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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 4  |  Page : 246-252

Effectiveness of problem-solving training, exposure therapy, and the combined method on depression, anxiety, and stress in mothers of children with special needs


1 Department of Family Therapy, Family Research Institute, Shahid Beheshti University, Tehran, Iran
2 Department of Clinical Psychology, Islamic Azad University, Science and Research Branch, Hamedan, Iran

Date of Web Publication31-Aug-2015

Correspondence Address:
Prof. Mojtaba Habibi
Shahid Beheshti University, P.O. Box 1983963113, Tehran
Iran
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2395-2296.163931

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  Abstract 

Aim: This study was designed with the aim of comparing the effectiveness of three methods of cognitive-behavioral therapy, including problem-solving, exposure therapy, and the combined method (the combination of both methods of problem-solving and exposure therapy) on depression, anxiety, and stress in mothers of children with special needs.Methods: Research samples consisted of 44 mothers who had children with special needs and were divided randomly into 4 groups of 11: (1) The problem-solving group, (2) the exposure group, (3) the combined group, and (4) the control group, by the use of an experimental design with pretest and posttest. The measurement tool in this study was Laviband depression, anxiety, and stress questionnaire and the data were analyzed by descriptive statistic methods such as frequency, percentage, and standard deviation; inferential statistics methods such as covariance test and post-hoc test least significant difference (LSD). Results: The results showed that all three methods were effective on improvement of both the general mental health and problems such as depression, anxiety and stress (P < 0.01). Conclusion: Based on this research and previous literature, cognitive-behavioral therapy methods, including problem-solving, exposure therapy, and the combined method were proved to be beneficial for mothers of children with disabilities, retardation, or other disorders, which can affect mental health. Therefore, it is strongly recommended that the above-mentioned interventional methods are considered for these mothers.

Keywords: Anxiety and stress, depression, exposure therapy, problem-solving, special needs


How to cite this article:
Habibi M, Zamani N, Abedini S, Jamshidnejad N. Effectiveness of problem-solving training, exposure therapy, and the combined method on depression, anxiety, and stress in mothers of children with special needs. Int J Educ Psychol Res 2015;1:246-52

How to cite this URL:
Habibi M, Zamani N, Abedini S, Jamshidnejad N. Effectiveness of problem-solving training, exposure therapy, and the combined method on depression, anxiety, and stress in mothers of children with special needs. Int J Educ Psychol Res [serial online] 2015 [cited 2019 Sep 21];1:246-52. Available from: http://www.ijeprjournal.org/text.asp?2015/1/4/246/163931


  Introduction Top


A child's disability is an experience, which involve interactions among the disabled children and family that is affected by it.[1] The diagnosis of disability probably is the most difficult experience.[2] Families either adapt effectively and plan for effective actions or show a high level of emotional stress and have ineffective reactions.[1] Child's care needs changes of life routines, which have significant effects on family functioning.[3] The difficulties should be encountered by parents of the disabled child, have been cited as a source of anxiety, depression and family stress.[4] Parents of children with disabilities experience greater stress in comparison with a larger number of caregiving challenges, such as greater feelings of restriction, more health problems, and higher levels of parental stress, anxiety, and depression symptoms than parents of nondisabled children.[5] Mothers communicate with their children more and as a consequence experience higher levels of parenting stress. Furthermore mothers of children with special needs experience more mental disorders, low self-esteem, guilt, physical tiredness, and exhaustion.[6] Several studies have found that mothers of children with disabled children report higher levels of child-related stress, parenting stress, depression, and anxiety more than other members of the family.[7] It has often been assumed that the extra stress of caring for a child with disabilities places mothers at risk of suffering from depression, low level of self-esteem, high level of marital conflict, stress, and anxiety.[8] The high amount of stress effects parents' abilities for raising their children and has dramatic negative effects on their children.[8],[9] Review of the literature demonstrates that psychological symptoms such as depression, anxiety, and stress in mothers have a considerable negative effect on children's mental health.[10] Moreover, these symptoms can interfere with healthy development in children and lead to more behavioral problems in children[11],[12] because of the considerable benefits of mother's psychological health.[13] By studying and comparing the factors which can effect on the level of emotional distress in parents of children with special needs, we can apply some effective interventions to address psychological distress in these mothers. These interventions can protect this population from emotional distress and help them to enhance their ability for being more resilience.[14] By carrying out stress-management interventions a great deal amount of parenting issues can be prevented.[15] Thus, an intervention with the aim of lowering the emotional pain and suffering of mothers is needed.[16] There is a significant need for immediate intervention for decreasing the anxiety, stress, and depression's signs and symptoms, and making these educational treatment programs more popular with the aim of generalizing these learning's and making them applicable for all circumstances.[17] Among various treatment methods, that are beneficial for enhancing mental health and decreasing depression, anxiety, and stress, cognitive behavioral therapy (CBT) is well-documented for addressing these symptoms.[18] The basic assumption of cognitive therapy is that people have a pivotal role in forming their own psychological problems and psychological symptoms, and as a consequence individuals can change their emotional status. This method is based on the fact that cognitions, emotions, and behaviors highly interact with each other and have a cause and effect relationship.[19] This method consists of different therapeutical techniques including exposure therapy, problem-solving skills, stress inoculation training, assertiveness training, and combined methods that help people change their negative trends of thought and consequent behavior.[20] In this study, the CBT method was carried out in groups. An advantage of group therapy is that more people participate, and the group provides for training with inter-personal skills. Furthermore, group experiences are closer to the reality of clients' daily life. Other benefits include raising hope, being a part of a whole, information sharing, being in touch with humanistic values, growth of social skills, modeling, learning from each other, correcting emotional experiences, and catharsis.[21] This method has been successful in overcoming depression, restlessness, phobias, anxiety, anger, interpersonal problems, etc. Researches done by D'Zurilla and Nezu and Butler et al., Chapman et al., Forman et al., and Beck et al. have proven CBT effectiveness in decreasing depression, anxiety, and mood disorders.[22],[23]

