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October 2017 -
Volume 15, Issue 8

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From the Editor

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Original Contribution/Clinical Investigation

Immunity level to diphtheria in beta thalassemia patients
DOI: 10.5742/MEWFM.2017.93048
[pdf version]
Abdolreza Sotoodeh Jahromi, Karamatollah Rahmanian, Abdolali Sapidkar, Hassan Zabetian, Alireza Yusefi, Farshid Kafilzadeh, Mohammad Kargar, Marzieh Jamalidoust,
Abdolhossein Madani

Genetic Variants of Toll Like Receptor-4 in Patients with Premature Coronary Artery Disease, South of Iran
DOI: 10.5742/MEWFM.2017.93049
[pdf version]
Saeideh Erfanian, Mohammad Shojaei, Fatemeh Mehdizadeh, Abdolreza Sotoodeh Jahromi, Abdolhossein Madani, Mohammad Hojjat-Farsangi

Comparison of postoperative bleeding in patients undergoing coronary artery bypass surgery in two groups taking aspirin and aspirin plus CLS clopidogrel
DOI: 10.5742/MEWFM.2017.93050
[pdf version]
Ali Pooria, Hassan Teimouri, Mostafa Cheraghi, Babak Baharvand Ahmadi, Mehrdad Namdari, Reza Alipoor

Comparison of lower uterine segment thickness among nulliparous pregnant women without uterine scar and pregnant women with previous cesarean section: ultrasound study
DOI: 10.5742/MEWFM.2017.93051
[pdf version]
Taravat Fakheri, Irandokht Alimohammadi, Nazanin Farshchian, Maryam Hematti,
Anisodowleh Nankali, Farahnaz Keshavarzi, Soheil Saeidiborojeni

Effect of Environmental and Behavioral Interventions on Physiological and Behavioral Responses of Premature Neonates Candidates Admitted for Intravenous Catheter Insertion in Neonatal Intensive Care Units
DOI: 10.5742/MEWFM.2017.93052
[pdf version]
Shohreh Taheri, Maryam Marofi, Anahita Masoumpoor, Malihe Nasiri

Effect of 8 weeks Rhythmic aerobic exercise on serum Resistin and body mass index of overweight and obese women
DOI: 10.5742/MEWFM.2017.93053
[pdf version]
Khadijeh Molaei, Ahmad Shahdadi, Reza Delavar

Study of changes in leptin and body mass composition with overweight and obesity following 8 weeks of Aerobic exercise
DOI: 10.5742/MEWFM.2017.93054
[pdf version]
Khadijeh Molaei, Abbas Salehikia

A reassessment of factor structure of the Short Form Health Survey (SF-36): A comparative approach
DOI: 10.5742/MEWFM.2017.93088
[pdf version]
Vida Alizad, Manouchehr Azkhosh, Ali Asgari, Karyn Gonano

Population and Community Studies

Evaluation of seizures in pregnant women in Kerman - Iran
DOI: 10.5742/MEWFM.2017.93056
[pdf version]
Hossein Ali Ebrahimi, Elahe Arabpour, Kaveh Shafeie, Narges Khanjani

Studying the relation of quality work life with socio-economic status and general health among the employees of Tehran University of Medical Sciences (TUMS) in 2015
DOI: 10.5742/MEWFM.2017.93057
[pdf version]
Hossein Dargahi, Samereh Yaghobian, Seyedeh Hoda Mousavi, Majid Shekari Darbandi, Soheil Mokhtari, Mohsen Mohammadi, Seyede Fateme Hosseini

Factors that encourage early marriage and motherhood from the perspective of Iranian adolescent mothers: a qualitative study
DOI: 10.5742/MEWFM.2017.93058
[pdf version]
Maasoumeh Mangeli, Masoud Rayyani, Mohammad Ali Cheraghi, Batool Tirgari

The Effectiveness of Cognitive-Existential Group Therapy on Reducing Existential Anxiety in the Elderly
DOI: 10.5742/MEWFM.2017.93059
[pdf version]
Somayeh Barekati, Bahman Bahmani, Maede Naghiyaaee, Mahgam Afrasiabi, Roya Marsa

