Comparison of the Effectiveness of Positive Thinking Group Training and Acceptance and Commitment Therapy on Psychological Well-being and Risky Behaviors of Patients with HIV

Abstract
Background: The purpose of the present study was to compare the effectiveness of positive thinking group training and acceptance and commitment therapy on psychological well-being and risky behaviors of patients with HIV.
Methods: A quasi-experimental pretest-posttest research method was used with a control group. Accordingly, 45 HIV patients, referring to Imam Khomeini Hospital in Tehran, were selected and randomly assigned to groups 1-3, including positive thinking (n=15), ACT (n=15), and control (n=15) groups, respectively. Scales of Psychological Well-being by Ryff (1989) and Risk Behaviors Standard Scale (2010) were administered for all three groups (pretest). Subsequently, the participants of the experimental groups attended eight 90-minute sessions of group training.  The posttest was performed two weeks after training. Multivariate and univariate analyses of variance (MANCOVA and ANCOVA) were used to analyze the data.
Results: The results showed that positive thinking group training was effective in promoting psychological well-being and reducing high-risk behaviors. The results also demonstrated that acceptance and commitment therapy was effective in promoting psychological well-being and reducing high-risk behaviors. According to the findings, there was no significant difference between the effectiveness of positive thinking group training and acceptance and commitment therapy on psychological well-being and risky behaviors of people living with HIV (p >0.05).
Conclusion: Both educational interventions (positive thinking and ACT approach) can increase psychological well-being and reduce high-risk behaviors of HIV+ patients, and there was no significant difference between the two intervention approaches. Therefore, both approaches have beneficial effects on improving the quality of life among people living with HIV.
Keywords: Acceptance and commitment therapy, HIV, Positive thinking, Risk taking, Social behavior

Introduction
Acquired Immunodeficiency Syndrome (AIDS) is a condition caused by infection with the Human Immunodeficiency Virus (HIV) and has recently become an epidemic that threatens the international community (1). HIV patients have limited access to occupation, educational and health services (2). Research shows that HIV is often stressful and affects the patients’ psychological well-being (3,4). According to Ryff (5), psychological well-being means striving for improvement, manifested in the realization of individual talents and abilities and formed by main dimensions of self-acceptance (positive attitudes towards the self and the past and present behaviors), purpose in life (a sense of directedness), personal growth (emphasizing the importance of continued development and realizing potentials), positive relations with others (empathy and mutual interpersonal relationships), environmental mastery (ability to choose or create contexts suitable to personal needs and values), and autonomy (ability to maintain personal standards and resist adaptation and internal control). Related research shows that HIV seems to have the greatest effect on psychological well-being compared to other chronic diseases and is a threatening factor to psychological well-being (6).
Risky behaviors are important for public health intervention because of their association with HIV infection. Not only do risky HIV-related behaviors contribute to disease transmission, but also their changes and patterns are among the main determining factors in the HIV epidemic within the community (7). Risky sexual behaviors are a major threat to the physical and social health of adolescence and young ages (8). According to several studies, people tend to reduce risky behaviors and show safer sexual behaviors after becoming aware of their disease (9,10). Research has shown that psychological interventions can be effective in reducing high-risk behaviors (11). Hence, it seems that HIV patients face many problems and challenges in individual and social life, necessitating psychological interventions to enable them to deal with the psychological and social problems of their disease.
Some treatment interventions are done in groups. Group therapy is done to promote mental development and reduce mental problems. The goals of promoting mental development and reducing psychological problems are achieved through cognitive and emotional exploration of interactions between members and therapist (12).
Positive psychology is one of the interventions considered by therapists in recent years. Positive psychology interventions aim to enhance positive emotions and pleasure, engagement, and purpose in life (13). Research has shown that the positive thinking approach decreases depression significantly while increasing happiness and a sense of mental comfort (14), as well as psychological well-being (15).
Acceptance and Commitment Therapy (ACT) is another psychological intervention that affects various psychological factors and has been considered by researchers because of its emphasis on psychological flexibility (16).  Empirical evidence for research in the field of the ACT approach indicates its effects on emotional and behavioral problems and disorders. For example, this treatment has been significantly effective in reducing disorders such as depression and anxiety (17), and stress and depression (18). It has also been shown to have a significant effect on psychological well-being and resilience (19).
Based on the results of previous research, acceptance, and commitment therapy, successful and standard intervention methods in correcting habits and improving and reducing psychological problems have been considered in other groups, but very limited investigations have been done on their effectiveness among HIV+ patients. No significant investigation has been implemented on the effectiveness of a positive approach on psychological problems. Thus, there was a need to implement extensive measures in this field. The, to the purpose of the current study was to find whether there is a difference between the effectiveness of positive thinking approaches and acceptance and commitment therapies in psychological well-being and risky behaviors of HIV patients in order to empower this population.

