. J Research & Health2016; 6(1): 167-174. Keywords: Addiction, Depression, Hopefulness, Logotherapy, Opiates

Introduction Drug addiction is a global problem, and somehow the world health organization, adolescents’ involves every country; each adopting different needs, tendencies and behavioral patterns are solutions according to its own economic, social changing in parallel to progress of societies, and cultural infrastructures [1]. In today's and the pattern of drug abuse among youths is world, addiction is the biggest social problem, rapidly changing from traditional to industrial with increasing spread among the youth. Use of drugs across the globe, including in Iran and addictive substances has a long history in Iran, its capital, Tehran. UN office on drugs and and the plants from which substances such as Crime in Iran has warned about the spread opium and cannabis are produced are native of industrial drugs in Iran [2]. Nothing has to Iran; however, according to statistics and ever threatened human society like addiction. reports from international institutions such as Despite dangers and side-effects of addiction, Group therapy on depression and life hope victims of this deadly trap are increasing daily, paths toward desired goals, and necessary and witnessing its frightening scenes is not for using these paths. Hope is deemed serious by other people, especially the powerful only when it includes worthwhile youth [3]. Given the lowering age of addiction, goals, and when there is possibility to achieve human and material costs of fighting the them in medium-term, despite challenging but supply and distribution of drugs, physical and feasible obstacles [7]. Hopelessness causes psychological complications, spending a lot the individuals to be passive, so they cannot of time and money, low success rate, and lack assess their different situations or make of rehabilitation motivation for addicts who decisions about them. Hopelessness leaves the receive treatment only to relieve withdrawal individuals defenseless and trapped against symptoms, has led to unfavorable outcomes of stressors, and weakens their problem-solving addicts’ treatment. Moreover, studies show that skills. It further makes them constantly assess 20% to 90% of addicts undergoing medication their experiences negatively and incorrectly, therapy relapse [4]. Review of previous studies and consider worrying outcomes for their shows that without psychosocial interventions, problems [10]. maintenance medication therapy is not very One of the strategies to reduce hopelessness and successful, due to emphasis on medication only depression in people is through logotherapy, [5]. It seems rehabilitation and harm reduction which is an existential approach that provides centers need psychological therapies to change an excellent philosophical and theoretical attitude of drug abusers. Thus, the need for context for teamwork. Group logotherapy psychological and non-medication therapies is can prepare the conceptual structure to help felt more than ever before [6]. patients in the challenge to find Beck defines depression as a disorder that in their lives [11]. Thus, logotherapy is a involves changes in emotional, motivational, method that steers the patient toward finding behavioral, cognitive, and physical domains. meaning of life. The principle of logotherapy Depression is a state of sadness and boredom, is an endeavor to find meaning in life, which and as an illness, it involves a wide range of is the most essential motivational force in mood disorders with many forms. The central human being [12]. Frankl argues that there is features of depression include profound loss nothing in the world that can help mankind of desire for normal pleasurable activities more than finding his existential "meaning" such as friendly talks, leisure, exercise, food [13]. Frankl is of the opinion that a sense of and libido. Anhedonia is a penetrating and meaninglessness is a major existential neurosis persistent state, and its severity depends on in modern life. Meaninglessness leads to the number of symptoms and their depth. In emptiness or a condition that Frankl refers some people, facing obstacles causes a kind of to as existential emptiness. Since there is no depression, in which a sense of abandonment, predetermined plan in life, people are faced vacuum, and harsh memories of separations are with the task of creating their own meaning. revived [7]. Aging, loss of dear ones, especially Sometimes, people with a sense of emptiness, spouses, distance from children, chronic avoid any attempt to create a purposeful life. diseases, use of various medications, cognitive Experiencing meaninglessness and forming decline, and natural and biological factors are values that are part of a meaningful life are all predisposing factors for depression and issues that should be raised in counseling anxiety in the elderly [8]. The theory of hope sessions. The new concept of "logotherapy" was proposed by Snyder, and provides an was created to help patients to find meaning important framework for understanding hope in in life [14]. Yalum and Frankl basically counseling and clinical works [9]. Hope is one expect that like pleasure, meaning should be of the concepts in teachings of Quran and Islam. implicitly sought. Finding meaning in life Hope is a of personal capabilities for creating results from engagement that is a sense of