Post-mortem Distribution of Morphine in Cadavers Body Fluids
DOI: 10.5742/MEWFM.2017.93060
[pdf version]
Ramin Elmi, Mitra Akbari, Jaber Gharehdaghi, Ardeshir Sheikhazadi, Saeed Padidar, Shirin Elmi

Application of Social Networks to Support Students' Language Learning Skills in Blended Approach
DOI: 10.5742/MEWFM.2017.93061
[pdf version]
Fatemeh Jafarkhani, Zahra Jamebozorg, Maryam Brahman

The Relationship between Chronic Pain and Obesity: The Mediating Role of Anxiety
DOI: 10.5742/MEWFM.2017.93062
[pdf version]
Leila Shateri, Hamid Shamsipour, Zahra Hoshyari, Elnaz Mousavi, Leila Saleck, Faezeh Ojagh

Implementation status of moral codes among nurses
DOI: 10.5742/MEWFM.2017.93063
[pdf version]
Maryam Ban, Hojat Zareh Houshyari Khah, Marzieh Ghassemi, Sajedeh Mousaviasl, Mohammad Khavasi, Narjes Asadi, Mohammad Amin Harizavi, Saeedeh Elhami

The comparison of quality of life, self-efficacy and resiliency in infertile and fertile women
DOI: 10.5742/MEWFM.2017.93064
[pdf version]
Mahya Shamsi Sani, Mohammadreza Tamannaeifar

Brain MRI Findings in Children (2-4 years old) with Autism

DOI: 10.5742/MEWFM.2017.93055
[pdf version]
Mohammad Hasan Mohammadi, Farah Ashraf Zadeh, Javad Akhondian, Maryam Hojjati,
Mehdi Momennezhad

Reviews

TECTA gene function and hearing: a review

DOI: 10.5742/MEWFM.2017.93065
[pdf version]
Morteza Hashemzadeh-Chaleshtori, Fahimeh Moradi, Raziyeh Karami-Eshkaftaki,
Samira Asgharzade

Mandibular canal & its incisive branch: A CBCT study
DOI: 10.5742/MEWFM.2017.93066
[pdf version]
Sina Haghanifar, Ehsan Moudi, Ali Bijani, Somayyehsadat Lavasani, Ahmadreza Lameh

The role of Astronomy education in daily life
DOI: 10.5742/MEWFM.2017.93067
[pdf version]
Ashrafoalsadat Shekarbaghani

Human brain functional connectivity in resting-state fMRI data across the range of weeks
DOI: 10.5742/MEWFM.2017.93068
[pdf version]
Nasrin Borumandnia, Hamid Alavi Majd, Farid Zayeri, Ahmad Reza Baghestani,
Mohammad Tabatabaee, Fariborz Faegh

International Health Affairs

A brief review of the components of national strategies for suicide prevention suggested by the World Health Organization
DOI: 10.5742/MEWFM.2017.93069
[pdf version]
Mohsen Rezaeian

Education and Training

Evaluating the Process of Recruiting Faculty Members in Universities and Higher Education and Research Institutes Affiliated to Ministry of Health and Medical Education in Iran
DOI: 10.5742/MEWFM.2017.93070
[pdf version]
Abdolreza Gilavand

Comparison of spiritual well-being and social health among the students attending group and individual religious rites
DOI: 10.5742/MEWFM.2017.93071
[pdf version]
Masoud Nikfarjam, Saeid Heidari-Soureshjani, Abolfazl Khoshdel, Parisa Asmand, Forouzan Ganji

A Comparative Study of Motivation for Major Choices between Nursing and Midwifery Students at Bushehr University of Medical Sciences
DOI: 10.5742/MEWFM.2017.93072
[pdf version]
Farzaneh Norouzi, Shahnaz Pouladi, Razieh Bagherzadeh

Clinical Research and Methods

Barriers to the management of ventilator-associated pneumonia: A qualitative study of critical care nurses' experiences
DOI: 10.5742/MEWFM.2017.93073
[pdf version]
Fereshteh Rashnou, Tahereh Toulabi, Shirin Hasanvand, Mohammad Javad Tarrahi

Clinical Risk Index for Neonates II score for the prediction of mortality risk in premature neonates with very low birth weight
DOI: 10.5742/MEWFM.2017.93074
[pdf version]
Azadeh Jafrasteh, Parastoo Baharvand, Fatemeh Karami

