Health is one of the most important aspects of life
[1] and one of the important categories in the discussion of health is paying attention to the type and severity of the disease
[2,3]. Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects sensory and motor function
[4] and is associated with periods of worsening in 85-90% of patients
[5,6]. Symptoms of the disease exacerbation are a clinical reflection of increased inflammatory activity in the central nervous system
[7]. These periods of progression with the unknown prognosis of the disease are a major challenge for patients
[8].
MS is the third leading cause of disability in the world
[9], affecting approximately 2.5 million people worldwide
[10]. There are no accurate statistics on the number of patients with this disease in Iran
[11]; nevertheless, according to the experts of the MS Association, about 5,000 new cases of this disease are identified annually in Iran
[2], which is 2.8 to 3.6 times more prevalent in females, compared to males
[12]. However, there is no definitive treatment for this disease
[13] and the existing treatment methods cause a wide range of unpleasant symptoms
[7]. These effects, in turn, affect the mental health of women and have many profound effects on their lives. Many of these patients experience communication problems in their lives and are led to depression, which is due to the low psychological capital of these patients
[14,15].
Psychological capital is a positive psychological state which provides a realistic and flexible approach to life
[16] that consists of four structures, namely hope, optimism, resilience, and self-efficacy
[17,18]. It must be noted that each structure is defined as a positive psychological capacity
[19] that has a valid measurement scale, is based on theory and research, is state-dependent, is able to grow, and has a significant relationship with functional outcomes (20). Psychological capital is considered to be a higher-order structure
[20] that includes one’s self-perception, goals to achieve success, and endurance in the face of problems. It leads to the expression of emotions and is low in chronic patients
[21,22].
Psychological capital means to be confident to make the necessary effort to succeed in challenging situations, have a positive outlook on success in the present and the future, have the perseverance to move toward one’s goals or changing goals to achieve success, and show self-resistance in the face of problems and hardships and accept them
(28). According to previous studies, emotional empowerment makes it easier to face life challenges and helps people achieve mental health
[23]. People with emotional health can recognize their feelings and express them to others in an appropriate manner
[24].
Given the above, the psychological capital and emotion expression styles in patients, especially the chronically ill, are lower than in healthy individuals, and there is a need for treatment to increase these variables. Given the nature of acceptance and commitment therapy (ACT), it can be used to fulfill this purpose. It is a cohesive treatment system based on the way all human beings consciously communicate with each other and the world around them
[25].
Objectives
This study aimed to investigate the effectiveness
of ACT on psychological capital and emotional expression styles of females with MS.
Materials and Methods
This quasi-experimental study was conducted based on a pre-test and post-test design with a two-months follow-up period and a control group. The study population consisted of all women with MS who were a member of Iranian MS Society in 2019. In total, 36 female patients were selected voluntarily who were randomly divided into three groups (ACT, placebo, and control groups). The inclusion criteria in the study were age range of 25-45 years, the passage of at least three months since their diagnosis, passage of at least three months since the beginning of their medical treatment, and education level of at least third grade of elementary school. The exclusion criteria included lack of a mental illness, use of psychiatric medications, and use of psychological services. The subjects were assessed before and after the intervention with the Luthans Psychological Capital Questionnaire and the Ammons and King Emotional Expression Questionnaire
.
Luthans Psychological Capital Questionnaire
This questionnaire was designed by Luthans, Olivier, Avi, and Norman in 2007 and includes four subscales of hope, resilience, self-efficacy, and optimism. In a research performed by Luthans and Olivo, the Cronbach's alphas of the subscales of this questionnaire were calculated at 0.88, 0.89, 0.89, and 0.89, respectively [26].
In a study performed by Ghane Sang-e-Atash, Mirzazadeh, Azimzadeh, and Abdolmaleki, the validities of the subscales of self-efficacy, hope, resilience, and optimism and the whole scale were calculated by Cronbach's alpha at 0.676, 0.738, 0.705, 0.786, and 0.84, respectively. The four factors obtained in total can account for 61.72% of the variance, which indicates the construct validity of the questionnaire
[27].