The third wave of CBT is a newborn treatment that has attracted lots of attention in authentic academic centers of the world and is widely used in urgent situations, crisis interventions, and treatment of troubled people and those with complicated disorders. This research aims to provide an appropriate groundwork for studying and comparing the effectiveness of three CBT methods including problem-solving, exposure therapy, and the combined method (simultaneous application of problem-solving and exposure methods) on depression, anxiety and stress in mothers of children with special needs.[24],[25] One of the treatment methods which is widely used for addressing psychological distress is the training of problem-solving skills, which is widely used and is consist of teaching mental and social skills to clients. In this method, clients are taught how to solve the problems which they face in life in a step-by-step process.[24] Nezu and Nezu believe that the problem-solving method is the main point in all cognitive behavioral therapies.[24] The reason is that this method enhances people's skills for understanding that how they can think when faced with problems, and not what to think about. Furthermore, the preventive and therapeutic effects of the problem-solving method are verified. For instance, Malouff, Thorsteinsson, and Schutte emphasize on the importance of how to face a problem and on how it effects on people's mental health. They also mentioned two types of coping strategies.[26] One is problem-focused which is painful and involves attempts to change or modify the problematic situation by finding a solution or asking for help or guidance. The second one is emotion-focused that includes strategies such as denial, wishful thinking, and expression of emotion instead of planning for solving the problem. Furthermore, in related areas, researches have shown positive, preventive, and therapeutic results of problem-solving skill on mental health, increasing self-confidence, satisfaction, and decreasing suicidal thoughts, and PTSD signs and symptoms.[24]

Different styles have been presented in order to teach problem-solving skills. There are various styles with the same points. The reason is that various methods and patterns of problem-solving are designed with the aim of making cognitive changes in patients and are used for effective analysis of situations, issues and problems of life and decision-making based on the existing responses and results. In this study, Davidson and Goldfried's viewpoint is used, because of the general approved of the effectiveness of this therapy in previous researches.[27]

The second popular treatment method is exposure therapy, which is another technique in CBT and its effectiveness was confirmed in increasing mental health. In this method, the goal is to train people involved in emotional situations, in order to face different circumstances, thoughts, and feelings.[28] The patients, in this method, face the description of the details of their emotions and experiences, in a safe environment and free of judgment, under the guidance of the therapist, and the stimulus does not fade away until the emotions of the patients are decreased. Exposure therapy is safe and effective, only when it is directly performed by the therapist and the process leads not only to extinction of the conditioned response, but also it alters the significance of these events for the patient.[28] Like other methods, exposure therapy can be carried out separately and along with other methods too.[29] Studies report significant and lasting results after 9–12 sessions.[30] Hence, these two kinds of treatment can be effective for enhancing psychological well-being of mothers of children with special needs. Review of literature show and still no researches have been carried out in Iran for investigating the effectiveness of this method on reducing stress, depression, and anxiety in mothers with special needs. Therefor this study follow these aim to compare the three CBT methods of problem-solving, exposure therapy, and the combined method (a combination of problem-solving and exposure methods) on depression, anxiety, and stress in mothers of children with special needs.