168 Khaledian et al commitment to creating, loving, working, and group logotherapy effective in increasing constructing [15]. hope in drug addicts"? Results of a study by Mohrinejad and Rajabi- Moghadam on the efficacy of logotherapy in Method increasing hope in addicts passing a short-term This is a pretest-posttest experimental study rehabilitation program confirmed the efficacy of with a control group. Study population logotherapy [16]. Results of a study by Garfami consisted of 70 drug addicts attending et al, on the effect of group logotherapy in methadone-therapy center in Gharveh (the reducing symptoms of psychological problems west of Iran) 2013, of whom, a sample of 60 in women with breast cancer showed reduction was randomly selected according to Chrissie- in psychological disorders including depression Morgan Table [21]. Then, 20 with the highest in these women [17]. Similarly, Moshtaghi et al scores in depression scale and the lowest [18]. study on the effect of group logotherapy scores in hope scale were selected, who were in improving psychological health of the blind then randomly divided into control and trial in Isfahan showed enhanced psychological groups. The trial group received 10 sessions health and reduced depression in this group of group logotherapy based on Frankl theory, [18]. In a study by Shoaa-Kazemi and Saadati but the control group received no intervention. [12], hopelessness in women with cancer Study instruments: In this study, data were was reduced after teaching them logotherapy collected using two questionnaires: dimensions (responsibility, freedom, value, and 1. The revised Beck's Depression Inventory …) [12]. In Gholami et al [19]. study, life and (BDI-II): A 21-item, self-reporting questionnaire, general health were improved and depression designed to assess depression, with 4 options for was reduced in female thalassemia patients as each item, and scores ranging from 0 to 3, with a result of group logotherapy [19]. Results of a overall score from 0 to 63. Beck that study by Ghanbari, Zarandi and Godarzi [20] the revised version is able to show severity of showed improved general health and reduced depression in patients and normal population, depression (as a dimension of general health) in including adolescents and . Internal women victims of earthquake (In Zarand city) consistency of this tool has been reported 0.73 to through group counseling with logotherapy 0.92 with mean 0.86 and Cronbach's alpha 0.86 approach [20]. for patients, and 0.80 for non-patients [7]. In this Since logotherapy and attending groups are study, reliability was found 0.81 by Cronbach's effective in creating a sense of empathy and alpha. preventing loneliness, researchers decided to 2. Adult Hope Scale, designed by Snyder use these techniques and study their effects et al to measure hope, contains 12 items in in reducing depression and increasing hope self-report form [22]. Of these items, 4 assess in addicts. Since addiction is likely to cause agency thought, 4 assess pathways thought, hopelessness and depression, it is essential and 4 are diversion items. Therefore, this to have knowledge of appropriate therapies, questionnaire measures two subscales of including group logotherapy to plan appropriate agency and pathways. Mean validity and actions, improve psychiatric health services reliability coefficients of this tool was reported and develop related policies in the community. 0.91. Internal consistency of the whole test is Such knowledge is beneficial in providing 0.74 to 0.84, and test-retest reliability 0.80, psychological help for these patients, so that which can increase further with intervals of depression may be reduced and hope can be 8 to 10 weeks [23]. In a study on 660 female increased in these patients. Thus, the present students in Tehran, Cronbach's alpha for this study aims to find answers to the following scale was found 0.89 [24]. In the present study, questions: "Is group logotherapy effective in reliability was found through Cronbach's reducing depression in drug addicts" and "is alpha as 0.84.

