Effectiveness of Group Training of Reliance Therapy Components on Quality of Life and Resilience of Mothers of Children with Learning Disabilities

Introduction isabled children affect family functions and cause stress to the parents. Presence of a disabled child greatly changes the family circumstances (1). Families with a severely disabled child may evaluate their quality of life (QOL) to be different from normal families (2). The World Health Organization defines QOL as people's perception of their living conditions in relation to culture, human values, goals, standards, and personal interests. In other words, the QOL is related to the mental health of individuals, levels of social attachment, and personal beliefs (3). The results of a research conducted by Shan Leung, & Li-Tsang indicated a positive relationship between parents' QOL and the level of disability of their children. Parents whose children suffer from severe disabilities may experience more stress while caring after them (4). In addition, having a child with learning disabilities has a significant impact on the mothers' beliefs and feelings, to the extent that these mothers experience different emotions, including confusion, depression, hopelessness, and many other negative emotions. These feelings affect the mothers' resilience; consequently, negatively influence and lower their QOL. This disturbs their mental well-being and causes their mental health to decline. The most D Abstract


Introduction
isabled children affect family functions and cause stress to the parents. Presence of a disabled child greatly changes the family circumstances (1). Families with a severely disabled child may evaluate their quality of life (QOL) to be different from normal families (2). The World Health Organization defines QOL as people's perception of their living conditions in relation to culture, human values, goals, standards, and personal interests. In other words, the QOL is related to the mental health of individuals, levels of social attachment, and personal beliefs (3). The results of a research conducted by Shan Leung, & Li-Tsang indicated a positive relationship between parents' QOL and the level of disability of their children. Parents whose children suffer from severe disabilities may experience more stress while caring after them (4). In addition, having a child with learning disabilities has a significant impact on the mothers' beliefs and feelings, to the extent that these mothers experience different emotions, including confusion, depression, hopelessness, and many other negative emotions. These feelings affect the mothers' resilience; consequently, negatively influence and lower their QOL. This disturbs their mental well-being and causes their mental health to decline. The most common maternal reaction to having these children include a range of emotions from sadness to helplessness (5). Alvord and Grados define resilience as a set of skills and abilities which enable people to adjust to difficult situations (6). Newman defines resilience as a human's ability to cope with life's disasters and stressors. In line with this, a research carried out by Alriksson-Schmidt, Wallander, and Biasini demonstrated that resilience is a variable that can enhance QOL in adolescents with motor disabilities (7). Nowadays, how to adapt to life changes and ways to deal with mental pressures, especially in vulnerable groups, is one of the most important psychological issues. One of the therapeutic strategies for reducing stress is reliance on God (8). According to Naraqi on the account of Behdani and his colleagues, tawakkul is to trust in God in all the affairs (9). tawakkul in almighty God increases human resistance to hardships and adversities (10). Moreover, tawakkul in him has many effects, including: 1) Its first result is self-sufficiency and no need to others but only him; people only seek his help, and the Lord will answer their prayers affirmatively, 2) To satisfy the need of the poor, they lend to God and in return receive better and more back, and eventually they will be grateful for the blessings and see God as their helper (11). Introduction to the concepts of satisfaction and tawakkul and the difference between tawakkul, satisfaction, and patience In this session, based on verses and narrations, the concepts of tawakkul and satisfaction were explained, and then, in a group discussion, it was tried to explain the difference between tawakkul, satisfaction, and patience.
2 Introduction to satisfaction and tawakkul and its philosophy At this stage, different types of satisfaction were described using methods of competing behaviors enhancements. Then, through verse 12 of Surah Ibrahim interpretation, all kinds of tawakkul and its philosophy were expressed. 3 Introduction to characteristics of the believers and those pleased with God At this stage, role modeling and replication techniques based on the models of satisfaction and tawakkul were used (e.g., tales of the prophets Hood and Noah, the events of Ashura). 4 Ability to recognize one's weaknesses and strengths in the time of satisfaction and trust in God during adversities At this point, each individual was encouraged to reflect on their strengths and weaknesses during stressful situations, so that they can identify different parts of their personality without anxiety. This intervention resulted in an increase in self-awareness 5 Ability to understand the causes of sufferings and the hardships of life The participants were asked to talk about the problems that bothered them. The answers were assigned to two groups of optimistic and pessimistic views. The trainer tried to change one's cognitive schema about the problems. 6 Increased ability to satisfy and rely on God in adversities At this stage, desensitization and some methods were used instead of avoiding and escaping from the adversities. They also need to be positively reinforced when they have strong faith and reliance at the time confronting hardships. 7 Reminding of the blessings when faced with adversity At this point, participants learned to compare their blessings with hardships in times of adversity to avoid sadness and anxiety. 8 Introduction to the outcomes of satisfaction and tawakkul: 1. Divine reward At this point, the participants were introduced to the divine rewards in the light of satisfaction and tawakkul. This reinforces their efforts and they realize their trust in the almighty God is valuable. Therefore, even if they fail to achieve their goal, they do not perceive themselves as non-functional and do not become anxious. 9 2. Excess of blessings as a result of satisfaction and tawakkul in God at the time happiness At this stage, participants were taught to help others to benefit from blessings in order to preserve their own blessings. Compassion for other people is for the sake of satisfying God and creating a sense of satisfaction with life. Since it drives man from selfishness to altruism. 10 3. Relaxation and selfesteem Restriction of some desires (which are not regarded acceptable by God) represents a form of personal control that leads to a self-management practice that increases self-esteem and decreases moral anxiety that makes people feel at ease with their conscience. 11 4. Anger control Relaxation techniques lower the level of anger in individuals and help them to maintain their peace by relying on God. At this session, individuals learned to not focus their anger on themselves but to let go of their revenge for the good of God. 12 Generate spiritual motivation in individuals At this session, participants were encouraged to connect with God and were asked to say parts of the prayer with translation.
Newton and McIntosh signified that parents of disabled children who positively perceived God had more effective psychological coping and were more resistant to stress (12). In this regard, the findings of a study conducted by Jenaabadi et al. showed that the level of attachment to God and life's meaningfulness of parents with mentally retarded children are above average and there is a positive and significant relationship between attachment to God and life's meaningfulness in this group of parents (13). Research on the impact of spiritual interventions to enhance resilience and QOL of parents of children with learning disabilities is scarce, and the existence of a gap is apparent in this regard. In particular, previous studies conducted on the QOL and resilience of these families have been mostly descriptive and fewer intervention studies can be found in this regard. Therefore, the current research aimed to investigate the effectiveness of group training of reliance therapy components on the resilience and QOL of mothers of children with learning disabilities.

