Volume 12, Issue 2 (Mar & Apr 2022)                   J Research Health 2022, 12(2): 121-130 | Back to browse issues page


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Esteki Azad N, Golparvar M, Sajjadian I. The Effectiveness of Filial Therapy and Cognitive-Behavioral Art-Play on Meta-emotion View of Mothers of Single-parent Children During Coronavirus Quarantine. J Research Health. 2022; 12 (2) :121-130
URL: http://jrh.gmu.ac.ir/article-1-2030-en.html
1- Department of General Psychology, Faculty of Educational Sciences & Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran.
2- Department of General Psychology, Faculty of Educational Sciences & Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran. , drmgolparvar@gmail.com
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1. Introduction
The world’s social developments in recent decades have presented the family system with new changes, problems, and requirements while also expanding the family’s exposure to numerous factors [1]. The most challenging catastrophe a person may experience is the death of a close relative. If the family system fails to adjust to the new situation due to a lack of resources, it may be destroyed [2]. In the absence of either parent, the other parent’s role in the child’s development becomes more significant; as a result, the characteristics of maternal and paternal parenting may alter depending on the presence or absence of another parent [3]. Psychological characteristics in mothers may also influence the quality of parent-child connections [4]. The emotional condition of parents (primary caregivers) impacts children’s emotions. Children who have a better relationship with their parents and whose parents show less stress and anxiety have fewer behavioral problems and follow better treatment plans [5]. Family support is also essential in coping with the loss [6]. Inadvertently, the single parent children gets embroiled in paradoxes that he cannot comprehend or deal with [7].
In this respect, “parents’ cheerful viewpoint” is a novel concept that has lately been brought to the realm of psychology. The resident should be aware that emotions are split into two categories: primary emotions, which are felt automatically and intuitively, and secondary emotions, which are felt willingly in reaction to primary emotions. Sub-emotion, according to Greenberg, is a sub-scale of secondary emotions that encompasses basic emotions. Some scientists believe that people’s mental impressions of feelings influence the quality of emotion. In other words, negative sensations (like shame and extra-anxiety) imply a rejection of a certain feeling or emotion, but good feelings (like hypersensitivity and hypersensitivity) are receptive and seem beneficial [8]. Meta-emotion perspective of parents are divided into two categories. The first variable is awareness that indicates parents' awareness of their own and their children's emotions and their ability to discuss the dimensions of emotions in the family [9]. 
The second variable is guidance, which refers to a level of parental intervention such as direct instructions and talking to children about their emotions. Because of their wide variety of contacts and activities, parents’ extra-emotional styles (as a family component) impact their children’s psychological performance. By highlighting the relevance of parents’ ideas and sentiments regarding emotions, the mother’s transcendental viewpoint also protects children against the detrimental impacts of unbearable conditions [4]. Meta-emotion beliefs are an essential component of people’s emotional regulation methods because they allow them to adapt to external events more flexibly [10]. State and Turner also emphasize the role of parents in the formation of emotions, as well as the impact of parental awareness and guidance in their children’s emotional situations, and believe that receiving emotional training makes children feel more competent and adequate in the face of external obstacles and stress [11]. The function of parents’ responses to their children’s good and negative emotions in the establishment of positive and negative emotions in children was studied by Shewark and Blandon [12]. Their findings revealed an association between the child’s emotional negativity and the parents’ unsupported responses to the child’s good feelings. Katz and Hunter also discovered that mothers who were more conscious of their emotions had better-adjusted children [13]. 
People with a negative attitude of emotions, according to Leahy, do not behave effectively or efficiently in coping with life situations and often employ unsafe tactics to control their surroundings [8]. Compared to Children whose parents don't see parents' meta-exciting philosophy as very efficient, children whose parents employ the emotional guidance approach have a high degree of emotional organization [14] and social skills [15]. After establishing meta-emotion as one of the factors associated with mental health [12], the critical question is how and via what means this variable can be promoted in single-parent women, improving their health and capacity. The mothers’ mental health during the COVID-19 pandemic and the consequent quarantine must be taken into account in therapy and intervention plans. Play therapy combined with art therapy is one of the approaches that can help both mothers and children because therapeutic relationships are an essential component of children’s therapy. The emotional relationship between parent and child is well established and maintained in a play-based interaction [16]. Play therapy, according to Farnam, Soltani Nejad, and Heidari, is a therapeutic strategy used to treat a broad variety of illnesses in children [17]. 
Previous research has found that play therapy, in the form, structure, and process described, can affect various problems in different samples, such as increasing the range of interpersonal relationships of girls with separation anxiety [18], the frequency of externalized behaviors of marginalized children [19], reducing symptoms of insecure attachment, separation anxiety in preschool children [20], and self-confidence of children with mental disabilities [21], Social skills and academic achievement of students [22] demonstrate significant effectiveness.
Lantz and Rise employed art and play therapy to assist parents and their children enjoy a safe atmosphere by creating images, telling tales, and acting in a study entitled The Use of Art and Play in the Treatment of Existential Trauma of Children and Their Parents, Lantz and Rise, using art therapy and play method, helped parents and their children to succeed in a safe space by drawing pictures, telling stories, puppet shows and sandboxes to bring trauma from the unconscious to the level of awareness, to share trauma with the therapist. and take over them [23]. In general, few studies have attempted to integrate the dimensions and powers of both treatments to address the concerns and requirements of mothers and their children by integrating both art therapy and play therapy based on the situations and needs of single mothers. Because of the increased load of duties single-parent moms face, positive therapies with long-term benefits are needed to sustain the mother’s happiness and solid ties with her kid. On the other hand, essential findings may be accomplished to increase the quality of excitement and depleted functions of mothers by commencing research in this sector and propagating it in other psychological functions. 
There is a significant lack of scientific knowledge and information on the combination of two methods of play and art therapy for single parent children, as is widely recognized in domestic and international research. This study will pave the way for closing the knowledge gap described before. As a result, it is feasible to address the difficulties of mothers and children via parent-child play (filial therapy) and art-play therapy, which is consistent with the inner dynamics of the children engaged in the parenting problem. This research focuses on using filial therapy in conjunction with a new integrated approach to cognitive-behavioral art-play so that single mothers address their parenting difficulties by playing with and connecting with their children. The study’s major objective is whether Filial therapy and cognitive-behavioral art-play therapy impact the mothers of single-parent children’s meta-emotion.

