The Effectiveness of Group Positive-Therapy (PPT) and Well-Being Therapy (WBT) on Attitude towards Drug Abuse in Patients under Methadone Maintenance Therapy

Treatment of substance abuse has been associated with many challenges. The aim of this study is to compare the effectiveness of group positive therapy (PPT) and well-being therapy (WBT) on attitude towards drug abuse in patients under methadone maintenance therapy. The present study is a quasi-experimental with pre-test and post test analysis and control group. The population was including all substance abusers in the city of Lavasan who were resident in the clinics center of city Lavasan. Participants included thirty-six men who were eligible for the study were chosen by random selection method and randomly allocated in three groups. Two groups received positive psychotherapy (PPT) and well-being therapy (WBT) for 2 months, 14 sessions of 1hours (Two times a week), while the control group received no therapy at all. Data were collected by Questionnaire of attitude to drug which was given to the test subjects before and after completion of the therapy. The collected data was put to one way variance analysis and Scheffe’s test. The study demonstrated that group positive therapy and well-being therapy had positive effects on the attitude towards drug abuse improvement in both groups who received interventions ( P<0.00001, F =16.03) in comparison to the control group. Actually, both methods were effective in boosting attitude towards drug. Both positive therapy and well-being therapy methods were found effective in decrease attitude towards drug abuse in patients under methadone maintenance therapy but have not a significant difference between the effectiveness positive-therapy and well-being therapy. purpose to compare the effectiveness of positive-oriented treatment (PPT) Well-being therapy (WBT) as a group on the changing attitudes of patients treated with methadone to drug abuse. The results showed that the positive- oriented and well-being treatment had no significant difference in reducing drug attitudes, but both treatments had significant effect compared to the control group. Changing attitudes to drug was the factor that led the of drug or vice versa discouraged them from using drugs 2002). It both create positive to change their attitude of attitude

combination with cognitive behavioral therapy (Fava, Rafanelli, Cazzaro, Conti, Grandi, 1998). Well-being therapy is organized in a short-term therapy plan (eight sessions) and is guiding and problem-focused and based on the model of psychological well-being of the Ryff (Ryff, 1989) in which self-concept, regular memorial writing and interactions of the client and the therapist are used to increase the client's psychological well-being (Peterson, Seligman, 2004). Ryff psychological pattern (Ryff, 1989) has six dimensions, including environmental mastery, personal growth, and purpose of life, autonomy, self-acceptance and positive relationships with others. The purpose of the use of therapist is to help the clients to reach high levels of psychological wellbeing from lower levels of functioning in all six areas of interest, (Fava et al, 1998). Therapist helps the clients to contribute to their optimum functional level from the impairment of the function and their past experience well-being in their life. These experiences are valuable no matter how short. After Clients were informed fully of well-being cases in their lives, in the next stage of therapy, they are helped to identify their beliefs and thoughts that disturb the well-being experience and also their feelings and well-being (Fava et al, 1998). This phase of treatment of identifying the automatic thoughts or irrational beliefs is similar to conventional cognitive therapy (Rafanelli, Park, Fava, 1999).The difference is that in the well-being therapy, client's self-concept of his thoughts are more based on well-being than on the problems and tensions. And in general, the main methods to help the clients to overcome shortcomings in the psychological well-being include automatic thoughts, cognitive restructuring, the timing of activities that produce a sense of mastery and control or pleasure, education, assertiveness, courage and problem solving (Ruini, Fava, 2004). Therefore, due to the significant prevalence of drug use in Iran, this study aimed to compare the effectiveness of positive-oriented psychological treatment (PPT) with well-being therapy (WBT) in group on attitudes to drug abuse in the addicts were treated with methadone.

