:: позитивная психотерапия, призванная повысить терпимость к бедам и уменьшить чувство запугиваемости у пациентов с множественным склерозом.

Introduction

Multiple sclerosis is a neurodegenerative disease of the central nervous system. In multiple sclerosis (MS), a total of 2.8 million people are estimated. The global prevalence has risen since 2013.[ 1 ] For all time periods, the peak incidence occurred between ages 25 and 35 years. Patients with MS experience a set of cognitive, motor, and sensory manifestations.[ 2 ] Fatigue is a common, debilitating condition in patients with multiple sclerosis (MS).[ 3 ] Neuropsychiatric manifestations are important in MS. Psychiatric comorbidities are very prevalent in MS patients and linked to various negative consequences like decreases in quality of life and functional status, nonadherence to MS treatment, and negative influence on the progress of the program. Reason of suicide risk, therefore, early diagnosis and treatment of the disorders are of vital importance[ 4 , 5 ] The disease and the stage of progress fall into several different diagnostic categories[ 6 ] Considering the destructive cognitive and physical effects of suffering from a chronic disease like MS that affects all aspects of a person’s life, it seems to be one of the influential factors in how to accept MS and increase their capacity distress tolerance and in the form of hyperemotional structures and structures that are expressed as a person’s ability to experience and persevere against negative emotional states. This structure, which can be created as a result of cognitive or physical processes in a person, is an emotional state that is mostly characterized by practical tendencies to reduce the negative effects of emotional experience of a multidimensional nature.[ 7 ] Distress tolerance is an emerging structure that has been conceptualized in several different ways. However, broadly, it refers to the “perceived capacity of a person to withstand negative emotions and/or other anxiety-related states (for example, physical discomfort) and the behavioral tolerance of internal states of distress caused by certain types of stressors”.[ 8 ] On the other hand, low distress tolerance leads people to risky behaviors.[ 9 ]

In the meantime, one of the most recent structures that have been presented in the clarification of psychological and emotional disorders is to pay attention to the role and effect of feeling entrapment, which many people feel trapped and disability after suffering from chronic diseases such as MS. Entrapment describes a feeling of being stuck in an inescapable aversive situation.[ 10 ] This feeling often arises in the context of uncontrollable and/or chronic stress and is associated with various psychopathologies.[ 10 ] Feeling entrapment is a special thought and feeling that refers to a person being trapped in a situation that he wants to escape from.[ 11 ] Entrapment is the feeling of wanting to leave an unbearable situation but believing that there are no options to do so.[ 12 ] A person who experiences feeling entrapment thinks that his or her defensive behaviors are not effective. For this reason, he or she has to escape from his position; At the same time, he or she thinks that all possible ways for him or her to win this situation are blocked. Interest in resolving feeling entrapment includes psychological disorders and psychosocial aspects. To solve feeling entrapment, this phenomenon has been evaluated in several researches. Previous studies show that failure and trouble are closely related to different types of human psychology, such as depression, anxiety, and suicide.[ 13 , 14 ]

Receiving a diagnosis of multiple sclerosis makes accepting this chronic disease challenging, especially in the first years after diagnosis adapting psychosocially to living with the disease can be problematic during this initial time period as well.[ 15 ] It makes the affected person face many psychological challenges. Therefore, there are many psychotherapies to help chronic diseases reduce symptoms and help to accept and increase the skills of a person facing stressful factors with this disease.[ 16 , 17 ]

One contemporary approach is positive psychology. This approach studies both conditions and processes that allow individuals and communities to thrive. Positive psychology research focuses on examining strengths and virtues that enable human beings’ optimal development and performance.[ 18 ] One of the primary goals of positive psychology research is the development and evaluation of positive psychology interventions, which are mainly activities or treatment methods that cause well-being and optimal performance. In other words, they cultivate positive feelings, behaviors, or thoughts and include examples, such as gratitude exercises, exercises using personal strengths, and forgiveness. Positive psychological factors can play a role in buffering against mental illness, which may help strengthen future mental health.[ 19 ]