2. Methods
The current research was a quasi-experimental study with a pre-test-posttest design and three study groups: a cognitive-behavioral art-play group, a Filial Therapy group, and a control group. In the spring of 1400, all mothers with a single child aged 6 to 12 years living in Isfahan City, Iran, who joined the study procedure by a call were included in the statistical population. Purposive sampling based on the inclusion and exclusion criteria was used to pick 54 eligible mothers and their children (18 persons for each study group). They were then divided into three groups using a simple random approach (lottery). After the research, one member of the cognitive-behavioral art-play therapy group and three members of the Filial therapy group dropped, reducing the sample size to 17 and 15 participants, respectively. The group decline was attributable to coronary heart disease throughout the sessions. The exclusion criteria included reluctance to participate in the study, participating in alternative psychological or psychiatric treatment, and absence of more than 2 sessions of treatment. The inclusion criteria included having a single child in the age group of 6 to 12 years, not being placed in other psychological or psychiatric treatments, lacking psychological disorders, and having full consent to participate in treatment and research. Ethical considerations included the observance of the principle of confidentiality, the use of data only for the research without mentioning the names of individuals, the freedom and full authority of participants to cancel their participation in the research if desired, and to get accurate information about the research at the request of participants. Written consent was obtained from the participants. Besides, after the treatment was completed, the control group could ask for and receive either program of the cognitive-behavioral art-play therapy or Filial Therapy.

Research Instruments 
The Parental Meta-Emotion Scale (PMES) was utilized to gather data online. The short form of the Parental Meta-Emotion Scale was prepared in 2006 by Evelynekehe. In this survey, parents are asked to share their ideas and feelings about their own and children’s anger, sorrow, and worry. The original version of this questionnaire included 30 items, but three items were eliminated, and the total number of questions was lowered to 27 when Parsayi and Foladchang [24] translated and examined the psychometric features of the questionnaire in Iran in 2010. So, this questionnaire has 27 items in two subscales: leadership beliefs (18 items, questions 1–18) and competency beliefs (18 items, questions 1–18). (9 terms, questions 19 to 27). The answers are scored on a 5-point Likert scale from “strongly agree=5” to “strongly disagree=1.” The total scores vary from 27 to 135. Higher scores imply that parents have a strong viewpoint and style. Ivlinico used factor analysis to test the questionnaire’s validity [8]. Parsaei and Fooladchang tested the validity of this questionnaire utilized factor analysis with the main components approach and varimax rotation [24]. The questionnaire’s reliability was 0.98 for the guidance subscale, 0.85 for the sufficiency and competence subscale, and 0.79 for the whole scale using the Cronbach alpha. The Cronbach's alpha method has been used in the study of Parsayi & Foladchang to determine reliability. In this research, Farahijan’s Cronbach alpha, attitudes about leadership, and beliefs about acceptability and competence were 0.93, 0.92, and 0.87, respectively.
Two groups of art - cognitive-behavioral play therapy and Filial therapy and a control group, art - play therapy [25] and Filial therapy [26] during sessions received the treatments in person and complementary to the groups formed in virtual networks. A weekly session with play therapy equipment was held in person in the play therapy room of a psychological counseling center in Isfahan, with the participation of mother and child at the same time, under the supervision of a master therapist with official credentials and a hygienist. During this time, the control group was on the waiting list and did not get any treatment. Then, after the end of the post-test treatment sessions, it was performed for all three groups. Tables 1 and 2 provide the treatment sessions and a short description of each session for the two therapies employed in the research.

