The Effect of Short-Term Solution Focused Therapy on Distress Tolerance and Social Adjustment of Patients with MS in Sari

The present study aimed to investigate the effect of short-term solution focused therapy on distress tolerance and social adjustment of patients with MS (Multiple Sclerosis) in Sari. The sample of this study consisted of all MS patients in Sari who were members of MS society of Mazandaran province including 480 patients. Accordingly, two groups of 13 subjects, each including 10 women and 3 men, were randomly assigned into experimental group and control group. Using pretest and posttest, the effect of short-term solution focused therapy on the experimental group was investigated. For data collection, Distress Tolerance Scale (DTS) and Social Adjustment Scale (SAS) were used. Data were processed using analysis of covariance and the results confirmed research hypotheses. This means that short-term solution focused therapy increased distress tolerance and social adjustment of patients with MS.


Introduction
Multiple Sclerosis is a chronic progressive disease that destroys central nervous system myelin that influences sensory and motors functions [1]. According to the National Institute of Neurological Disorders and Stroke, about 25000-35000 people in the United States suffer from this disease (MS Society of America). In Iran, no accurate statistics of the number of patients exist. In 10 th International Congress of MS in Iran, the number of patients was estimated around 63000. MS Society of Iran, by 2010, identified about 15000 patients and the statistical indicators show that 65% of patients were young women and 35% were young and active males of the society [2].
Chronic diseases such as Multiple Sclerosis, in addition to creating physical problems, cause frequent psychological disorders for the patient. Stress as a multidimensional phenomenon can be the result of Multiple Sclerosis as well as an agent in intensifying the symptoms caused by the disease [3]. Also, stress can be threatening for the patient is some aspects such as divorce, losing job, and family conflicts [4]. Anxiety and depression are the major psychological disorders in patients with MS. The reason for high levels of depression and anxiety in these patients is unknown and a mixture of psychosocial and neurological factors are involved [5].
Distress tolerance is one of the usual constructs for studies on affective disorder. Distress tolerance is defined by person's ability in experiencing and tolerating negative emotional states [6]. Distress tolerance is an important structure in the development of new vision about mental disorders as well as prevention and treatment [7]. People with low distress tolerance in a wrong attempt to deal with negative emotions, involve in behavioral disorder [8]. Psychological distress is defined as a set of physiological and behavioral diseases such as anxiety, depression, restlessness, reduced intellectual ability, sleeping disorder, and absence from work. Psychological distress puts pressure on people around the patient and creates stress on the relationships between couples, children, and friends [9].
Another variable that is disrupted due to MS is social adjustment. Social adjustment means person's adjustment with the social environment that can be created by adapting the self to the environment to satisfy needs [10]. Lack of social relations that occurs due to undesired social adjustment can cause negative effect on incentive and psychological health of the person [11] and leads to weak psychological functioning such as feel guilty, negative self-concept, low self-esteem, isolation, and low life satisfaction [12].
Short-term solution focused therapy is one of the effective medical approaches to help those that suffer from stress. This approach is classified as a post-modern approach regarding behavioral interventions dependent on the cooperation between the therapist and authorities [13]. In this approach, instead of concentration on problems, solutions are emphasized [14]. Therefore, short-term solution focused therapy is based on making solutions and not problem solving and is directed through discovering current forces and optimism about the future [15]. This approach has been used in different situations such as couple therapy [16], family therapy [17], and intellectual disability therapy [18] and has provided efficient results. Sanaie, Davarnia, Bakhtiari, and Shakermi [19] investigated the effect of shortterm solution focused therapy on decreasing marital burnout and improving life quality of married women and showed that after short-term solution focused intervention, the burnout level of women in experimental group decreased. Reddy, Thirumoorthy, Vijayalakshmi, and Hamza [20] investigated the effect of short-term solution focused therapy on improving depression symptoms of a young girl with depression symptoms and showed that after intervention, depression symptoms were improved. In another study, Grant and Antoni [21] compared positive changes between solution focused therapy and problem focused therapy on 225 subjects and concluded that both methods are successful. Also, the results showed that solution focused therapy indicated better results compared to problem focused therapy.
According to the results of previous studies that indicate the effect of short-term solution focused therapy on improving most of psychological disorders, the present study aims to answer this question that can short-term solution focused therapy affect distress tolerance and social adjustment of patients with MS.