On the other hand, in the positive psychology intervention in which people with MS participated, the results were a significant increase in positive feelings, optimism, general health, and resilience in the intervention group compared to the control group, and at least 50% improvement in 10 weeks after they maintained the treatment.[ 20 ] In another study, in a five-week positive psychology intervention, a group of MS patients participated in four or more sessions in 82%. They reported improvement of fatigue (vitality) and reduction of depression after group intervention.[ 21 ]

Concerning what was mentioned, it is clear that multiple sclerosis is one of the chronic diseases that have a great impact on the quality of life of those suffering from this disease. Reducing the costs of treatment and controlling the disease to prevent its recurrence makes it necessary to use nonpharmacological psychotherapy approaches. This research was conducted with the aim of investigating positive psychotherapy, which increases distress tolerance and decreases feeling entrapment in MS patients.

Material and Methods

Study design and setting

This quasi-experimental study utilized an intervention and control group design with a one-month follow-up period. The research was conducted in Isfahan, Iran, in 2021. The study population consisted of patients with multiple sclerosis who were conveniently recruited via a call posted on the WhatsApp social media platform. Interested individuals were then referred to a neurologist’s office for screening and potential inclusion in the study. Eligible participants were randomly assigned to either the intervention or control condition.

Study participants and sampling

The statistical population included all multiple sclerosis patients who voluntarily registered during the visit to the neurologist’s office, as well as a call on the WhatsApp social network. Before the intervention, necessary explanations about the time of the research process were given to the subjects and after obtaining informed consent, the subjects entered the project.

The sample consisted of 30 patients (15 people in each group). The required sample size was estimated using G*Power 1.3 software. According to the values of the first type error (0.05 = prob err α) and the second type error, Power (1-β err pro Power) =0.95 (effect size f = 0.5 for each sample size) = actual power (this value is meaningful). In the next step, simple random sampling was used to place people in two experimental and control groups [ Figure 1 ] The sampling method for this project is available and based on the entry and exit criteria, they are randomly divided into two experimental and control groups.

Consort

Data collection tool and technique

The data was collected using distress tolerance and feeling entrapment questionnaires. This study was conducted according to the guidelines (CONSORT). The selected samples that met the criteria for entering the study were as follows: MS diagnosed by a specialist doctor, age range between 18 and 55 years, willingness and signature of a written consent form to participate in the research project, not suffering from any severe physical disease, severe neurological disorders, or the presence of symptoms of psychotic dissociation, and exclusion criteria: disease recurrence and inability to continue sessions, the absence of more than two sessions. Positive psychotherapy intervention was held in eight sessions of 90 min (two sessions per week) [ Table 1 ] as face-to-face sessions in a quiet environment. During the intervention, the control group was on the waiting list. After the last treatment session, the participants completed the questionnaires again. And finally, the data was analyzed based on multivariate analysis of covariance and SPSS 22 software.

Table 1 Treatment based on positive psychotherapy Session Objective Content of meetings - Pretest implementation First Familiarity with treatment Registration of a positive self-introduction on a page by referents Orienting clients in the framework of positive psychotherapy, the assumptions of this perspective, and the role of the psychotherapist Second Record the capability of each person by himself/herself Identifying personal capabilities, getting familiar with the classification of capabilities and moral virtues, and using personal capabilities in a new way. Third Counting blessings Remembering blessings by remembering three good (positive) things in daily life Planting positive emotions and mentioning blessings and good things in life Fourth Having meaning in life, using the technique of personal heritage Repeating the task done in the session. Reviewing whether writing three good things or three blessings and emphasizing positive reminders and memory during the past week had a positive effect. Fifth Gratitude technique to promote positive thoughts, feelings, and behavior Use the gratitude worksheet Focused on gratitude. Also, the role of bad and good memories was reexamined. Sixth Forgiveness and the practice of forgiveness letter Mid-treatment review. Clients reviewed their progress in writing notebooks and letters of forgiveness and gratitude and using their capabilities in practice based on their activity plans that started in the second session. Seventh Hope and optimism Noting three incidents or three things that they wanted to do but failed, then check whether there is another door or another solution in their way. Focusing on themes of hope, faith, and optimism, as well as practicing “one door closes, another door opens” Eighth Constructive and active response technique Satisfaction with life Using the technique of improving relationships and creating positive social relationships and happiness in life. Response style training and training to improve relationships, completion of questionnaires by participants