Ambivalence over Emotional Expression Questionnaire
This questionnaire was developed by Ammons and King in 1990 and has 28 items. It has a high internal consistency. The Cronbach's alphas of the whole questionnaire and the subscales of ambivalence in expressing positive and negative emotions were 0.89, 0.87, and 0.77, respectively. Moreover, its test-retest reliability value was 0.78 after six weeks, which is considered good
[28].
In Iran, Alavi et al. examined the psychometric properties of this questionnaire. In the exploratory factor analysis, five questions were omitted, resulting in a 23-item version. Accordingly, 10 and 13 statements about the ambivalence in expressing positive and negative emotions, respectively. Cronbach's alpha for the first, second, and total factor was reported as 0.82, 0.77, and 0.86, respectively. In examining the criterion validity of the questionnaire, the correlation of this questionnaire with the Beck Depression Inventory (0.35) and Social Panic (43) was calculated
[29].
Data analysis was performed using descriptive and inferential statistics. The descriptive statistics section included the demographic information and statistics of the central index (mean) and dispersion index (standard deviation). In the inferential statistics section of data analysis, after confirming the existence of hypotheses using parametric tests, repeated measures analysis of variance was used to eliminate the effect of the pretest. Furthermore, the adjusted means of the studied groups were compared with each other.
Results
Based on the findings, the mean values of the disease duration for the participants in the ACT, placebo, and control groups were 6.62±11.00, 9.08±7.58, and 7.10±3.14, respectively. According to the results of the Shapiro-Wilk test, the self-efficacy component in the ACT group at the follow- up
stage was significant at the level of 0.05. This indicates the non-normal distribution of the components in the aforementioned group and stage; nevertheless, considering the significance level of the Shapiro-Wilk test, it can be said that the deviation from the assumption is not severe and this issue can be ignored.
The result of the Leven test also showed that the difference in the variance of scores related to the four components of psychological capital is not significant at the level of 0.05. This suggests that the assumption of homogeneity of variance is established among the psychological capital data. The hypothesis of independence of the dependent variable at the pre-test stage of group membership was also compared using multivariate analysis of variance. It showed that the F value (P<0.05, F (141 and 16) =0.966) was not significant at the level of 0.05. Therefore, the presumption of independence of the pre-test variable from group membership was also established for data related to psychological capital.
According to Table 1, ACT affected the components of hope (F (30.63 and 1.70) =11.97) and resilience (F (36 and 2) =10.91) at the significance level of 0.01, compared to the control group. Moreover, it was able to affect the components of self-efficacy (F (22.72 and 1.27) =3.68) and optimism (F (33.34 and 1.85) = 3.55) at the significance level of 0.05, compared to the control group. Table 1 also shows that ACT has caused an increase in the component of hope (F (35.70 and 1.78) =13.60) and resilience (F (40 and 2) =5.19) at the significance level of 0.01 and the component of optimism (F (27.36 and 1.37) =4.51) at the significant level of 0.05, compared to the placebo group. Therefore, in the first hypothesis test, it was concluded that ACT was able to significantly increase the mean value of psychological capital components in patients with MS.
The Shapiro-Wilk index of the negative emotion ambivalence is significant at the level of 0.05 in the ACT group. Given the significant level of the Shapiro-Wilk index, this does not invalidate the results. In addition, based on the results of multivariate analysis of variance, before the implementation of independent variables, there was no significant difference between the groups in terms of dimensions of ambivalence (P<0.05, F (96, 8) =561). Therefore, it was concluded that the assumption of independence of the pre-test variable from group membership is also valid for the dimensions of ambivalence.
According to Table 2, the ACT reduced the positive emotion ambivalence (F (32.09 and 1.78) =5.08) and negative emotion ambivalence (F (22.36 and 1.24) =63.22) at a significant level of 0.05, compared to the control group. Furthermore, the ACT caused a decrease in positive emotion ambivalence (F (31.42 and 1.57) =7.89) and negative emotion ambivalence (F (27.97 and 1.40) =7.26) at a significance level of 0.01 in comparison with the placebo group. Hence, it can be said that ACT significantly reduced the mean scores of the ambivalent components at the post-test and follow-up stages compared to the control and placebo groups. Therefore, in testing the second hypothesis, it was concluded that ACT significantly reduces ambivalence in patients with MS.