METHOD
The present research was a quasi-experimental study using pre-test and post-test with control group. The study population comprised all male addicts treated with methadone maintenance during the winter of 2014 who referred to the methadone maintenance treatment centers in Lavasanat city, Iran. And they were diagnosed having impairment dependence on opiates (opium syrup and crystals) using structured clinical interview conducted by a clinical psychologist according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria and were in the methadone maintenance treatment center.
From the population, 39 males were selected and randomly assigned to three groups: positiveoriented treatment (13), well-being (13) and control group (n = 13), respectively. During the course of treatment in experimental groups, 2 left before the end of the study, treatment. In the control group, 1 person did not participate in the test. The final number of participants in the positively oriented treatment group was 12 patients, 12 patients in group well-being treatment group and 12 patients were in the control groups which were replaced randomly in groups 1 to 3. Entry criteria were: 1) age range between 20-50 years, 2) a minimum level of literacy 3) a history of abuse between 1-10 years 4) the amount of methadone prescribed (60 to 120 mg daily in a period of consolidation). Exclusion criteria were as follows: 1) dependence on other materials at the same time 2) personality disorders, retardation or severe mental disorders 3) severe physical diseases. Also, the two groups were homogeneous in terms of social class, age and experience and the possible effect of these variables on the dependent variable was removed. In this study, a demographic questionnaire, the Structured Clinical Interview for Disorders IV.DSM-(SCID) and Drug Attitude Inventory (Rezai, Delaware, Najafi, 2012) were used. Demographic questionnaire was used by the researcher to collect personal information such as age, education, socioeconomic status, history of diabetes, history of substance abuse treatment and preparation time. Structured Clinical Interview for Disorders DSM -IV (SCID) is a clinical interview used for the diagnosis of a disorder according to DSM -IV. The coefficient of inter-rater reliability for SCID has been reported 0.60 (First, Spitzer, Gibbon, Williams, 2002). Diagnostic agreement of this instrument in Persian has been good for most specific and overall diagnosis with higher reliability of 0.60.
Kappa coefficients for the current and lifetime diagnosis were obtained as 0.52 and 0.55, respectively (sharifi et al, 2009).
Drug Attitude Inventory is made by Rezaiee, Delaware and Najafi (Rezai, Delaware, Najafi, 2012) and includes 40 questions with 5 options based on the Likert scale (strongly agree, agree, no comment, disagree, strongly disagree) and consists of three components: attitude the effects of drug use, attitudes toward the dangers of drug use and attitudes toward drug use. Validity of the questionnaire was obtained using principal components analysis and direct varimax rotation and oblimin method. The results of varimax rotation showed that these three factors determine the 27/44% of the total variance of the questionnaire. 18.7% of the variance is related to the first component (attitude toward the drug), 41/17% of the variance to the second component (attitude toward drug use) and 15.8% of the variance was related to the third component (attitude toward risks Drugs). The results of the direct oblimin rotation also showed that the equity of the first component was 39/9, second component 20/9 and the third component was 99/4 (Rezai, Delaware, Najafi, 2012).

PROCEDURE
The present study was conducted in one of the Methadone maintenance treatment centers of Lavasanat, Iran by a clinical psychologist. Research ethical standards were established as written informed consent of the sessions and the condition to leave the study at any point, the participants' privacy, and protection of their well-being and comfort for all participants. In this design, intervention (three levels: positive-oriented treatment group, the well-being treatment group and control) was considered as the independent variable and attitude towards drug abuse as the dependent variable. Positive-oriented intervention was proposed by Rashid  and had the four components of pleasure, engagement, meaning and perfect life. Further, well-being treatment offered by Reef was implemented in group for 14 sessions, twice a week for one hour.
After the sessions, all participants in both groups were evaluated by the scale drug attitude and rate of change in the index was also evaluated. ANOVA and Scheffe post hoc test were used to compare the three independent variables (both intervention and control) on the dependent variable (attitude toward substance abuse). The basic hypotheses of this approach include variance equality and non-significant Levene's' test (p= <0.05), normality of the dependent variable and the linear relationship between the dependent and mediator variable which were obtained testing the research hypotheses. Data were analyzed using SPSS software version 18. Compact guide of the positive oriented and well-being treatment sessions is briefly presented based on the sessions order (table 1).
Both the first and second sessions included the clinical interview, referrals, mutual duties description and familiarity with the process and therapy and the final session was devoted to separation from the group and the results of evaluations. In the third session storytelling abilities and emotional (Pennebaker, 2012;King, Miner, 2000) were discussed. Therefore, it is better that the researcher knows about the ability of the twenty-four questionnaires VIA (Peterson, Seligman, 2004), thirty-five talent-finding capabilities of Clifton 2 (Rath, 2007) and also be familiar with cultural capabilities. Growing ability to express emotions and treatment were discussed in the fourth and fifth meetings. The sixth meeting devoted to the writing task based on forgiveness, but forgiveness did not mean forgetting, apologize or ask forgiveness of the offenders and the purpose was not reconciliation and peace (Enright, Coyle, 1998;McCullough, Witvliet, 2002;Seligman, 2002). But forgiveness is an action taken for him and to reduce psychological stress out and in case of not forgiving; his health might be at risk while the guilty person is not suffering from any disease (van Oyen Witvliet, Ludwig, Vander Laan, 2001). The idea to see and appreciate a person in general, can reduce the intensity of the hatred and accelerates the process of forgiveness (Reivich, 2004). Generous people have better mental health (Krause, Ellison, 2003).Understanding the thanksgiving structure at the seventh session is the confessional to the fact that there is something good and pleasurable in this world (Emmons, 2007). Thanksgiving is associated with positive psychological, physical and interpersonal outcomes (Emmons, McCullough, 2003) and requires attention to people and things that are often ignored or neglected (Snyder, Lopez, 2007). People who are thankful have higher levels of happiness and lower depression (Seligman et al, 2005).
Today, it is undisputed that thanksgiving is an incentive for friendship or prosocial behavior (socially desirable behavior) (Bartlett, DeSteno, 2006). Ninth session is based on the training content to the maximum (Schwartz, Ward, Monterosso, Lyubomirsky, White, 2002). At this stage, the trainee is encouraged for sufficient satisfaction rather than the maximum. Activeconstructive responding (Gable, Reis, Impett, Asher, 2004) in session ten had many advantages for the patient and those interacting with him. The studies confirmed that those who interact with others in active-constructive way, report more happiness and daily joy and satisfaction and have more confidence and show little difference in their relationships (ibid). The fun activity  on twelfth session means an activity that involves the patients completely, so that they can use their individual capacity (Seligman, 2004). Moreover, the use of Enjoy techniques (tasting pleasure) increases positive experiences (Seligman, 2002;Bryant, Veroff, 2002). The pre-final session is devoted to the full meaning of life and the final session is for the separation from the treatment groups and providing feedback from clinical evaluation and interventions. The content of each session included a review of the previous session assignments, discussions, exercises and presentations of assignments for the next session.