Method
The research method of this study includes pretest and posttest with control group. The population of this study included all MS patients in Sari who were members of MS Society of Sari and 480 were selected as the sample of this study.
Since 70% of patients were women and the rest were men, the numbers of women and men with MS is Sari were 336 and 144, respectively. According to the ratio, 21 women and 9 men between 30 and 40 years old were selected according to the classification method and were randomly assigned into experimental group (10 women and 5 men) and control group (11 women and 4 men). Finally, due to lack of cooperation and absence of some of them, two groups of 13 subjects were selected as experimental group and control group that each consisted of 10 women and 3 men. In this study, in order to investigate dependent variables, Distress Tolerance Scale (DTS) and Social Adjustment Scale (SAS) were used.

Distress Tolerance Scale (DTS)
THIS scale is a self-assessment index for emotional distress tolerance that was designed by Simons and Gaher [6]. The items of this scale assess distress tolerance based on individual abilities to tolerate emotional distress, mental assessment of distress, attention to negative emotions, and regulative measures to sedate distress. This scale is consisted of 15 articles and 4 sub-scales as emotional distress tolerance, attraction by negative emotions, mental estimation of distress, and efforts to decrease distress. The items of this scale are scored based on five-point Likert scale. High scores in this scale indicate high distress tolerance. Alpha coefficients for this sub-scale were 0.72, 0.82, 0.78, 0.70 and 0.82. Internal consistency after six months was 0.61. Also, it was specified that this scale has acceptable criterion validity. This scale has a positive relationship with positive behavior and shows negative relationship with coping strategies regarding alcohol and marijuana. In a study by Anadamikhoshk [22], the Cronbach's alpha of this scale was obtained as 0.86.

Social Adjustment Scale (SAS)
THIS scale is designed to assess drug treatment and psychotherapy of depressed patients. By now, this scale is widely used to assess the adjustment of patients and healthy individuals [23]. This scale assesses interpersonal relationships in various roles such as emotions, satisfaction, disputes, and performance. The structure of this scale shows two different dimensions. This questionnaire was translated and introduced by Mirzamani [24]. This 54-item scale is a semi-structured interview that includes social adjustment in adjustment areas in occupation, social activities (leisure), relationships, marital relations, parenthood, and total social adjustment. High score in each subscale indicates low social adjustment of subjects in the area of interest [25]. Koohsali et al. [25] used this questionnaire in a study and estimated the Cronbach's alpha (0.93). Also, to determine validity, correlation coefficient was used that showed correlation level between 0.32 and 0.98. The details of therapy sessions that included 5 sessions of 40 minutes (1 session per week in 5 consecutive weeks) is presented in Table 1. It should be noted that to observe moral issues in the present study, after the interventions, a short period including 3 short-term solution focused therapy sessions was held for subjects in Adjustment of Patients with MS in Sari control group. After introducing themselves, distress tolerance and its theoretical foundations are described and intervening factors are explained. Then, the subjects are asked to comment about what was discussed and say which one of these factors affect distress tolerance. Then, the concept of social adjustment and decision-making styles were described and subjects received factors affecting decision-making styles and lack of social adjustment and they were asked to write down their factors affecting their distress tolerance and social adjustment. Then, short-term solution focused therapy was described and the research goals were clarified. The subjects were asked to write down their own opinions about distress tolerance and social adjustment.

Second
Restatement of goals and starting the process with the intervention and activities of subjects In this session, short-term solution focused therapy was described again and foals were determined. Subjects prepared treatment goals with the help of researcher and their implementation was discussed, so that at the end of the session, subjects had different homework consistent with their goals.

Third to fifth
Reviewing the goals and receiving feedback about practical actions and determination of new goals or reviewing them At this step, in addition to reviewing previous sessions and controlling plans and goals, control measures were implemented and weak points were assessed and solved by active participation of the subjects as well as group work and supports provided by the researcher to complete and review goals and writing new practical measures by the subjects for each of them and on time control.
To analyze data, descriptive statistics methods including mean comparison diagram of pretest and posttest, t-test for independent groups, and analysis of covariance were used. It should be noted that for statistical analyses in this study, SPSS was used.