Effect of pre-colporrhaphic physiotherapy on the outcomes of women with pelvic organ prolapse
DOI: 10.5742/MEWFM.2017.93075
[pdf version]
Mahnaz Yavangi, Tahereh Mahmoodvand, Saeid Heidari-Soureshjani

The effect of Hypertonic Dextrose injection on the control of pains associated with knee osteoarthritis
DOI: 10.5742/MEWFM.2017.93076
[pdf version]
Mahshid Ghasemi, Faranak Behnaz, Mohammadreza Minator Sajjadi, Reza Zandi,
Masoud Hashemi

Evaluation of Psycho-Social Factors Influential on Emotional Divorce among Attendants to Social Emergency Services
DOI: 10.5742/MEWFM.2017.93077
[pdf version]
Farangis Soltanian

Models and Systems of Health Care

Organizational Justice and Trust Perceptions: A Comparison of Nurses in public and private hospitals
DOI: 10.5742/MEWFM.2017.93078
[pdf version]
Mahboobeh Rajabi, Zahra Esmaeli Abdar, Leila Agoush

Case series and Case reports

Evaluation of Blood Levels of Leptin Hormone Before and After the Treatment with Metformin
DOI: 10.5742/MEWFM.2017.93079
[pdf version]
Elham Jafarpour

Etiology, Epidemiologic Characteristics and Clinical Pattern of Children with Febrile Convulsion Admitted to Hospitals of Germi and Parsabad towns in 2016
DOI: 10.5742/MEWFM.2017.93080
[pdf version]
Mehri SeyedJavadi, Roghayeh Naseri, Shohreh Moshfeghi, Irandokht Allahyari, Vahid Izadi, Raheleh Mohammadi,

Faculty development

The comparison of the effect of two different teaching methods of role-playing and video feedback on learning Cardiopulmonary Resuscitation (CPR)
DOI: 10.5742/MEWFM.2017.93081
[pdf version]
Yasamin Hacham Bachari, Leila Fahkarzadeh, Abdol Ali Shariati

Office based family medicine

Effectiveness of Group Counseling With Acceptance and Commitment Therapy Approach on Couples' Marital Adjustment
DOI: 10.5742/MEWFM.2017.93082
[pdf version]
Arash Ziapour, Fatmeh Mahmoodi, Fatemeh Dehghan, Seyed Mehdi Hoseini Mehdi Abadi,
Edris Azami, Mohsen Rezaei


Middle East Quality Improvement Program
(MEQUIP QI&CPD)

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE

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medi+WORLD International
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The contents of this journal are copyright. Apart from any fair dealing for purposes of private study, research, criticism or review, as permitted under the Australian Copyright Act, no part of this program may be reproduced without the permission of the publisher.

October 2017 - Volume 15, Issue 8

The Effectiveness of Cognitive-Existential Group Therapy on Reducing Existential Anxiety in the Elderly


Somayeh Barekati
(1)
Bahman Bahmani
(2)
Maede Naghiyaaee
(3)
Mahgam Afrasiabi
(4)
Roya Marsa
(5)

(1) MA, Department of Counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
(2) Assistant Professor, Department of Counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
(3) PH.D, Department of Counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
(4) MA, Department of Counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
(5)MA, Department of Counseling, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran


Correspondence:
Bahman Bahmani
Assistant Professor, Department of Counseling,
University of Social Welfare and Rehabilitation Sciences,
Tehran, Iran

Email
: ba.bahmani@uswr.ac.ir

Abstract


Introduction and Objective:
The elderly experience significant developmental changes due to the effects of aging; a common consequence is the activation of existential anxieties. In spite of the natural and constructive nature of existential anxiety, inappropriate response may lead to neuroticism. This study aims to investigate the effectiveness of cognitive-existential therapy on reducing existential anxiety in the elderly.

Method: The present study was carried out using a pretest-posttest semi-experimental design with control group and random assignment. The statistical population included all the elderly women in Yas Daily Rehabilitation Center. In this study, 20 people were selected through non-random sampling and after answering the Existential Anxiety Questionnaire (Masoudi Sani, Bahmani, 2015) and Cognitive Distortions Questionnaire (Abdollahzade et al. 2010 quoted from Farmani-Shahreza et al. 2016) were randomly assigned to experimental and control groups (each group included 10 people). The experimental group participated in 12 cognitive-emotional group therapy sessions (each session 90 minutes) once a week in, but the control group did not receive any intervention. The collected data were processed using SPSS-20 software to calculate covariance analysis.