RESULTS
The data were analyzed in both descriptive (mean, standard deviation) and inferential statistics (ANOVA test and Scheffe post hoc test) using SPSS software version 18, which are shown in the following tables. In Table 3, the demographic of the sample is provided in terms of educational levels and marital status. Table 4 shows the descriptive data consisted of the average, minimum and maximum scores in the three groups. The lowest and highest average in the pre-test was devoted to the positiveoriented group and in post-test was devoted to the well-being treatment and control group. In Table 5, the results of ANOVA of attitude to drugs are presented.
Considering the results of Table 5, there was a significant difference in the variance of scores in the three groups (df = 2/33, F = 16/03, P > 0.0001).
Scheffe's test was used to compare the mean scores of attitude to drug in three groups and the results are presented in Table 6.
According to the results, there is no significant difference between positive-oriented treatment and well-being groups at 99% confidence level (P=0.208), but the positive-oriented treatment group and the control group (P< 0.0001) and the well-being treatment and the control group (P=0.002) had significant differences in their attitude to drug.

CONCLUSION
Today, the positive -oriented treatment tries to create reconciliation between logic and emotion and acts as a complement to traditional treatments in clinical psychology, which is mainly damage-oriented approach. The future task of positive-oriented psychology is to understand the factors that make capabilities. The positive-oriented psychology requires the development of effective interventions for enhancing these potentials. This study was also conducted regarding the change from the problem focused approach to capability development approach. Positive- oriented psychology and well-being treatment are emerging approach extracted from within the CBT, developed and validated by several clinical trials. They are considered as the most widely used cognitive-behavioral therapy approaches to treat addiction (Curry et al, 2001) and help these patients to deal effectively with problematic behavior by training techniques (Mollazadeh, Ashuri, 2009). The purpose of this study was to compare the effectiveness of positive-oriented treatment (PPT) Well-being therapy (WBT) as a group on the changing attitudes of patients treated with methadone to drug abuse. The results showed that the positive-oriented and wellbeing treatment had no significant difference in reducing drug attitudes, but both treatments had significant effect compared to the control group. Changing attitudes to drug was the factor that led addicts to the use of drug or vice versa discouraged them from using drugs (Ellis, 2002). It seems that both treatments have been able to create positive emotions to change their attitude towards drug use. The objective of this study was to create a negative attitude towards addiction. However, after reviewing the research literature, the researcher could not find a similar study but other researchers also confirmed the impact of cognitive behavioral therapy in patients with drug dependence (Fierro, 2009;Kathleen, 2002;Ashouri, Mollazadeh, Mohammadi, 2008;Nick, 2006;Ahghar, 2010;Momeni, Moshtagh-e-Beydokhti, Pourshahbaz, 2010;Dabaghi, Asgharnezhad, Atef Vahid, Bolhari, 2008;Jafari, Shahidi, Abedin, 2009). Cognitive-behavioral approach is a strategy which leads to change in thinking, reducing irrational beliefs and negative attitudes toward drug. The cognitive and behavioral interventions can be effective against drug-using false beliefs (Abolghasemi, Ahmadi, Kiamarsi, 2007;Alizadehsahraei, Khosravi, Besharat, 2010). The effectiveness positive-oriented psychotherapy was approved in the treatment of depression and creating happiness symptoms either in a group or individually (Seligman, Rashid, Parks, 2006). And the summarized and group from of the study in school children lead to increase in their wellbeing (Rashid, Anjum, 2008). The research results indicated the effectiveness and efficiency of therapy in the treatment of emotional disorders and emotional well-being (Fava et al, 1998;Fava, Tomba, 2009;Moeenizadeh, Kumar, 2010), stress reduction (Golbaryazdy, Sharbaf, Moyinizadeh, 2012) and the treatment of panic (Fava et al, 1998), respectively. The purpose of this study was to compare the effectiveness of positive-oriented treatment (PPT) Well-being therapy (WBT) as a group on the changing attitudes of patients treated with methadone to drug abuse. The results showed that the positive-oriented and well-being treatment had no significant difference in reducing drug attitudes, but both treatments had significant effect compared to the control group. A limitation of this study was the difficulty in making time coordination to participate in therapy sessions. In the end, it is recommended that positive -oriented and wellbeing treatment are examined for change in women's attitude toward drug use.

LIMITATIONS
This study has particular limitations. The first limitation of this study is a small sample size. Although the number of participants did not decrease in this study but small sample size is one of its limitation s that obstacles accurate measurement of program effect. The second limitation is related to using self-report tools. These tools have some essential problems