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Procedia Social and Behavioral Sciences 5 (2010) 832837

WCPCG-2010

Comparing the Effectiveness of Group Movie Therapy (GMT) Versus Supportive Group Therapy (SGT) for Improvement of Mental Health in Grieving Adolescent Girls in Tehran
Molaie, A.a *, Abedin, A.b , Heidari, M.c
a b

Department of Psychology, Shahid Beheshti University, 1983963113, Evin, Tehran,Iran Department of Psychology, Shahid Beheshti University, 1983963114, Evin, Tehran,Iran c Department of Psychology, Shahid Beheshti University, 1983963115, Evin, Tehran,Iran Received January 12, 2010; revised February 3, 2010; accepted March 6, 2010

Abstract

36 female university students in the city of Tehran, who had lost a close family member in 2008-2009 year, randomly assigned into a control and two experimental groups. The two experimental groups received twice a week intervention for eight weeks and then was post tested and once again reassessed in a two-month follow up by GHQ28. Mixed ANOVA showed the GMT wasnt more significant than SGT on improving mental health in post test but that was in follow up. The GMT was an efficacious and permanent technique among adolescent.
2010 Elsevier Ltd. All rights reserved.
Keywords: Group movie therapy, mental health, bereavement, adolescence, supportive group therapy.

1. Introduction Grief following the death of a loved one is a natural and necessary process with fairly common features amongst people. This process is accompanied by changes in cognitive, emotional, physical, social, and behavioural characteristics of the bereaved individual (Khosravi, Akbarzadeh, & Hagian, 1998). Resolution and coming to terms with bereavement requires cognitive and emotional processing. It also necessitates a cathartic experience of loss to a point where remembering and speaking about it feels less painful and more pleasurable over time (Khosravi, 1995; Worden, 1991). Sometimes people lack the necessary skills, ability or opportunity for natural processing of grief (Khosravi & et al 1998). The advent of industrialization and gravitation towards small families has resulted in an individualistic life style and insurmountable distances being created amongst people. Such a development prevents

* Azam Molaie Tel.: 009821 44149765; fax: 009821 22431688. E-mail address: afkhammolaie@yahoo.com.