Results: The results showed a significant reduction in the existential anxiety and cognitive distortions compared to the pretest. Also, in a two month follow-up session, existential anxiety and cognitive distortion scores were significantly reduced compared to pretest.

Conclusion: The findings of this research can be considered as a confirmation of the basic assumption of the cognitive-existential approach about the effect of correcting cognitive distortions that activate non-authentic responses to the existential anxieties.

Key words: cognitive-existential group therapy, existential anxiety, cognitive distortions, the elderly


INTRODUCTION

Elderliness is a phenomenon that is caused by changes in biology, physiology, biochemistry and anatomy in the cells of the body, these changes affect the function of the cells, and it begins at age 60. It is not a disease but a natural process of transformation that cannot be stopped or reversed (World Health Organization, 2001).

Iran is experiencing the establishment of aging phenomenon. Statistics show that in 2011, the population of the elderly over 60 was about 3.8% of the total population of the country (Iran Statistics Center, 2013), and it is expected that the number of elderly will reach 10 million people, that is about 10% of the total population (Malayeri & Jafari, 2004).

Elderly people experience different consequences in terms of physical, socio-economic, family, psychological, and (existential) being dimensions. In the physical aspect, the elderly experience several problems, including: 1. chronic physical illnesses such as high blood pressure and cardiovascular diseases and diabetes; 2. decreasing abilities such as vision and hearing; 3. Neuropsychological disorders, such as dementia, Alzheimer’s and Depression (Duberstein et al., 2008).

In socioeconomic and family dimensions, problems such as declining financial status, loss of job and social status, death or immigration of close relatives, friends and peers (Wurtman, 1993), and loneliness due to physical weakness and reduced mobility (Mussen et al., 2005) have been reported. In the psychological aspect major problems include: depression (Stuart et al., 2005), feelings loneliness (Heravi Karimloo et al. 2007; Wurtman 1993), impatience, anger, feelings of emptiness, anxiety and concern, insomnia, tiredness and fatigue ( Kaldi & Foroughan, 2004).

From other dimensions of aging, one can point out existential anxieties that are not necessarily clinical and illness but can be painful and annoying (Yalom, 1980). The increasing awareness of the elderly about the finiteness of life manifests itself with the emergence of the first signs of aging, and anxiety about the loss of control, t physical deterioration (Robbins, 1392) which indicates the arrival of the last stage of life. Diseases such as cancer and heart disease, among friends and acquaintances of the same age, inform the person they are entering this stage. One thinks that he has had limited time, while he has many unfinished projects (Wayne Saint, 2003). In the eyes of the elderly, loneliness is an unpleasant, negative, agonizing, hard, terrible and painful personal experience that creates a sense of impatience, uselessness, frustration, sadness, anxiety and hopelessness (Heravi Karimloo et al. 2007). Confronting existential issues including death, feelings of emptiness and meaninglessness, loneliness, uncertainty and unpredictability of the future, the elderly may face problems which provoke existential anxieties.

Existential anxiety is the result of awareness of the unstable characteristics of human situations. Indeed, since each of us desperately needs eternity, solidity, coexistence and purposefulness of life, and at the same time, all of us will end up with the inevitability of death, groundlessness of existence, loneliness, and absurdity, as a result of this conflict we experience existential anxiety (Yalom, 1980)

According to Kierkegaard, the main axes of anxiety are death, freedom, loneliness and meaning (Kierkegaard, 1848; Poiman, 1990; Yalom, 1980).

The fundamental conflict that causes the anxiety of death is the desire for survival, the continuation of life, and the awareness of mortality and the inevitability of death (Yalom, 1980, 2008; May and Yalom, 2000). According to Yalom, responsibility and choice are the attendants of freedom. The fundamental contradiction arises from the fact that human beings need to have a structural basis for life but there is no basis. The conflict between groundlessness and the desire to have a firm base leads to anxiety (Webb, 2008; Sand, 2008). The loneliness anxiety begins where one loves to be part of a whole; have an honest relationship with others and be protected by others, but in the real world he/she finds that none of these events are realizes and he/she is unmercifully lonely (Kierkegaard, 1848). Stager and Frasber (2006) considered the nature of man to find meaning in life. Because the basic human need is searching for meaning and achieving perfection this quest does not necessarily lead to a meaningful life (Kernan & Lepore, 2009). The existential conflict is created because we must find meaning for a universe that lacks any design and semantics by itself, and set goals for a future that is unpredictable (Yalom, 1980; Sand, 2008).