Methods
The present research was a quasiexperimental study with pre-and post-test and a control group. The sample population included the mothers of children with learning disabilities (n=120) in district 2, Zahedan, Iran, in the academic year of 2018-2019. A simple random sampling method was used to select the sample, in which 30 mothers of students referring to the Alavi Education and Rehabilitation Center for Learning Disabilities in district 2, Zahedan, Iran, were entered into the experiment.
The inclusion criteria entailed: 1) at least basic literacy, 2) The final diagnosis of their child's learning disability by the instructors of the Learning Disabilities Center, 3) no other mental illness, 4) non-participation in any other training groups, simultaneously.
The participants were randomly selected and assigned to two groups of 15 in each control and experimental groups. Exclusion criteria were not doing the assignments and absence for more than two sessions. Furthermore, the subjects' consent to participate in the current research were obtained. The research instrument consisted of the following questionnaires: 1. The Quality of Life Scale: This questionnaire measures the QOL using 26 items in four health-related domains, namely physical health (items 3-4-10-15-16-17-18), psychological health (items 5-6-7-11-19-26), social relationships (items 20-21-22), and living environment (items 8-9-12-13-14-23-24-25) on the Likert scale (very bad=1 and very good=5) and items 3, 4, and 26 are scored in reverse (10).
In Iran, Nejat, Montazeri, Holakouee, and Vajdzadeh (2006) translated this questionnaire into Persian and standardized it. Its reliability values were measured at 0.77, 0.77, 0.75, and 0.84 in the field of physical, psychological, social relationships and, living environment, respectively. In addition, based on Cronbach's alpha, the obtained results indicated that the QOL questionnaire had acceptable reliability of 0.70, 0.73, 0.55, and 0.84, respectively (14). In the present study, the total reliability of the Cronbach's alpha was estimated at 0.81.
2. Resilience Questionnaire: This 25-item questionnaire was developed by Connor and Davidson (15). It measures the resilience structure on a five-point Likert scale (from completely false=0 to always true=4) and the total score range is within 0-100. The results of studies on psychometric properties of this questionnaire in normal and patient samples have confirmed its validity and reliability (16). In the present study, the total reliability of the Cronbach's alpha was calculated at 0.84.
In order to carry out the current research, the subjects were selected by available sampling. Thereafter, in a briefing for parents of the students participating in the study, additional to the outlining the aims of the study, they were asked to complete a written consent on behalf of their children regarding their participation in the study. Ethical considerations included obtaining parental consent, the possibility to withdraw from the research at any stage, secrecy, dissemination of results without bias, and citing only trusted sources.
The mothers were asked to answer the research questionnaires first (pre-test), then the experimental group received 12 sessions of group training of reliance therapy for 6 weeks (i.e., 2 sessions of 60 min long in each week); however, the control group received no intervention. Then, the post-test was taken from both groups. Intervention in the experimental group training used techniques, such as intellectual challenge, panel discussion, role modeling, and providing stories from the Holy Qur'an and religious scriptures, literary texts, group prayer, and relaxation ( Table 1).
The collected data was analyzed using SPSS software (version 19). Moreover, descriptive statistics methods (e.g., mean and standard deviation) and inferential statistics, including univariate analysis of covariance were performed.