169 Group therapy on depression and life hope

Group logotherapy: statements for the interaction of members, Session 1: Determination of group objectives members’ emotional support of one another, and rules, introducing members, counseling and encouragement of members to ask for and discussing addiction, and presenting group emotional support from one another charter and therapy contract. Session 10: Summarizing and conclusion, Session 2: Problem statement, discussion talking about learning within the group, and about addiction and its effect in causing mental filling out depression and hope scales disorders Data were analyzed using descriptive and Session 3: Briefing on the concepts and sources inferential statistics (covariance analysis test). of meaning, and accountability Session 4: Change of attitudes and eliciting Results meaning through exploration of meaning The present study aimed to assess the effect of Session 5: Eliciting meaning from creating group logotherapy in reducing depression and values and accountability increasing hope in drug addicts. Descriptive Session 6: Drawing meaning from experience data relating to pretest and posttest depression of values, and from wishes and hopes and hope scores in the trial and control groups Session 7: Meaning of death, life, freedom, and and results of covariance analysis on mean responsibility scores of these tests, results of homogeneity Session 8: Responsibility, self-support, social of gradients test are presented below: interest and overcoming despair, increased hope Scores in each scale were added up to calculate Session 9: Members’ supporting one another the whole scale score. Thus, the scale used emotionally, completion of unfinished was minimum interval. According to data

Table 1 Descriptive information on depression and life expectancy in the pretest and posttest in the experimental and control groups Life expectancy Depression Group Stage Mean SD (±) Mean SD (±) Pretest 16.9 1.91 40.4 4.57 Experimental Posttest 20.01 1.7 32.7 3.74 Pretest 17.2 1.75 37.6 5.06 Control Posttest 17.9 1.37 37.7 6.9 presented in table 1, pretest and posttest mean and 32.7±3.74 respectively in the trial group, and SD of hope were 16.9±1.91, and 20±1.7 and 37.6±5.06 and 37.77±6.9 respectively in respectively in the trial group, and 17.2±1.75, the control group. and 17.9±1.37 respectively in the control According to results in Table 2, homogeneity group. Pretest and posttest mean and standard of gradients was not significant for deviation of depression scores were 40.4±1.57 depression with F (1,16)= 2.092. Thus,

Table 2 The homogeneity of slopes assumption test Sum of Squares d.f Mean Square F Sig Group 7.96 1 7.96 0.72 0.409 Pretest 322.53 1 322.53 30.04 0.001 Pretest group 23.16 1 23.16 2.09 0.167 Error 177.11 16 11.07 assumption of homogeneity of regression shown in Table 3. gradients is realized for depression. Given Table 3 shows a significant difference the above results, covariance analysis was between the trial and control groups in used to assess the hypothesis, and results are posttest (F= 22.26 and significance level

170 Khaledian et al

Table 3 Results of the covariance analysis on the pretest and posttest in the control and experimental groups with regards to depression Changes Sum of Mean D.F F Sig Eta Square Sources Squares Square Pretest 353.928 1 353.928 30.043 0.001 0.639 Depression Group 262.279 1 262.279 22.263 0.001 0.567 Error 200.272 17 11.781

0.001). Thus, results suggest the effect the trial group participants. of group logotherapy method in reducing Results presented in table 4 show homogeneity participants' depression. In other words, group of gradients with F (1,16)= 0.576 was not logotherapy was able to reduce depression in significant for hope. Thus, assumption

Table 4 The results of the homogeneity of slopes assumption test Sum of Squares D.F Mean Square F Sig

Group 0.015 1 0.015 0.02 0.889 Pretest 29.986 1 29.986 41.239 0.001 Pretest group 0.419 1 0.419 0.576 0.459 Error 11.634 16 0.727 of homogeneity of regression gradients in in Table 5. variable of hope was realized. According to Table 5 shows a significant difference these results, covariance analysis was used to between the trial and control groups in posttest assess the hypothesis, and results are presented (F=37.49 and significance level 0.001). Thus,