1877-0428 2010 Published by Elsevier Ltd. doi:10.1016/j.sbspro.2010.07.194

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an emotional and natural outpouring and purging of grief. The absence of a loving and protective social network for the bereaved person increases the difficult and negative side effects of expressions of grief (Qadimi, 1997). Grief has a long lasting impact on teenagers mental health (Khosravi & et al 1998; Harris, 1991; Grollman, 1995; Gray, 1987). The results of a meta-analysis study indicate that bereaved teenagers are less observed and studied, in comparison to adults (Balk & Corr, 2001). In reality, sometimes they are referred to as "the forgotten mourners" (Leighton, 2008). Bereaved girls show more vulnerability than boys in a number of areas such as intensity in expression of grief, physical reaction to bereavement, guilt, feeling of rejection (Mahdipur, 2007), depression, anxiety, sleep and somatic problems (Barlow-Irick, 1997; quoted by Molaie, 2009). Symptoms of distress and anxiety caused by grief may continue for one to three years (Murphy, 1997). Passage of time and human nature's tendency to forget or bloc out unpleasant and distressful events, are instrumental in diminishing feelings of loss and grief. However seeking regular consulting services and therapy are useful and necessary in resolution of the negative emotional and mental impacts of bereavement (Worden, 1991 quoted by Khosravi, 1995). Teenagers considered opening up to peers and access to a sympathetic listener after experiencing a loss, as the most helpful means of overcoming their suffering (Gary, 1989). Group therapy with grieving peers is very effective in treatment of distressed teenagers (Balk & Corr, 2001; Lindeman, 1994; McCallum & Pipper, 1990; Opie, 1992). Its usefulness can be attributed to a series of potential factors such as emotional catharsis, inter-intra personal learning, provision of information, self-awareness, existential and altruistic factors, cohesiveness, universality, enhancement of hope, and corrective reconstruction of family origin's experiences (Yalom, 1995). Among different therapeutic approaches, supportive group therapy (SGT) provides an accommodating environment in which, by verbalizing and reviewing the story of painful experiences, the emotional process is implemented. As a result, awareness is provided with regards to the repressed and unexpressed feelings. Through adoption of role models and feedback from other participants, new coping skills are acquired (Goodkin et al, 2001; Davis, 1992 quoted by Molaie, 2009). SGT is an effective intervention (Fine, Forth, Gilbert, & Haley, 1991) in reduction of distress, (Davis, 1992) improvement of mental health in teenagers (Qadimi, 1997), relief of physical symptoms (Opie, 1992), encouragement of interpersonal exchange, enhancement of self-esteem, increasing life satisfaction, and coping with the loss (McCallum, 1993; McCallum & Pipper, 1990). To facilitate processing of anxiety stemming from emotional catharsis related to grief for children and teenagers, the more indirect and nonconfrontational methods such as art (Dalton & Krout, 2005), bibliotherapy (Briggs & Pehrsson, 2008), and metaphors (Sharp, Smith, & Cole, 2002) may be more effective. The results of a specific study indicate that bibliotherapy was effective in treatment of somatic symptoms, depression, sleep and eating disorders in bereaved adults (Briggs & Pehrsson, 2008). Marrs (1995) in conducting a meta-analysis of 70 bibliotherapy studies covered viewing of videotapes in his definition of bibliotherapy. He acknowledged the larger impact of an audiovisual medium compared to bibliotherapy involving only reading books. He concluded that movie therapy (MT), a contemporary method and off-shoot of bibliotherapy is likely to be a more powerful intervention than bibliotherapy in itself covering only reading assignments. The novelty of (MT) prevents widespread support and recognition of its effectiveness (Portadin, 2006). The results of the one month follow up assessment in one empirical study using this approach, indicated that bereaved girls showed more significant reduction in experiencing the intensity of grief and its subscales including the feeling of guilt and rejection, as well as somatic reactions, than the control group. Using the movie "Elina", in that study also assisted in providing a more tangible meaning of loss (Molaie, 2009). Allowing for a number of potential uses in the therapeutic process, MT can be utilized as a one-off intervention, regardless of the therapists theoretical orientation (Schneider, 2002). It may also increase therapeutic alliance by providing a common experience shared by both the therapist and patient(s) (Berg-Cross, Jennings & Baruch, 1990). Movies are a combination of imagination, symbols, metaphors, music, special effects and dialogue; hence they have a more powerful effect upon us than any other form of art (Wedding & Boy, 1997). It can be used as a stimulus for discussion in therapy or as a metaphorical intervention (Sharp and et al, 2002). According to Mangin, (1999), Aristotle theorized that tragic plays have the capacity to purify the spirit and aid us in coping with those aspects of life that cannot be reconciled by rational thought. This approach allows the patient to distance himself/herself from a problem by providing a relatively non-threatening means of addressing the problem. Subsequently the move can potentially reduce resistance in the therapy process.

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Sharp and et al (2002) assert, however that MT is more than simply watching a movie. MT is a therapeutic technique that involves careful selection and assignment of movies for clients to watch, followed by processing of their experiences during therapy sessions. Among other benefits, this process can provide solutions to problems, encourage growth, reframe problems and build rapport (Powell, Newgent, & Lee, 2006). Therefore, it is recommended that characters in the movie be used as the focal point of the discussion in the pursuant therapy session. Typical questions might include (Hamzeh khan poor, 2006): Tell me about the characters in the movie. What was the character thinking/feeling? What did the character see as his or her main problem? How did the character resolve his or her issues? What other solutions might the character have used? What was his or her relationship to other characters? Who did you like/not like? Movie characters can become models of problem-solving behaviour for patients. By watching the movie, clients gain awareness of alternative coping strategies without having to worry about negative consequences of various options directly impacting their lives (Newton, 1995 quoted by Sharp and et al, 2002; Schulenbrg, 2003). There are four processing stages in self-development often identified in the process of MT which are: identification, emotional catharsis, universalization, and insight (Sharp and et al, 2002) The movies can incite emotions bringing about biological changes in levels of stress hormones and release of neurotransmitters like endorphin (Portadin, 2006). Internalized like a cotherapist, the characters and the conveyed message in the movie can remain as a companion even after the termination of therapy; they help to strengthen clients' ego (Portadin, 2006; quoted by Molaie, 2009). MT is particularly effective with youth, as movies are a suitable medium in contemporary society and significant part of the teenage culture in particular (Hebert & Neumeister, 2001) Considering the extensive negative impact of bereavement on teenagers' mental health, an area to which little attention has been paid by researchers, the use of methods facilitating the cognitive and emotional processing of loss are indispensible. The goal of the present study is to compare the effectiveness of MT as one of the new and suitable methods in reaching teens in SGT. According to available literature it is considered as one of the most effective methods alleviating the sense of grief and loss of bereaved adolescents. 2. Method The sample comprised of 36 girls (17-19 year old; Mean= 18; SD= 0. 2) selected through purposive sampling. They were all freshmen at one of Tehran's universities having experienced the loss of one of their immediate relatives (including parents, siblings and grandparents) during 2008-2009 (length of time since the loss M=11 month, SD= 0.3). Criteria for participation in the study were experience of only one loss, no experience of therapy since the loss or during implementation of the present study, and not having watched the movie "Elina" (2002) before and during the research. 14% of subjects in MT, 12% in supportive group and 14% in control group had suffered the loss of one of their parents. 8% of subjects in MT, 15% supportive therapy group and 14% of control group suffered the loss of father or grandmother. 8% in the movie therapy group, 5% in supportive group therapy and 10% in the control group suffered loss of a sibling. 2.1. Instruments 1-Demographic Questionnaire: This form was drafted by a researcher aiming at gathering information such as age, gender, nature of death (expected or sudden), length of time since the passing away, relation with the deceased, degree of closeness and intimacy and amount of grief suffered. 2-GHQ-28: The 28 item General Health Questionnaire (Goldberg, 1988) also adopted by the Iranian population was used. It serves as a self-administered tool for assessment of general mental health and mental distress in four areas of depression, anxiety, somatic symptoms, and social dysfunction. GHQ-28 asks about the presence of a range of symptoms during the past month in four relevant areas. Responses are evaluated on 4-point likert scale ranging from 0 ('not at all') to 3 ('much more than usual'). The higher the score, the lower the well-being reported. Palahang, Nasr, & Shahmohammadi, (1996) studied reliability and validity of 28-item GHQ in Iran. They obtained 91% Pearson correlation reliability coefficient of the 28-item for GHQ-28 with the Iranian sample. 3-Movie: "Elina" (2002) was used. It is a story about Elina, a nine year old girl who lives with her mother and two smaller siblings in a village in northern Sweden in the 1950s. She misses her dead father and during the course of the movie, she goes from denial to acceptance of the loss.