And the hypothetic is: CBT is effective in improving the mental health of mothers of children with special needs.


  Methods Top


Participants included 44 mothers of children who diagnosed with cerebral palsy, autism, physical and mental retardation, learning disorders, speech-language and communication who referred to Taban, Tabesh, and Aram Institutes and were assessed through preintervention assessment and postintervention assessment by the Depression Anxiety Stress Scales (DASS, Lovibon and Lovibond). Eligible participants were screened based on inclusion and exclusion criteria. Patients who: (a) Have 8-year-old children or younger who receive just one diagnosis of disorder from psychiatrics and neurologists (b) had a diagnosis of depression, anxiety, or stress based on 5th edition of American Psychiatric Association, diagnostic and statistical manual of mental disorders,[30] (c) have 19–37-year-old, (d) have diploma in minimum, (e) no psychological intervention and psychiatric medications for 6 months before the study and (d) having just one children with special needs. Exclusion criteria were: being absent more than three sessions in experimental groups.

Of a total 55 mothers, 11 declined to be interviewed and others divided to four group (three experimental and one control group). Others were approached by a clinical psychologist to read a letter containing information about the research protocol. The interview was conducted, after mothers signed written and informed consent. DASS questioner were completed by mothers. The mothers in the experimental group were thought about problem solving and exposure therapy prettiness by clinical psychologist who have been trained for both treatment. Furthermore, treatments protocol has been monitored by two clinical psychologist supervisors. The research protocol was approved by research ethic committee of the family research institute of Shahid Beheshti University. The assumption of normality was checked, and skew was not evident. Stages of this semi-experimental study consisted of: (1) Pretesting all four experimental and control groups; (2) introducing the independent variable (problem-solving training, exposure therapy, and the combined method) to the experimental groups; (3) posttesting of all four experimental and control groups.

Experimental group programs consisted of:

  1. The problem-solving group program: Therapeutic program was based on Davidson and Goldfried's model of eight 90 min group sessions. Subjects training contained diagnosis of the problem and definition of the problem of that, trying to understand the problem, determining related goals, generating and presenting alternative solutions, examination and selection of the best suggestion, application of the chosen solution, evaluation of the effectiveness of the applied method on solving the problem, examining the tactic evaluation methods, application of the solutions, examination of the treatment process, deciding for continuing or ending the treatment, following up the results, and examining the patient's problems regarding the problem-solving process[32]
  2. The exposure group program: This method was scheduled to be carried out in eight 90 min sessions too and consisted of focusing and reviewing the trauma, separating the negative emotional aspects of it with the guidance of the therapist, along with relaxation and home practices of mental imagery, making notes or recording the voice for reviewing the trauma with and without relaxation, and studying the improvement of the patient[33]
  3. The mixed program: This group's treatment was a combination of the programs prepared for the two groups of problem-solving and exposure therapy, in eight sessions, aiming to train problem-solving skills, along with relaxation and methods of recognition of negative thoughts and stopping the thought process, focusing on the traumatic situation in problem-solving process and the exposure therapy method.[32],[33]



  Measures Top


The Depression Anxiety Stress Scales (DASS, Lovibon and Lovibond) include of three self-report scales for measuring negative emotional symptoms in depression, anxiety, and stress.[34] Lovibond and Lovibond,[34] performed a factor analysis on the above-mentioned scale and the results showed the three factors of depression, anxiety, and stress. The alpha coefficient for depression, anxiety, and stress were relatively 2.97, 0.0, and 0.95. Correlation calculations showed in Antony et al., study.[35] The correlation coefficient was about 0.53 between anxiety and stress, and 0.28 between anxiety and depression. The questionnaire's validity and reliability were examined[36],[37] in Iran, and the test-retest reliability for measures of depression, anxiety, and stress were relatively 0.80, 0.76, and 0.77. And the Cronbach's alpha for the measures of depression, anxiety, and stress were reported relatively 74.81, 0.0, and 0.78. Each subscale of the test consists of seven items, the final score of which is calculated from the sum of the relevant items.

Finally, the pre and posttest data were analyzed using descriptive statistics methods (frequency, percentage, mean, and standard deviation) and inferential statistics methods (ANCOVA for examining the significance of the difference between means, and LSD test for comparing and finding significant difference between groups).