Findings
In this section, consistent with the research goals and questions, the results of questionnaires and related measures are classified. Generally, the findings are presented in two parts: From 26 subjects that answered the questionnaire, 3 subjects from experimental group and 6 subjects from control group had diploma and AD, 5 subjects from experimental group and 5 subjects from control group had BA, and 5 subjects from experimental group and 2 subjects from control group had MA. Also, 10 subjects from experimental group and were female and 3 subjects were male. As can be seen from Table 3, mean and standard deviation of research variables after short-term solution focused therapy are better than before short-term solution focused therapy (it should be noted that in social adjustment, low score after intervention indicates improvement in the variable).

Inferential Analysis of Data
H1: short-term solution focused therapy influences distress tolerance of MS patients. As can be seen, (Eta-0.86, p-0.00, F (1, 26)-142. 22) show that there is a difference between two groups. In other words, there is a significant difference between experimental group and control group in posttest. Eta-0.86 shows that 0.86% of improvement in distress tolerance of MS patients in experimental group can be related to the effect of short-term solution focused therapy on distress tolerance of patients. The results of Bonferroni test show that there is a significant difference between experimental group and control group in terms of distress tolerance after intervention (p<0.05).
H2: short-term solution focused therapy influences social adjustment of MS patients. As can be seen, (Eta-0.47, p-0.00, F (1, 26)-20.55) show that there is a difference between two groups. In other words, there is a significant difference between experimental group and control group in posttest. Eta-0.47 shows that 47% of improvement in social adjustment of MS patients in experimental group can be related to the effect of short-term solution focused therapy on social adjustment of patients. The results of Bonferroni test show that there is a significant difference between experimental group and control group in terms of social adjustment after intervention (p<0.05).

Discussion
The findings of this study show that the use of short-term solution focused therapy can improve social adjustment and distress tolerance in patients with MS. Regarding the first hypothesis, comparison of means from two groups showed positive effects; therefore, short-term solution focused therapy increased distress tolerance of subjects in experimental group. This is consistent with the results of studies by Dashtizadeh et al. [26], Dahl [27], and Spilsbury [28] who investigated the effect of short-term solution focused on decreasing depression and anxiety symptoms. The results confirm the second hypothesis of this study. Social adjustment in people in experimental group was improved after intervention. These results are consistent with the results of a study by Yonesi et al. [29] and both studies confirm the efficiency of solution focused therapy. Finally, it should be noted that many studies are consistent with this study such as Sehhat [30], Davoodi and Bahrami [31], Shakermi [32], Dashtizadeh et al. [26], Lindfors [33], Bond [34] and Smith [35]. Solution focused therapy model looks at subjects as experts who can solve their problems and considers treatment as a process that helps therapist to recover optimal realities [36]. Short-term solution focused therapy concentrates on effective solutions for challenging situations to strengthen patients for discovering solutions for problems and to repeat effective behaviors that form the solutions for research purposes [37]. One of the key interventions of solution focused therapy for stress is to find exceptions for stress. Finding the intervals that are free from stress can be efficient in restructuring patients' understanding of choices and their environment [38]. According to the problem/exception of solution focused therapy, distress is conceptualized as distress/lack of distress. In other words, distress has a distinctive point that is distress-free moments. In this approach, it is assumed that distress preserves itself to a large extent, because authorities consider it as a common event. Miracle questions are effective intervention is distress tolerance, because they force authorities to concentrate of effective aspects [39].
Solution focused therapy is among short-term approaches that provides immediate medical results for patients; therefore, for those patients that ask immediate treatment, this approach is suitable. This should be stated that simple and effective techniques of this model can be easily taught and improve optimism in patients. According to the results of this study and similar studies in this regard, it is suggested that family and marriage counselors should use this approach to help patients reach their goals in short period of time. Also, it is suggested that this approach can be effective in decreasing psychological problems. According to the limitations in sample size in this study, to clarify the effects of this approach, studies with larger sample size should be conducted and include demographic variable as well. The limitations of this study consisted of topic, variables, time, sample size, age, and other demographic variables. Since the