Treatment based on positive psychotherapy

Distress tolerance questionnaire (distress tolerance scale—DTS)

The DTS[ 7 ] is a 15-item self-report scale that assesses an individual’s ability to tolerate negative emotions. It consists of four subscales: appraisal of capacity and distress experienced (e.g., “I can tolerate being distressed or upset as well as most people”), absorption in one’s negative emotions (e.g., “When I feel distressed or upset, all I can think about is how bad I feel”), regulation of emotions (e.g., “I’ll do anything to stop feeling distressed or upset”), and tolerance of distressing emotions (e.g., “Feeling distressed or upset is unbearable to me”). Participants rate these items on a 5-point Likert scale that ranges from strongly agreeing to strongly disagreeing. The DTS is scored by calculating the mean score for each of the four subscales, and/or generating a mean total score (noting that item 6 requires reverse-coding). When interpreting DTS scores, lower DTS scores indicate a poorer ability to tolerate distress. The DTS demonstrated good test-retest reliability. In the current study, the DTS demonstrated good to excellent internal consistency in the current sample, α = 0.92 for the total score and α = 0.76–.86 for the DTS subscales.

Feeling entrapment questionnaire (feeling entrapment scale—Gilbert and Allan)

In both samples, the 16-item entrapment scale was administered to assess entrapment. This scale, which consists of two subscales (internal and external entrapment), was developed to assess entrapment within depressed samples.[ 11 ] This scale was initially developed to assess feelings of entrapment within the context of depression.[ 3 ] Respondents are asked to indicate on a 5-point scale (0 = “not at all like me,” 1 = “a bit like me,” 2 = moderately like me”, 3 = “quite a bit like me,” 4 = “extremely like me”), how much each statement applies to the respondent. The first 10 items are related to external entrapment, such as “I am in a situation I feel trapped in.” The last six items refer to internal entrapment (example: “I want to get away from myself”). The total score can range from 0 to 70.

Data analysis

Since the present research design is true experimental with heterogeneous groups, with pretest, posttest, and follow-up, the best statistical method for data analysis is the mixed-design analysis of variance (ANOVA) (factor analysis with repeated measures).

Results

The sample consisted of 30 participants randomized into two groups. The positive psychotherapy group included seven men (46%) and eight women (54%). The control group had eight men (54%) and seven women (46%). Regarding age, the positive psychotherapy group had a mean age of 33 years with a standard deviation of 4.65. The control group’s mean age was 33.67 years with a standard deviation of 5.27.

The types of multiple sclerosis (MS) and disease durations were reported for each study group. In the positive psychotherapy group, 40% had primary progressive MS, 40% had relapsing MS, and 20% had secondary progressive MS. Meanwhile, the control group comprised 26.66% with primary progressive MS, 46% with secondary progressive MS, and 26.66% with relapsing MS. Regarding disease duration, the control group had a mean of 6.4 years with a standard deviation of 3.29 years. The positive psychotherapy group’s mean disease duration was 7.33 years and the standard deviation was 4.13 years.

Table 2 displays the mean and standard deviation of statistical variables feelings of entrapment and distress tolerance scores at the three time points of evaluation for each study group. According to Table 2 , the mean feeling of entrapment in the positive psychotherapy group compared to the control group has a significant difference in all three stages of pretest, posttest, and follow-up. And the amount of feeling of entrapment in the posttest and follow-up compared to the pretest show a significant relationship. Also, the mean distress tolerance in the positive psychotherapy group compared to the control group has a significant difference in all three stages of pretest, posttest, and follow-up, and the level of distress tolerance in the posttest and follow-up shows a significant relationship compared to the pretest.