According to the existential view, genuine response to existential anxieties depend on our awareness and acceptance of such anxieties (Prochaska & Norcross, 1999). All people experience those anxieties but not all of them face personality and communication problems (Blinderman & Cherny., 2005). Misunderstanding of self as a human being and overlooking the givens of existence paves the way to neuroticism (Poiman, 1990).

Pathological anxiety is the product of an individual’s quest for escaping and overcoming the inevitable givens of being, through the use of defense mechanisms, causing self-deceit, self-alienation, and getting away from the realities of existence. This type of anxiety is usually out of consciousness and prevents the individual from movement. Therefore contrary to the natural anxiety that is constructive, pathological anxiety is a destructive mental disorder (Corey, 2005).

Also in the elderly, this process can lead to the formation or intensification of psychological problems. The elderly need to have the ability to respond to fundamental existential problems and as they get older, responding to these issues can be a significant contribution to their inherent and fundamental concerns (Langle & Probst, 2000). If they cannot find genuine answers to their existential issues they will suffer pathological anxiety.

A range of psychological interventions have been used to reduce the psychological problems of the elderly, which indicates the need for psychological services for these elderly people. This range includes: cognitive-behavioral therapies (Hedayat, 2015; Barghi Irani, 2015), existential group therapy (Mooziri, 2013), spirituality-based cognitive therapy (Rahimi, 2014), group logo therapy (Poorebrahim, 2006; Fakhar, 2007, Yazdan Bakhsh, 2015); memory telling (Majzoobi, 2012), and hope therapy (Parvaneh, 2015). The literature indicates that existential group therapy and group logo therapy were not effective on the elderly (Mooziri, 2013; Poorebrahim, 2007; Fakhar, 2007).

Furthermore, the focus of most interventions for the elderly has been on the treatment of death anxiety, feelings of loneliness, depression, and enhancement of life expectancy, happiness, self-efficacy, mental health, quality of life and quality of sleep in the elderly. It seems essential to address the anxieties of being due to the prevalence, while less attention has been paid to existential anxieties in the elderly. Also the studies on existential anxiety in the elderly have just focused on one of the four factors of existential anxiety. Therefore, in this study, the Existential Anxiety Questionnaire (Masoudi Sani, Bahmani, 2015) has been used for the first time.

It would be beneficial to find the most effective and practical intervention method to reduce existential anxiety subsequent to aging due to the need to respect the human rights of the elderly and also to save time, effort and facilities. In cognitive-existential group therapy, it aims to use techniques of “cognitive therapy” to refine some schemas, negative automatic thoughts, and to correct the cognitive errors that contribute to the formation of psychological distress caused by the non-genuine response to existential anxiety. Moreover, this method pays attention to existential concerns such as death anxiety, uncertainty, meaninglessness, loneliness, and uncontrollability of the world that are intensified by the death threat in patients. In most intervention methods such concerns do not receive systematic attention. Therefore, it is expected that through this intervention, individuals will find their own unknown fears and conflicts over the issues of existence and will be able to cope with them in a genuine and effective way (Bahmani, 2010). Previous studies indicate that cognitive-existential therapy plays an effective role in reducing psychological distress in different populations (Bahmani, 2010; Naghyiaee, 2014, Farmani Shahreza, 2014; Eskandari, 2013; Paknia, 2015). In this regard, we seek to investigate the impact of this intervention on the elderly and to answer the question of “whether cognitive-existential group therapy can reduce existential anxieties in the elderly?

METHOD

The study was carried out using a pretest-posttest semi-experimental design with control group and random assignment. The statistical population included all the elderly women in Yas Daily Rehabilitation Center. The sample included 20 people selected through a non-random sampling from among the elderly present in the center during the sampling period (summer 2016) who were prepared to participate in the group therapy and were eligible for inclusion criteria. The sample was divided into experimental and control groups in a random assignment (10 individuals in each group).