Statistical analyses 
The obtained data were analyzed by multivariate analysis of covariance and Bonferroni post hoc test in SPSS software, v. 27.

3. Results
The findings of the Chi-square test showed no significant difference between the experimental and control groups regarding the child age, mother’s education, child gender, number of children in the household, and years of single parenting. In two phases of research, the Mean±SD of meta-emotion components for experimental and control groups revealed that the two groups of art-play therapy and filial therapy exhibited more significant changes in the post-test stage than the control group (Table 3).

In addition to validating the normality of the data distribution, Levene’s test revealed error variance equality (P=0.05) before starting the analysis of covariance. The slope of the regression lines was equal after the interaction of group membership with the pre-test. The Box’s M test for the equality of the variance-covariance matrix was also tested (Table 4).

Parent meta-emotion has a normal distribution (P<0.01) and error variance equality (P<0.01) in all three phases of pre-test, post-test, and follow-up (Table 5), except for the post-test and follow-up periods (which have not been observed). The variance-covariance matrix equivalence (by Box’s M test) (P<0.05) and sphericity default (via Mauchly’s or Maxwell test) were not detected. The Greenhouse-Geisser statistic in the final analysis tables may be used when the sphericity default is not observed. As a final resort, the slope of the regression lines was checked.
After testing the hypotheses, a multivariate analysis of covariance revealed that, after controlling for the pre-test, the factor of group membership (art-play, cognitive-behavioral therapy, Filial Therapy, and the control group) in the variable meta-emotion (P<0.01, F=54.19) is significantly different from leadership (P<0.01, F=47.31) and adequacy and competence (P<0.01, F=44.76). This finding suggests a substantial difference in meta-emotion, leadership views, and adequacy and competence beliefs, at least between the two groups of the three study groups (Table 5).
The results of Bonfroni's follow-up test in order to compare the two groups of the research showed that in the overall meta-emotion scale and its components including beliefs related to guidance and beliefs related to adequacy and competency between art-play therapy and philial therapy with the group There was a significant difference (P<0.01), and there was a significant difference between the two interventions (P<0.01) so that two groups was used for Both dimensions of beliefs related to guidance, competence and competence were much more effective (Table 5).