Table 2 Mean and Standard deviation of Statistical variables distress tolerance and feeling entrapment Statistical variables Level Group positive psychotherapy Group control (witness) Feeling entrapment Pretest 52/80 (16/13) 50/13 (17) Posttest 38/47 (18/44) 51/13 (16/50) Follow-up 38/93 (18/94) 51/33 (17/15) Distress tolerance Pretest 32/73 (6/67) 31/80 (7/39) Posttest 43/60 (9/77) 31/67 (8/49) Follow-up 42/27 (11/07) 31 (9)

Mean and Standard deviation of Statistical variables distress tolerance and feeling entrapment

Table 3 shows the results of the mixed ANOVA test for distress tolerance and feeling of entrapment. The results showed that positive psychology measurements have significant differences in three stages. According to Table 3 and the significance of the factor within the groups, there was a significant difference between the three measurements of pretest, posttest, and follow-up for the variables of distress tolerance (0/01), which has a significant relationship at the level of P < 0/05. The case of the variable of feeling entrapment (0/169) was obtained, which indicates the absence of a significant relationship at the level of P < 0/05; Also, the intragroup interaction effect in the distress tolerance variable (0/01), which is equal to the significance level of the study, has a significant relationship, and regarding the feeling entrapment variable (0/125), which is more than the significance level of the study, there is no significant relationship.

Table 3 Variance analysis (ANOVA) between subjects and within subjects with three measurements of pretest, posttest, and follow-up for distress tolerance and feeling entrapment Variables Source Scale Sum of squares Df Mean square
F
Sig Eta Statistical power Distress tolerate Intergroup Factor 681/63 1 681/63 7/82 0/013 0/358 1 Interactive effect 372/1 1 372/1 7/98 04/01 0/363 1 Error 1219/8 14 87/13 Between groups Group 70329/8 1 70329/8 545/434 0/001 0/975 1 Error 1805/2 14 128/94 Feeling entrapment Intergroup Factor 974/70 1 974/70 2/10 0/169 0/131 1 Interactive effect 448/90 1 448/90 2/66 0/125 0/160 1 Error 6480/8 14 462/91 Between groups Group 98000/0 1 98000/0 358/78 0/001 0/962 1 Error 3824/00 14 273/14 *The mean difference is significant at the 0/05 level

Variance analysis (ANOVA) between subjects and within subjects with three measurements of pretest, posttest, and follow-up for distress tolerance and feeling entrapment

*The mean difference is significant at the 0/05 level

Moreover, two-way comparisons of intragroup and intergroup differences were investigated using the Bonferroni test. Intragroup comparisons show that in the research variables, the mean of posttest and follow-up tests in the experimental group is significantly higher than that of the pretest group. Also, the difference between posttest and follow-up test scores is not significant. Intergroup comparisons show that there is a significant difference between posttest and follow-up scores in the intervention group focused on IU compared to both control groups [ Table 4 ].

Table 4 Bonferroni test to compare the mean tolerance of distress and feeling entrapped pairwise in time series Scale Stage A Stage B Mean difference (A-B) Standard error Sig 95% confidence interval Lower limit Upper limit Distress tolerance Pretest Posttest *-40/38 9/67 0/001 -13/91 −66/86 Follow-up *-45/32 9/67 0/017 32/22 −20/72 Posttest Follow-up *-70/18 9/67 0/001 -43/71 −96/66 Feeling entrapment Pretest Posttest *-41/37 9/67 0/017 20/72 −32/22 Follow-up *-46/13 9/67 0/001 -20/12 −72/15 Posttest Follow-up *-75/93 9/67 0/001 -49/92 −101/95

Bonferroni test to compare the mean tolerance of distress and feeling entrapped pairwise in time series

Discussion

This study showed that positive psychology is a practical and acceptable intervention that can affect emotional functioning and improve symptoms in patients with MS. The present study was conducted to investigate the effectiveness of positive psychology on distress tolerance and feeling entrapment in patients with multiple sclerosis. Our analysis showed that the amount of distress tolerance has increased significantly compared to the subjects in the control group and feeling entrapment has also decreased. The present results in this research are consistent with previous studies.[ 20 , 21 , 22 ]

Lee and Park[ 13 ] by increasing gratitude levels in people with MS, this may in turn lead to reduced perceived stress and mental health symptoms, which in turn may enhance their life satisfaction. The present study has a valuable contribution to the concepts of distress tolerance and its significant impact on accepting the pain and well-being of MS. In extensive studies, various concepts have been considered to describe distress tolerance, and the effects of distress tolerance are highlighted by the effects of emotions caused by disease injuries.