In this research, the dependent variable is measured before and after the presentation of the independent variable, and its design graph is as follows:

T1 and T¬4 represent the pretest, T2 and T5 the posttest, T3 and T6 show the follow-up and X is the Cognitive-Existential Group Therapy.

Instruments
In this research, Existential Anxiety Questionnaire, developed by Masoudi Sani and Bahmani (2015), was used to measure existential anxieties. This questionnaire has 29 statements and 4 subscales: 1- Death anxiety, 2- Responsibility anxiety, 3- Meaning Anxiety, and 4. Loneliness anxiety. The content validity of the instrument is based on the opinion of 10 experts, using the ICC method was 0.95 and the reliability of the instrument was 0.83 and 0.86, respectively, by Cronbach’s alpha and test-retest method.

In order to measure cognitive distortions, the 20-item scale of Cognitive Distortions developed by Hassan Abdollahzadeh and Maryam Salar (2010) was used. The standardized Cronbach’s alpha was 0.80. The questionnaire consists of 20 statements to measure the cognitive distortions proposed on the basis of Albert Ellis’s theory and each irrational thought has 2 statements. Thus, statements 1 and 2 assess Polarized thinking; 3 and 4, Overgeneralization; 5 and 6, Filtering; 7 and 8, Disqualifying the positive; 9 and 10, Jumping to conclusions and fortune telling including mind reading and misconception; 11 and 14, Exaggeration and Minimization; 12 and 13, Emotional reasoning; 15 and 16, Should statements; 17 and 18, Labeling; and finally 19 and 20 assess Personalization. The Higher total score reflects a more positive thinking; however statement 1 is scored in reverse (Abdollahzade et al. 2010 quoted from Farmani-Shahreza et al. 2016).

Procedure
After preliminary studies and preparation of the protocol, and receiving a referral letter from the University of Welfare and Rehabilitation Sciences to the Welfare Organization of Tehran province, we got the necessary permissions and referred to the Yas Daily Rehabilitation Center. The research process began after permission was gained from the head of the Center. First, through broadcasting announcements and talks with the elderly in the Yas Daily Rehabilitation Center, they were informed of the study. Subsequently, describing the research goals and obtaining consent from the elderly and observing the ethical rules, the conditions for the participation in the research were prepared. After interviewing the individuals and completing Existential Anxiety and Cognitive Distortions questionnaires, twenty elderly were selected according to inclusion and exclusion criteria and randomly assigned to the control and experimental groups. The inclusion criteria were: age of 60 and over, having the ability to speak, having no cognitive problems and a score of over 70 in the Existential Anxiety Questionnaire. Exclusion criteria included: having mind and brain disorders such as Parkinson’s and dementia, having any psychiatric disorders based on the written contents of their file in the center and use of any psychotherapy and counseling services at the time of the research.

Subsequently, cognitive group therapy was performed for 12 sessions of 90 minutes and once a week for the experimental group (Table 1), while the control group received no intervention. In order to observe ethical issues, after group treatment with the experimental group, group therapy was also performed for the control group.

At the last session, the mentioned questionnaires were repeated on the participants of both groups. In order to ensure the durability of the therapeutic results, two months after the completion of the group therapy in the follow up phase, the participants again were assessed using questionnaires.
Data from pretest and posttest was entered in version 21 of SPSS software. After analyzing the assumptions of covariance analysis, this statistical method was used to analyze the data. Covariance analysis limits or eliminates the effect of the pretest variable and measures it using the regression equation. Among the important assumptions of this statistical method was the homogeneity of variances using Levene’s test and Normality test by Kolmogorov–Smirnov test. These assumptions were checked and verified in the study.

The ethical considerations of this study included the following topics: 1) the participants in the research were assured that the information received would be confidential; 2) scores were given to those who would like to know their scores; 3) the planning of group counseling sessions was carried out in a way that would not interfere with the programs of the Yas Daily Rehabilitation Center; 4) The control group was assured that they would participate in eight sessions of Cognitive-Existential group therapy after the end of the research; 5) Any of the participants could freely leave the program at any time during the research.