Materials and Methods 
The present research used a quasi-experimental method. The pretest-posttest design with control and experimental groups was used to compare the effectiveness of positive thinking group training and acceptance and commitment therapy on psychological well-being and risky behaviors of patients with HIV and also to test the research hypotheses. Accordingly, the research steps included random allocation of the subjects into control and two experimental groups, implementation of pretest, pretest data collection, administration of independent variables for the experimental group, implementation of posttest, and posttest data collection. The statistical population of the study included all patients with HIV who referred to the Behavioral Counseling Center of Imam Khomeini Hospital in Tehran and had a medical record. Therefore, out of all HIV patients who volunteered to  participate in the training program, 45 patients were matched (in terms of age, education, and socio-cultural conditions) and selected as the research sample through purposive sampling. Then, participants were randomly assigned to groups 1-3, including positive thinking (n=15), ACT (n=15), and control (n=15) groups, respectively (Figure1).
HIV infection, complete satisfaction for cooperation, absence of acute psychological disorders, no drug use, and being literate were considered as the inclusion criteria. Exclusion criteria were discontinuing cooperation with the researchers, absence of more than two sessions in the medical training, and taking psychiatric drugs. 

Psychological Well-being Scale 
This questionnaire was designed and developed by Ryff (20), to assess the psychological well-being of individuals. There are 54 questions and 6 components of autonomy, environmental mastery, personal growth, positive relationships with others, purpose in life, and self-acceptance, scored on a Likert 6-point scale from completely disagree (1), to completely agree (6). Items 3, 5, 7, 8, 10, 12, 13, 14, 16, 18, 20, 22, 24, 25, 26, 27, 30, 31, 32, 39, 40, 41, 43, 44, 46, 49, 50, and 54 are scored inversely. Next, the scores of the 54 questions are added together, the minimum and maximum of which are 54 and 324, respectively. Low, moderate, and high levels of psychological well-being are represented by scores 54-108, 108-216, and >216, respectively. Ekhbaraty and Bashardost (21), reported Cronbach’s alpha coefficient of 0.79 for this questionnaire and validity of the questionnaire has been approved by the researchers. The Persian version of this questionnaire was used from the www.madsg.com website.

Risk Behaviors Standard Scale
The Sexual Risk Behaviors Scale by Zarei et al (22), can be used to measure risky behaviors. This questionnaire consists of ten questions, the first eight of which are scored directly from 0 to 4 and the last two questions inversely from 0 to 3. The sum of these scores identifies individuals’ risky behaviors, with higher scores indicating higher levels of risky sexual behaviors. The reliability of the questionnaire was 0.68 by retesting method, and its Cronbach’s alpha was 0.86 (22). Also, Mirzapour (7), reported the reliability of the risky sexual behavior scale by Cronbach’s alpha of 0.84.

Training procedure 
The first intervention group received eight 90-minute sessions of positive thinking group training. To implement positive education, the book entitled “Positive Psychotherapy: Happiness, Treatment, and Promotion” (12), was used. table 1 summarizes the structure of these sessions. Acceptance and commitment therapy training was performed for the second intervention group in eight 90-minute group sessions once a week. table 2 shows a summary of acceptance and commitment therapy sessions.Post-test was performed for all three groups after two weeks training. Then, descriptive statistics, MANCOVA, and ANCOVA were used to analyze the collected data.