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2.2. Procedure Thirty-six from the original 47 eligible volunteers were randomly selected and subsequently assigned to two experimental groups and one control group (12 in each). Intervention of both groups was carried out in eight weekly sessions (twice a week) sessions by two trained group therapists. The techniques used in SGT included facilitation of subjects' thoughts and feelings, discussions about the process of experiencing grief including denial, anger, vacillation of emotions, depression, and acceptance of grief. Ample time was spent on remembrance of the deceased and giving feedback to each other in the group. In GMT after a general introduction of members to each other and explanation of group processing rules, discussion of grief experience was conducted in parallel with that of the grieving character in the movie. In the second session, the movie Elina (2002) was shown. In sessions three through eight, subjects discussed their experiences, thoughts, and feelings of grief alongside their observation and interpretation of the movie. Subjects completed GHQ-28 once prior to the study, then at the end, and finally after the two month-follow up. Upon conclusion of the project, MT was also carried out for subjects in the control group.

3. Results Table 1 displays means and standard deviations for the three groups across the three trials (pre,- post, and twomonth follow-up) for overall GHQ-28 and its subscales.

Table 1: Means (Standard deviations) of GHQ and its subscales at the three trials SGT(n=12) Pretest 71 6 (4 4) 15 9 (1 9) 19 2 (3 6) 20 9 (1 3) 15 5 (2 1) SGT Posttest 37 4 (5 6) 9 5 (3 9) 11 (1 3) 9 5 (2 2) 10 5 (1 2) SGT Follow up 36 2 (3 6) 9 3 (3 8) 9.5 (1.4) 8.7 (1.9) 8.6 (1.1) MT(n=12) Pretest 70 7 (3 4) 15 3 (2 1) 19.5 (1.7) 20 (2.2) 15.9 (1.6) MT Posttest 37 5 (2 8) 9.25 (1.1) 10.5 (1.4) 8.2 (1.3) 9.5 (1.7) MT Follow up 25.7 (4.1) 6 (1.4) 7.4 (1.5) 6.9 (2.2) 5.4 (1.9) Control(n=12) Pretest 71(3.4) 15.9 (1.7) 18.8 (2.8) 20.5 (1.3) 15.7 (1.6) Control Posttest 66.5 (3.6) 16 (1.7) 17 (2.9) 17.5 (1.5) 15.5 (1.6) Cont Follow 64.5 (4 15 (1 17.4 (2 16.7 ( 14.6 (2

Variable Overall GHQ SomaticReaction Anxiety Depression Social dysfunct

Note. The higher the score, the lower the well-being reported.