RESULTS

Click here for Table 1: The protocol for cognitive-existential group

The sample consisted of 20 elderly women with an average age of 70 who were randomly assigned into two groups of 10 in experimental and control groups (waiting list). According to the results of the Mann-Whitney U test, the two groups were homogeneous in demographic variables of age and education. In addition, the assumptions of the covariance test for the normality of the data distribution were confirmed by Kolmogorov-Smirnov test and homogeneity of variances were confirmed by Levin’s test of two groups in dependent variables of existential anxiety and cognitive distortions.

Clicik here for Table 2: Mean and standard deviation of the existential anxiety scores and its subscales in the experimental and control groups in the pretest, posttest and follow-up

In Table 2, the comparison of mean scores in the pretest, posttest and the two-month follow up of the experimental group showed that the scores in the posttest and follow-up were reduced compared to the pretest.

Click here for Table 3: Mean and standard deviation of cognitive distortion scores in pretest, posttest and follow up

In Table 3, the comparison of mean scores of cognitive distortions in the pretest, posttest and follow-up tests showed that scores in post-test and follow-up were increased in comparison with the pretest. Considering that the higher the number of scores, the more positive the thinking is; the increase in scores shows that the cognitive distortions have been decreased.

Click here for Table 4: The results of covariance analysis of the comparison of the experimental group and control group in existential anxiety and its subscales’ post-test scores

As shown in Table 4, participation in the cognitive-emotional group therapy has significantly decreased the existential anxiety and its subscales in the elderly. Also in the follow-up phase, a significant decrease was continued.

DISCUSSION

The aim of this study was to investigate the effectiveness of interventions that are more appropriate to the specific needs of the elderly and to provide more effective helping methods for reducing the concerns and the existential crises of the elderly. In this regard we examined the general assumption that “cognitive-existential group therapy reduces the existential anxiety of the elderly”.

As the findings in Table 4 show, the findings confirm the mentioned hypothesis. It seems that the cognitive-existential group therapy and the elements proposed in the treatment protocol, as well as the special way of relations in the sessions have been able to create a positive and significant change in reducing the existential anxiety and its subscales. It should be considered that the treatment atmosphere in the cognitive-existential group therapy is based on listening to the subject’s stories considering the here and now, familiarity with the sufferings of others, the use of emotional support and receiving feedback from different people to reduce the feeling of being victim, the uniqueness of the problem, loneliness and helplessness, discrimination and oppression, feeling of security, secrecy, reflection and empathy, emotional release, self-disclosure, exposure, feedback, affection, acceptance and humour; this can be mentioned as a positive factor for this approach. In this method, the group continued the sessions assuming that the confidence and sympathy between the group members persists and the psychological refinement was done every session.

Part of the content of the cognitive-existential group therapy helps understanding the phenomenological world of individuals using the prepared existential concepts. Using such concepts helps individuals to encounter their existential anxiety and to communicate with their original selves with all the inevitable existential anxieties and instead of denying and reprimanding their unpleasant feelings and emotions, experience them and take responsibility for their feelings, and most importantly, express these feelings and emotions. According to Kissan it is a useful intervention method that can deal with these fears fast and clear enough and can help reduce mental health problems (Kissan, et al., 2002; quoted from Bahmani et al., 2010).

During the treatment process, the elderly were involved with their existential questions. These questions caused them to activate and discharge their existential anxieties. In general, during the sessions, it became clear that feeling of lack of a worthwhile future and lack of self-efficacy to achieve it, inevitability and fear of death, lack of faith in the future, feeling of hopelessness, lack of meaning and purpose, and loneliness deprives the elderly from the motivation to try. Existential crisis and disturbances are developed as a result of fear of confrontation with