Result
According to the results of the present study, in the control group, four mothers had a diploma, six with associate degrees, four with bachelor's degrees, and one with master's degree or higher. However, in the experimental group, three mothers had a diploma, five were graduates, six were bachelor's holders, and one had a master's degree and higher (Table 1).
In the experimental group as compared to the control group, a greater increase was observed in the resilience and QOL scores in the posttest than the pre-test. Before performing this test, the statistical assumptions of the normality of the distribution of the scores were analyzed by Kolmogorov-Smirnov test, covariance matrix homogeneity using box's M test, regression line homogeneity, and variance homogeneity using Levene's test. Moreover, the non-linearity from these assumptions permits the usage of the aforementioned tests.
According to Table 2, the obtained F value was measured at 18.833 and its significance level was less than 0.01 (P<0.01). Based on the higher mean scores of the experimental group in the post-test, it can be concluded that group training of reliance therapy components has been effective in increasing the resilience of mothers of children with learning disabilities. In addition, the F value was equated to 15.12 and its significance level was less than 0.01 (P<0.01). Accordingly, it can be inferred that group training of reliance therapy components has been effective in enhancing the mothers' QOL.

Discussion
The present study aimed to investigate the effectiveness of group training of reliance therapy components on resilience and QOL of mothers of children with learning disabilities in Zahedan, Iran. The results showed a significant difference between the resiliency of the experimental and control groups in the post-test. In addition, considering the higher mean scores of resilience in the experimental group in the post-test, it can be concluded that group training of reliance therapy components is effective and has increased the resilience of mothers of children with learning disabilities. The obtained results were indirectly consistent with the research findings (17)(18)(19). In a study entitled "attachment to God and resilience in mothers of mentally retarded children", Nemati et al. found that secure attachment to God increases resilience among the mothers of normal children and the avoidant attachment to God decreases resilience in mothers of mentally retarded children (17). The results of the aforementioned study showed that the type of attachment to God can influence peoples' level of resilience in the face of life's challenges. Furthermore, the results of another study conducted by Dehghani showed that group therapy based on acceptance and commitment was effective in increasing the resiliency of mothers of children with learning disabilities (18).
In explaining this finding, it can be concluded that a believer considers crises and hardships as tests from God and ways for human growth and excellence; therefore, s/he tries to deal with them rather focusing on the problem and distress. In fact, coping strategies are a set of cognitive and behavioral attempts to ameliorate a stressful situation; consequently, reducing the resultant suffering. Religious coping is a domain in which individuals with the help of beliefs and religious practices try to prevent stress caused by life's pressures and problems (20).
In psychological research, trust in God has been regarded as one of the most effective religious confrontations. When a person encounters problems and senses that s/he is not able to solve them alone, s/he appoints another empowered person as her/his lawyer. Based on religious teachings, such a person in order to compensate her/his weakness uses natural and material factors and relies on God's infinite power and seeks his help. People who do not trust in God and do not attach themselves to the infinite power of God are limited in their powers and abilities. Therefore, they find themselves powerless in dealing with problems; however, the believers put their hopes in God's support and have high selfconfidence (21).
Based on the definition, tawakkul is an attitude that leads one to trust in the almighty God in all of his deeds, and that trust creates a sense of comfort in his heart that he will not slip and doubt in the events of life (22). This increases their ability to cope with stress, pressure, and psychological problem; therefore, increasing their resilience. A significant difference was observed between the QOL of the two experimental and control groups in the post-test. In addition, considering the higher mean scores of QOL in the experimental group in the post-test phase, it was concluded that group training of reliance therapy components is effective and has increased the QOL of mothers of children with learning disabilities. The findings of the present study are indirectly in line with the results of previous studies in this field (22).
Nayeb Hosseinzadeh et al. in a study entitled "the effectiveness of acceptance and commitment training on improving the quality of life and self-compassion of the mothers of educable disabled children" showed that there is a significant difference between QOL and self-compassion variables between the two experimental and control groups' scores and resilience outcomes in the follow-up phase (22).
In explaining the obtained results, Yang and Mao believe that having a purpose and meaning in life, a sense of belonging to a higher meaning, hope in God's help in difficult situations, and receiving social and spiritual support are all ways that with their help, religious people may shield people from harm in the face of stressful life events (23). In addition, Fountoulakis, Siamouli, Magiria, and Kaprinis suggest that the belief that there is a God who is in control of all situations greatly reduces the peoples' anxiety (24). In other words, these people believe that uncontrollable situations can be managed through reliance on God.

Conclusion
People believe that God has infinite power and his remembrance comforts their hearts. Moreover, the Holy Quran has assured eternal life after death. This brings inner peace and this inner peace in return raises hope. This hope gives meaning to life, changes one's attitude, and helps to endure psychological problems in life. Consequently, all of the mentioned factors provide a basis for QOL improvement.
The small sample population and lack of control over the variables affecting the QOL, such as socio-economic class and social support were limitations of the present study. Regarding the effect of group training of reliance therapy on resilience and QOL, it is suggested that the abovementioned intervention training be provided for the assessment of the psychological status of families of children with learning disabilities. Future studies should be conducted through the selection of the sample population of mothers with normal children and with a larger size. In addition, considering the impact of various economic and cultural factors on QOL, it is recommended to conduct several studies with different sample populations.

Conflict of interest
There are no conflicts of interest regarding the publication of the current research.