Table 1. Structure of positive thinking group training sessions

Table 2. Structure of acceptance and commitment therapy group sessions

Table 3. Demographic characteristics of the sample groups

Table 4. Inferential statistics indices used to calculate multivariate analysis of covariance

Table 5. Pairwise mean comparison of psychological well-being in terms of intervention approach from Bonferroni test

Table 6. Inferential statistics indices used to calculate multivariate analysis of covariance

Table 7. Pairwise mean comparison of risky behaviors in terms of intervention approach from Bonferroni test

Results
According to descriptive statistics and the difference between the pre-test and post-test of the components of psychological well-being and risky behaviors, the scores of the experimental group improved in the post-test while this difference was negligible in the control group. The value of Wilks Lambda in these variables was 0.002, and the value of Pillai’s Trace was 1.4. Since the significance level of these indicators is <0.01, there was a significant difference between the experimental and control groups in terms of the combination of dependent variables (psychological well-being and risky behaviors) in the research sample. table 3 shows the demographic characteristics of  the three groups.
According to the results shown in table 4, the calculated F for the experimental variable in all components of psychological well-being was greater than the critical value of F (with df and p<0.01). It can be concluded with 99% confidence that there was a significant difference between the mean of all components of psychological well-being in the experimental (exposed to the independent variable) and control groups in the study population. According to the calculated effect size, the independent variable can explain a high percentage of the variance in all components of the psychological well-being of the study sample.
The result of the F-test indicated a significant difference between the mean of all components of psychological well-being in terms of the intervention approach. Paired comparisons were conducted using the Bonferroni test. According to the results of table 5, the significance level of the Bonferroni test is <0.05. Therefore, it can be concluded that there was no significant difference between the means of psychological well-being components in positive thinking group therapy and acceptance and commitment therapy.
According to the results of  table 6, the calculated F for the experimental variable (125.97) was greater than the critical value of F (with df of 2.41 and p<0.01).  It can be concluded with 99% confidence that there was a significant difference between the mean of all components of risky behaviors in the experimental (exposed to the independent variable) and control groups in the study population. According to the calculated effect size, the independent variable can explain 86% of the variance of all components of risky behaviors in the study sample.
The result of the F test indicated a significant difference between the mean of all components of risky behaviors in terms of the intervention approach. Paired comparisons were conducted using the Bonferroni test. According to the results of table 7, the significance level of the Bonferroni test is <0.05. It can be concluded that there was no significant difference between the means of risky behaviors in positive thinking group therapy and acceptance and commitment therapy.