  Results Top


The participants' age ranged between 19 and 37 and the mean and standard deviation of their age was 33.32 (3.56) for the problem-solving group, 34.69 (3.28) for the exposure therapy group, 33.84 (3.07) for the combined method group, and 34.94 (3.01) for the control group. Nineteen of the participants were working people (eight school teachers, one kindergarten teacher, one personal trainer, one building superintendent, and five carpet-weavers), and 25 (56.81) were housekeepers and unemployed. As group-therapy was to be carried out, 4 groups of 11 were formed. 0.25 more were selected so that subject drop-out would not cause any damage to the study. 52.28% of participants had high school diplomas, 22.72% had associated degrees, 20.45% had bachelor's degrees, and 4.54% had masters degrees or above. The mean and standard deviation of subscales of mental health is presented in [Table 1].
Table 1: The mean and SD of subscales of mental health, in regards to the groups‘ pretest and posttest

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In order to study the significance difference between means, analysis of covariance was used. Prior to the ANCOVA test, Levene's test for equality of variances was performed. The test was positive for all groups, and the equality of score variances in all four groups was approved. ANCOVA results in regards to the comparison of the means of the four groups are presented in [Table 2]. The results showed that there was a significant difference between the pre and posttests in the total score and the subscales at the level of P < 0.01.
Table 2: Results of covariance analysis of the difference among mental health scores in the four groups of problem-solving, exposure therapy, the combined method, and control

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In other words, the reduction of a score of the experimental groups in the mental health scale, showed the effectiveness of these methods, in comparison to the control group. The results also showed that the group membership factor was significant at the level of P < 0.01 in regards to the scores of depression, anxiety, and stress. The statistical LSD test, with the aim of comparing groups, was performed. Results showed a significant difference between the experimental groups and the control group.


  Discussion Top


Results of this study showed the effectiveness of problem-solving training, exposure therapy, and the mixed method on improvement of the mental health of mothers of children with special needs in experimental groups, in comparison to the control.

The effectiveness of problem-solving therapy is in concordance with the previous results,[38] which show the effectiveness of problem-solving in reducing depression, anxiety, and stress for different people.[39] This method can enhance cognitive skills, crises management, more cooperation as one of the main techniques for managing life issues and problems, social skills, self-confidence, and self-esteem. These methods were also proven to be effective in decreasing the signs and symptoms of stress.[40]

The "problem-solving therapies" may be characterized as a combination of cognitive restructuring techniques and coping skills training procedures. Problem-solving therapies may help mothers of children with special needs to develop general strategies for dealing with a broad range of problems, which are direct and indirect consequence of a child with special needs.[41] Moreover, an active collaboration and interaction between clients and other members in a treatment program may help them to receive empathy, which can help them to be more resilient.[42] Effective problem solving involves the abilities such as recognizing the range of possible problem situations depending to the child and generating multiple and alternative solutions, planning a series of steps necessary to managing the situation more effectively.[43] All of these methods help the mothers to experience a lower level of anxiety, depression, and stress.[44] In this study, the exposure method proved to be significantly effective on depression. Results are in accordance with the previous studies.[45] One of the reasons for this method is being effective on improving mental health is, having to face situations, thoughts, and feelings.[46] Exposure-based treatments aim to treat the core fears underlying anxiety and psychological-related disorders.[47] The efficacy of this treatment is well-documented in reducing anxiety, depression and stress. Exposure therapy allows participants to confront a feared experience in a safe and controlled situation. A sense of presence is essential for conducting exposure therapy which helps mothers to have a better psychological adjustment. Furthermore, exposure therapy help, the fear structure to be activated and modified and make its meaningless threatening. Exposure therapy, help patients, intentionally confronted with the anxiety stimuli in a therapeutic manner, activates the anxiety structure through confrontation with the threatened stimuli, which elicits the anxious responses. Therefore, this treatment can reduce anxiety and its related symptoms such as depression and stress.[48] The combined method, showed a higher level of mental health in comparison to the control group, and in accordance with the previous studies.[49] A reason for the effectiveness of this method is the simultaneous application of methods that cause a significant decrease of emotional pain and suffering. By applying skills which was taught in both treatments, mothers of children with special need can be more resilient and experience less emotional suffering. Cognitional and emotional managements witch was learned in combined method may help mothers to manage their stress, anxiety, and depression symptoms more effectively. There were some limitations for conducting this research such as limited number of participants in each group and having no follow-up assessment. Future researches can be done by recruiting more participants and assessing participants in different points after posttreatment.[50]

Acknowledgments

The authors would like to express their gratitude to all the participants and the staff of State Welfare Organization of Iran.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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