4. Discussion
This research aimed to examine the efficacy of Filial therapy and cognitive-behavioral art-play therapy on the meat-emotion of single-parent children’s mothers during myocardial quarantine. Between the control group and the two therapy methods, there is a considerable difference. The results also showed that there is a significant difference between art-play group with pillial therapy and control group, and between filial therapy group and control group. This finding suggests that cognitive-behavioral art-play treatment and later Filial therapy enhanced meta-emotion and its components single parent children mothers. These findings are generally in line with prior research findings. There are two types of research in the meta-emotion area of parenting that have been conducted so far: correlation and experimental studies (very few). However, in terms of causal limitations, the results of correlation studies cannot be directly compared with experimental and quasi-experimental studies such as the current study. However, considering that the results of correlation studies are the result of pre-experimental studies (such as qualitative-quantitative studies that are performed through the first quantitative stage based on path analysis or structural equation modeling), the results of correlation studies can be directly compared with the results of experimental and quasi-experimental studies [27].
According to this point, the results of studies on the relationship between meta-emotion styles Parents with things like self-efficacy and emotional intelligence students [9, 24, 28] Children's emotional regulation and anxiety [14], formation of positive and negative emotions in children [12], depression [13], shows alignment.
In addition to the correlation studies mentioned above, studies on the effectiveness of art therapy and play therapy in increasing the range of interpersonal relationships of girls with separation anxiety [18], the frequency of externalized behaviors of marginalized children [19], and reducing insecure attachment symptoms of separation anxiety [20] have been conducted. Self-confidence of children with intellectual disabilities [21], achievement of students [22], parental acceptance [29], emotion regulation [30, 31], internalizing problems [32], emotional-functional [33, 34], reducing symptoms of post-traumatic stress disorder [35], parental stress children with functional abdominal pain, also noted. Although the statistical population of the current study (mothers of a single child) differs significantly from that of the experimental studies mentioned, the results can be compared because some techniques in play therapy and art therapy are included in the package of art-play-cognitive-behavioral therapy. The experimental investigations were somewhat similar to the current study’s findings on the usefulness of art-cognitive-behavioral play therapy in enhancing mother enthusiasm.
Several significant processes contribute to the better efficacy of cognitive-behavioral art-play therapy in enhancing mother enthusiasm. The general content and structure of the cognitive-behavioral-art-play therapy course are based on creating positive interactions, establishing a relationship based on empathy, being friendly and warm with the child, identifying and naming emotions, and expressing conflicts, desires, and emotions (emotional discharge and fear and anxiety control). To teach emotional coping methods, proper expulsion and communication without causing injury to others, reconciling with rage and expressing it without violence, teaching emotional control and practicing communication without violence, and behavioral management training with siblings and parents to reduce clinical symptoms identification is essential. The focus of the therapy is on the repair of dysfunctional ideas and cognitive abilities, the development of desired social behaviors and skills, and the enrichment of communication with parents and peers. The cultivation of pleasant emotions such as attachment and transcendence represents the individual’s reality in embracing their feelings and higher meta-emotion. Children’s answers based on acceptance of their grief and rage raise the mother’s value of their emotions, and enhance the parent’s emotional understanding. Sub-emotional beliefs are a key aspect of people’s emotional regulation techniques, allowing them to adapt to external events more flexibly [13].
Considering the increase in parental excitement in terms of using play therapy based on parent-child relationships (Filial Therapy) in mothers of single children, it must be mentioned that recognizing emotions and understanding how they work plays a crucial role in ongoing family interactions. The dimension of the parenting perspective as a family element and increasing knowledge, acceptance, and guidance in recognizing and regulating emotions is a window to move towards a more harmonious family life. It facilitates the creation of interpersonal and individual interactions. The role of the parent in the formation of emotions, as well as the impact of parental awareness and guidance in children’s emotional situations, is always acknowledged because children who receive emotional training from their parents feel more competent in the face of external obstacles and stress. Parents who are sympathetic and consoling to their children through challenging emotional situations such as the death of a parent develop a greater bond with their children. They educate their children on how to handle their emotions in the case of a traumatic situation by sharing their experiences and recommendations. One of the critical objectives of Filial therapy is for parents to become more conscious of their own and their children’s emotions, as well as be able to talk about the many aspects of emotions in the family. Two-person play is led by the child and accompanied by the mother, and both provide the foundation for the development of interpersonal skills, emotional self-regulation, and extra-emotional skills [8]. Concern for emotions, respect for it, and acceptance of their children’s emotional experiences provide the basis for developing interpersonal skills, emotional self-regulation, and extra-emotional skills.
A few of the study limitations are the imbalance of personality traits of participating mothers, mothers’ absence from several training sessions due to limitations imposed by the spread of coronavirus, lack of follow-up due to time constraints, and inability to control social and economic class variables of parents. As a result, it is recommended that new research be conducted, considering the constraints above, to assess the therapeutic benefit of coordinated treatments by the therapist, family, and school in distinct groups. These strategies should also be investigated in other places and connected to the father’s parent households.

5. Conclusion
Considering the effect of two interventions of art - play and filial therapy on improving the meta-emotion of mother and the effect of this therapes on moderating beliefs related to guidance, adequacy and competence of mothers, it is necessary to pay attention to the meta-emotions of mothers of single parent children in the COVID-19 epidemic.

Ethical Considerations
Compliance with ethical guidelines

The Scientific Research Committee of the Islamic Azad University, Isfahan branch (Khorasgan), approved the current research (IR.IAU.KHUISF.REC.1399.060). 

Funding
The paper was extracted from the PhD thesis of the third author at the Department of Psychology, Faculty of Psychology and Educational Sciences, Islamic Azad University, Isfahan (Khorasgan) branch, Isfahan, Iran. We would like to thank all participants in the study who made this research possible with their presence and participation. Furthermore, the research is self-funded.

Authors' contributions
Writing – original draft, and Writing – review & editing: All authors; Nasim Esteki Azad; Data collection and Data analysis: Mohsen Golparvar; Methodology: Nasim Esteki Azad; Investigation: All authors.

Conflict of interest
The authors declared no conflict of interest.


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Type of Study: Orginal Article | Subject: Health Psychology and Social Health
Received: 2021/12/6 | Accepted: 2022/02/12 | Published: 2022/03/1

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