One of these concepts is uncertainty, and in this regard, the research conducted by Rahimi et al .[ 16 ] shows in a research that IU-based intervention can reduce psychological distress and improve the quality of life of MS patients. Accepting uncertainty can reduce the anxiety and stress of MS patients, which can increase the quality of life of these patients.[ 16 ] Since in many cases, stressful factors cannot be changed directly on the focused issue, increasing positive feelings can have a compensatory effect.[ 23 ] As a result, despite having minimal effects, positive psychotherapy can be helpful in coping with the disease’s distress, although the effects are small.[ 24 ] Additionally, Elliot et al .’s.[ 25 ] study demonstrates that there is significant heterogeneity in the emotional distress that people with chronic health conditions report. Interventions to increase distress tolerance are a comprehensive approach to chronic diseases to improve quality of life and overall health.[ 26 ] On the other hand, in the treatment of lack of distress tolerance, focusing on interventions and positive psychological resources is promising.[ 27 ] This study is consistent with the previous studies of Hruschak et al .,[ 28 ] GhotbinejhadBahre Asmani et al .[ 29 ]

Positive psychotherapy involves focusing on positive emotions, thoughts, and behaviors that improve mental health by increasing mental well-being and reducing psychological distress.[ 30 ] Feeling entrapment is one of the basic components of depression and anxiety[ 31 ] and the participants were taught about the effective mechanisms of positive psychotherapy during the sessions. Cultivating positive emotions is very important, which can act as a shield against negative experiences such as feeling trapped. By practicing components such as counting blessings, hope, and especially identifying strengths, positive psychotherapy can transform participants from passive and isolated individuals into their own people and help them accept adversities such as illness as a part of life. Know and be optimistic about life. Among the studies that are consistent with the results of our study, Otto et al .’s[ 27 ] positive psychology approaches hold promise to have large impacts on improving psychosocial outcomes for those coping with cancer. In the same vein, Sabouri et al .’s.[ 32 ] findings showed that positive thinking interventions could lead to improvements in hope and adherence to treatment in hemodialysis patients. Positive thinking training could be used in the care of hemodialysis patients to improve their hope and adherence to treatment. Pan et al .’s.[ 33 ] This meta-analysis demonstrates positive psychology is efficacious in treating most patients with depression or depressive symptoms.

Our findings are surprising and promising, considering the growing interest in using positive psychology interventions in different populations with specific clinical conditions. MS is a chronic disease without a known cure. People living with MS face ongoing health challenges. These can include anxiety, depression, and other mood disorders. MS symptoms may also worsen due to negative emotional states. Disease progression and relapses are long-term concerns for those with MS. Managing distressing emotions and feelings of entrapment may help address some challenges of the condition. Unlike traditional psychology, positive psychology tries to increase positive experiences instead of focusing on reducing negative emotions. By increasing positive experiences, it expands one’s perspective in a way that promotes constructive change and adaptive coping or prevents the situation from worsening.

Limitation and recommendation

This study had some limitations that should be addressed in future research. The sample size was small and participants were only recruited from Isfahan, limiting generalizability. Additionally, the follow-up period was short. Individual characteristics like personality traits and environmental factors were not accounted for as potential confounding variables. Given these limitations, larger trials are needed to validate the findings. Future studies could employ a larger sample recruited from multiple geographical and cultural areas. A longer follow-up duration would also allow for observing longer-term outcomes. Controlling for potential confounding personal and situational influences would help strengthen conclusions about treatment effects. Overall, more research is warranted to reproduce these promising initial results in broader populations over longer time periods.

Conclusion

In general, the findings indicate that positive psychotherapy may help people with MS more effectively treat their symptoms and improve both hidden and physical disabilities caused by the disease. By using positive psychology techniques, patients seemed to experience faster progress in managing issues. Therefore, it is recommended that mental health services and treatment centers incorporate this intervention into their short-term and long-term programs. Doing so could aid in preventing negative psychological effects often associated with living with MS. Further evaluating positive psychotherapy’s benefits is warranted.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

This article is taken from the doctoral thesis of the first author of the article and has the ethics committee code IR.UI.REC.1399.082. It should also be noted that this research has been registered on Iran’s clinical trial site with code IRCT20210808052113N1. All participants in this research are thanked and appreciated.

Funding Statement

Nil.

References