Discussion
The results demonstrated that there was a significant difference between the experimental and control groups in terms of psychological well-being of the study sample. According to the results of the study, it can be concluded that there is no significant difference between the effectiveness of the positive thinking group training approach and acceptance and commitment therapy in psychological well-being of HIV patients. In other words, both positive thinking group training and acceptance and commitment therapy affect the psychological well-being of HIV patients, and there is no significant difference between their effectiveness.
The results of the present study are consistent with the results obtained by Mostafa et al (11), Forgeard and Seligman (23), Satici (24), Yıldırım and Arslan (25), and Faezipour et al (18). Based on the results, it can be argued that both positive thinking group training and acceptance and commitment therapy promote the logical and cognitive thinking of individuals. The positive thinking group therapy teaches individuals to change their attitudes, respond to the problems of life, and not to focus on the losses by designing new programs such as setting goals, values, and giving meaning to sufferings. Thus, positive thinking training can promote six dimensions of psychological well-being (self-acceptance, autonomy, personal growth, positive relationships with others, environmental mastery, purpose in life, and personal growth) by changing the attitudes and thinking of HIV patients. During the course of acceptance and commitment therapy, participants are supposed to accept suffering as a part of the normal human experience. Patients can learn to be more adaptable to pain and correct their verbal associations with pain by accepting it as just another experience in life. This ability to use language can often alleviate problems (13). Consistent with the present study, Satici (24), also referred to positive thinking as an important source for individual psychological well-being and mental health. Having hope in positive people prevents negative thoughts and emotions that occur in unfavorable living circumstances. Besides, concentration on positive thoughts can enhance resilience in stressful life events. Therefore, hope and positive thinking reduce the negative effects of stressors and promote the mental well-being of individuals (25). Dambrun and Dubuy (26), showed that positive psychology reduces depression and anxiety and increases mental health, life satisfaction, and self-esteem. In line with the results of the present study, Forgeard and Seligman (23), examined the consequences of optimism and positive thinking and found that although optimistic people see negative events, they do not consider them coercive, leading to a constructive response to such events. They are also confident in dealing with problems. A positive thinker sees happiness, pleasure, health, and the successful outcomes of every situation or task.
The results showed that there was a significant difference between the experimental and control groups in terms of risky behaviors. According to the results of the study, it can be concluded that there is no significant difference between the effectiveness of the positive thinking group training approach and acceptance and commitment therapy in risky behaviors of HIV patients. In other words, both positive thinking and acceptance and commitment therapy decrease risky behaviors of HIV patients, and there is no significant difference between their effectiveness.
The results of the present study are in line with the results obtained by Reiter and Wilz (14), Lyubomirsky and Layous (15), and Yasaee seke et al (17). In explaining the results of the present study, it can be argued that patients become aware of the causes of their behaviors and try to improve their thoughts and attitudes when they receive acceptance and commitment therapy. Besides, the trust in the emotional support by loved one’s increases, and the lack of confidence decreases as HIV patients receive positive thinking training. Thus, positive thinking and acceptance and commitment therapy reduce the risky behaviors of HIV patients. Positive thinking training promotes self-awareness, while and purpose in life is considered as one of the foundations of positive psychology (27). Hence, HIV patients who receive positive thinking treatment can have a healthier life with higher levels of self-awareness, meaning, and purpose in life while they also experience the development of problem-solving abilities. Consistent with the results of this study, Reiter and Wilz (14), showed that positive psychology intervention reduces depression and feelings of stigma in HIV patients. On the other hand, acceptance and commitment therapy teaches individuals to respond to events more flexibly by reducing the undesirable functions of thoughts. Consequently, HIV patients can cope better with life problems and have higher levels of flexibility and resilience. Yasaee seke et al (17), showed that acceptance and commitment therapy could reduce depression and anxiety which confirms the results obtained in the present study. In general, according to the basic principle of acceptance and commitment approach, psychological sufferings usually prevent individuals from taking action based on the core values of their lives due to experiential avoidance. Acceptance and commitment therapy increases flexibility in responding to feelings and thoughts through the process of mindfulness, acceptance, and behavioral change (28). Thus, people who receive acceptance and commitment therapy and those undergoing positive thinking intervention can rationally control their emotions, which in turn reduces risky behaviors. 

Conclusion
Since this study was conducted on HIV patients, caution should be taken in generalizing the findings of the study to other groups. Besides, follow-up and long-time investigation of the effects of positive thinking intervention were not carried out due to time constraints. Other limitations of this research, which were beyond the control of the researchers, included the differences in personal, psychological, cultural, and social characteristics of the participants. Despite significant efforts, the effect of some factors such as the passage of time and experience of the subjects cannot be overlooked to control the confounding variables. Future studies should evaluate samples with other specific diseases and in other medical centers to further generalize the results. According to the results of the research, neither of the two interventions of positive thinking approach and acceptance and commitment therapy is superior to the other. Therefore, it is suggested that using therapeutic approach based on acceptance and commitment due to its underlying mechanisms such as acceptance, awareness raising, non-judgmental observation, and experiential avoidance by combining positivity techniques increase the effectiveness of treatment. It is recommended to teach the basic principles of positive thinking approach and acceptance and commitment therapy to the medical staff for treatment of specific diseases in medical centers.

Conflict of Interest
There is no conflict of interest. 
Acknowledgements
The authors thank the staff for their help. This article is extracted from the Ph.D. dissertation by Dr Pegah Mirzapour, Dr SeyedAhmad SeyedAlinaghi as the corresponding author, Dr Firoozeh Zangeneh Motlagh as the supervisor and Dr Esmaeil Mehraeen as the advisor, collaborated on this project. This study obtained its ethical approval from the Research committee of Islamic Azad University, Arak Branch Code: IR.IAU.ARAK.REC.1400.002.