existential anxieties. So during the group process, we tried to help the elderly understand the unpredictability of the world and the uncertainty of the universe, assess their thoughts and assumptions about the uncontrollability of death and loss of opportunities in the past and the resulting anxieties, identify and challenge their cognitive distortions about the meaning of death anxiety (seeing death as the end of everything, unwillingness to track down their illnesses, fear of being forgotten after death, fear of painful death, disqualifying their efforts in their lives, fear of disability) and end their fears by accepting the anxiety of unpredictability and death. We also tried to introduce the concept of fundamental loneliness anxiety and help them identify and challenge their cognitive distortions about the meaning of loneliness (not being understood by close people, especially their spouse and children, the feeling of failing to understand others, the feeling of separation from children, attachment to other individuals to escape loneliness) and accept loneliness as a genuine experience to increase the desire and motivation to be with others and family members. They were also helped to challenge the meaning of their lives created by psychological disturbances and existential anxieties, and find a meaningful term for their lives, and change their attitudes toward problems and tolerance of difficulties, and through giving meaning to the sufferings and pains, change their focus from what has been lost, because the sense of the new meaning and purpose in life during the aging period (which includes the ability to combine and integrate the experiences and achieve an understanding of themselves and the world) is a protective factor against meaninglessness. Also, in the process of group therapy, elderly people tried to accept responsibility and freedom of choice, to identify and challenge their cognitive distortions about the anxiety of responsibility and freedom of choice (assigning responsibility for life events to others or social, cultural, economic, etc. circumstances, leaving the choice to others, believing in luck, trying to show oneself as victim ) and to evaluate their priorities and decisions, and accept their own responsibility for their own destiny. In general, the group therapist tried to help the elderly to accept cognitive distortions that prevented them from experiencing existential anxieties and activated their defense mechanisms.

In general, according to previous studies, cognitive-existential group therapy can be considered as a suitable factor in reducing different types of mental disorders. Bahmani et al. (2010) in their research showed that cognitive-existential group therapy was more effective than cognitive therapy in reducing the mean of depression and increasing the mean of hopefulness.

Previous studies, consistent with the present study, Kissan et al. (1997) showed that using this method of treatment is helpful to reduce the amount of sadness and grief in patients with cancer, increase their problem solving ability and also create cognitive strategies. Breitbart (2001) suggested that existential therapies are one of the most appropriate approaches to reduce depression and increase hope in cancer patients. In addition Kissan et al. (2003) concluded that cognitive-existential therapy has a positive effect in reducing overall symptoms of psychological distress in women with non-metastatic breast cancer. In another study, Kissan et al. (2004) concluded that this method would greatly reduce psychological distress and anxiety, and improve family relationships.

Therefore, according to the findings, the cognitive-existential therapy has been able to affect people with chronic conditions such as cancers, breast cancer, human immunodeficiency virus, and the elderly. This should be due to the main distinguishing feature of this intervention method, namely, paying attention to the existential anxieties and considering here and now during the treatment sessions as compared to other methods.

Also, the results of the two-month follow-up showed that cognitive-existential group therapy has a lasting and stable effect on the improvement of existential anxiety. In explaining this finding, it can be said that Cognitive-Existential psychotherapy can lead to long-term changes in terms of creating philosophical insights and changing attitudes in individuals.

CONCLUSION

In general, cognitive-existential group therapy due to addressing the existential concepts, especially for the elderly and deal with these concepts and working with the unreasonable beliefs of individuals and substituting logical beliefs can lead to the reduction of psychological factors and existential anxieties. Therefore, this method of intervention can be used in the treatment of the elderly, since the elderly need to continue their lives with meaning and purpose without fear of confrontation with death, loneliness, and existential concerns.

Limitations
The most important limitation of this study was the use of available sampling and, consequently, semi-experimental design, and that the research was conducted only on elderly women, which reduced the generalization power of the research.

Suggestions
Given that existential anxiety is activated in the elderly and addressing these anxieties in counseling and psychotherapy sessions can help to improve the existential crisis of the elderly, it is suggested that counselors of care centers, rehabilitation centers for the elderly and counseling and psychology clinics be trained based on the treatment plan presented in this study and take advantage of it to help the elderly. In addition, the results of this study can be used to improve the design of educational programs for health care and rehabilitation providers, as well as to plan for prevention of existential crises and to improve the health of the elderly and to prevent serious problems such as suicide in the elderly. Also, it is suggested that the effect of this therapeutic approach on other psychological variables be examined and the effectiveness of this treatment method be compared with other types of cognitive therapies in order to reduce the psychological problems of the elderly in order to achieve the most effective treatment method for this group.

Acknowledgments
Thanks to my distinguished professors and the respectable staff of Yas Daily Rehabilitation Center and all the elderly who helped us with this research. This research is based on the master’s thesis of Ms. Somayeh Barakati in counseling department of Tehran University of Social Welfare and Rehabilitation Sciences.

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