Table 5 Results of the covariance analysis on the pretest and posttest in the control and experimental groups with regards to life expectancy Changes Sum of Mean D.F F Sig Eta square sources Squares Square Pretest 30.847 1 30.847 43.507 0.001 0.719 Life expectancy Group 26.58 1 26.58 37.49 0.001 0.688 Error 12.053 17 0.709 results obtained suggest the effect of group on one another [25]. They are heartened and logotherapy in increasing participants' hope. comforted by seeing other people's problems In other words, group logotherapy was able to similar to or worse than their own [26]. This increase hope in the trial group participants. effect can be explained in that logotherapy emphasizes the root of depression and Discussion hopelessness is meaninglessness of life. In The present study aimed to assess the effect other words, when someone believes life of group logotherapy in reducing depression is meaningless due to problems in life, they and increasing hope in drug addicts, and this become depressed and hopeless. They see life was confirmed according to results obtained, through fear, which they cannot overcome, which agrees with results in other studies and see themselves entrapped in life events. [16-20]. Importantly, group therapy has many An addict sees life meaningless, and feels he advantages that facilitate and accelerate has reached end of the line, without exploring treatment process. It helps people learn values and objectives of life. Purpose and effective social skills, and test their learning hope in life reinforce . Purpose

171 Group therapy on depression and life hope and meaning in life can help the individuals accepting this responsibility and their current overcome depression and hopelessness, and be circumstances, they are encouraged to try responsible for their life and existence by relying and improve themselves. This paves the way on freedom of will. In Frankl's logotherapy, it for increased hope and reduced depression. is assumed that the individual will be able to According to cognitive theories, participation overcome depression and hopelessness, and in such meetings can correct many cognitive mental disorders with purpose and meaning distortions such as "musts" and "obligations" in life, and can be responsible for their life and replace them with "sometimes", relieve and existence by relying on freedom of will. the person from personal choices and Logotherapy tries to make the individual aware assumptions, and make them more flexible of their responsibility, and that it is their duty toward the environment. According to to choose for whom and for what they are counseling and theories in responsible. This method has been effective Rogers’ client centered therapy, the principle in reducing depression and increasing hope. of accountability is particularly important Through logotherapy, patients learn to let in Bender’s Geshtalt-therapy and Frankl go of worry and concentrate on other things. logotherapy. With a sense of responsibility, In practice, Frankl was totally successful in people feel they are in control of life events switching patients' attention from neurotic and able to control situation by taking worries to more essential issues of life and responsibility. A feeling of authority over life meaning. Therefore, logotherapy eliminates events and changing internal control to internal symptoms of illness and enables the individual control leads to frustration in achieving to face difficulties in life and reach mental well- desired outcome. These interventions help being and health, which can lead to reduced patients not consider their current situation depression and increased hope in an addict [27]. unimportant, and not fear the future. One of the main objectives of logotherapy is to Considering the growing trend of drug use help people find meaning in life. When they do across the country, it is recommended that not think in this way, they become depressed. comprehensive studies be conducted on Thus, depression occurs when we believe life level of drug use. To familiarize people is meaningless [28]. A prominent attribute of with addiction and its complications, human is the effort to understand meaning and educational workshops should be held, purpose in life, and logotherapy provides a and authorities and experts should develop conceptual framework for people to challenge a comprehensive program for reducing meaning in their own lives, and put aside old drug use in the community. A variety of values, and create a new value system according prevention, treatment and preventing relapse to their existence. Accordingly, human suffering programs such as restricting drug supply by can be turned into success depending on the the government; the important role of mass individual's stance. In this method, people who media in increasing people's awareness of suffer from guilt, hopelessness and death can deal addiction complications; important role of with their hopelessness, and succeed. Finding parents in their interaction with each other meaning in life results from engaging in a sense and with children; teaching people to say no; of commitment to creating, loving, working teaching resistance to peer pressure etc. are and constructing [11]. According to Beck's among other recommendations. theory, people ruin their thoughts by excessively Study limitations included a lack of follow-up generalizing a few negative events [29]. due to unavailability of participants. Briefly, Participation in such educational sessions, knowledge and counseling techniques can emphasizing meaning, purpose and values reduce problems of people on the verge of in life, and also interacting with peers addiction and reduce the incidence of addiction increases accountability in the individual. By that is unfortunately growing today. This

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