Table 1 indicates that median scores on overall GHQ-28 and its subscales were more significantly reduced in the two experimental MT and SGT groups in comparison with the control group over course of time. Significant differences between the means in the three study groups were tested, using one-way ANOVA and Mixed ANOVA via SPSS version 16 package. First, a test of one-way ANOVA indicated that there was no statistically significant difference between three study groups at pre-test, F=0.180, df= 2, p= 0.836.
Table 2 : Results of Mixed ANOVA analysis Variable Source Group Time Time*Group Error(group) SS 10655 17281 5761 929 Df 2 2 4 33 * p .01 MS 5327 8640 1440 14 F 238 613 102 Sig. 0/001 0/001 0/001

GHQ

Results were also analyzed using Mixed ANOVA with one inter-group factor and one repeated-measure factor to look for differences amongst subjects and groups (table 2). Because the assumption of spherisity and equality of co-variances (Mauchly 's test, p=0.568) were not violated, no adjustment was made to the degree of freedom. Results of Mixed ANOVA on overall GHQ-28 indicated that there was a statistically significant main effect for the treatment groups (between groups), F (2, 33) =238, p=0.000; there was statistically significant main effect of time (within subjects), F (2, 33) =136.4, p= 0.000; there was significant interaction treatment groups and time, F (4, 66) =102.2, p= 0.000 (table 2). There was also statistically significant

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main effects for the treatment groups, time, and interaction treatment groups and time on all GHQ's subscales (pvalues of the Mixed ANOVA ranged between 0.000 and 0.009 which less than 0.01). This means that treatment groups (MT & SGT) have been significantly more effective than control-waiting list group as far as GHQ-28 and all its subscales are concerned. Furthermore, Scheffe's test of pair-wise comparisons revealed no significant differences between the impact of MT and SGT on overall GHQ-28 at post-test, but at two-month follow-up (D=0.167, df=2, 43, p=0.924; D= -10.50, df=2, 43, p=0.013 respectively) significant difference were noted. This means that MT has been significantly more effective and enduring than SGT as far as GHQ-28 and all its subscales at follow up are concerned. 4. Discussion Results of current research demonstrates that both Movie Therapy (MT) and Supportive Group Therapy (SGT) methods of intervention are more significantly effective than the control group on general mental health and all of its sub-scales (depression, anxiety, somatic reaction and social function). The results of post ad-hoc test indicated that although MT and SGT in post test did not differ significantly on mental health and all of its sub-scales but MT was more noticeably effective than SGT at the two-month follow up. Few researches have been conducted on comparison of the aforementioned therapy methods. The results of this study are congruent with those of other studies regarding the effects of SGT on improving mental health of grieving teenagers, relief of somatic signs (Opie, 1992), enhancement of interpersonal relations, and increasing the bereaved life satisfaction (McCallum, 1993; McCallum & Pipper, 1990). Resolution of grief and adjustment with loss requires emotional catharsis and expression of thoughts and feelings related to grief; in other words, grieving requires a cognitive and emotional process. Along these lines, supportive group therapy provides an opportunity for people to use other group members' support. Cognitive and emotional problems are processed by verbalizing related experiences, expression of repressed emotions and gaining awareness over them. New and functional strategies are achieved through emulating models and receiving feedback from other members (Fine et al, 1991; Qadimi, 1997). The results of the present project, based on the significant impact of GMT on enhancement of mental health and all of its sub-scales (depression, anxiety, the somatic reaction and social function) in post test and two month-follow up is congruent with the results of a study on the effectiveness of movie therapy group. Both result in significant reduction of intensity of grief experience, somatic signs, feelings of guilt and rejection, as well as assisting in formulating a meaning of the experienced loss (Moalie, 2009). In Portadin's (2006) opinion movies, by setting off the onslaught of happy and sad emotions, lead to emotional purging, purification and could reduce stress hormone and increase neuroandrophin. Movie therapy might then be effective in reduction of somatic reactions and negative emotions like depression and anxiety. Movies as metaphors create a non-threatening environment in which one may encounter denial and resistance. This can enhance insight and promote optimal growth (Sharp and et al. 2002; Powell and et al. 2006) In MT process, drawing similarities between the main movie character and other members in the group is instrumental in obtaining coping skills with the loss. Watching a movie in a group with similar problems, followed by group discussion over shared personal experiences and those of the characters in the movie is a pleasant activity for teenagers, and an effective method in reduction of their isolation as well as improvement of their social skills (Moalie, 2009). Movie characters and the story's message can be internalized as a co-therapist accompanying the patient like an auxiliary ego for a long time after termination of therapy (Portadin, 2006; Schneider, 2002). This could explain the reason as to why MT demonstrates more enduring effects than SGT. Group therapy's enduring effectiveness provides more opportunity for insight, formulation of loss coping skills, facilitating further emotional catharsis and cognitive process, and accelerating the process of learning. Considering the demographical control variables used in this research, caution should be used in generalizing the results. Other samples may be used in the future projects.

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