The Effectiveness of Reality Therapy Training Based on Choice Theory on Mental Health and Emotion Regulation in Female Middle School Students

Introduction

Adolescence is a transitional period marked by cognitive, biological, physiological, social, and psychological changes, spanning from ages 10 to 19 (Gharib-Balouk, Mikaeili, Basharpour, & Gharib-Balouk, 2023). Adolescents, due to their exposure to various events in peer environments, school, and home, experience significant mental health challenges (Yarvisi, Mihan Doost, & Mami, 2020). In recent years, mental health issues have increasingly escalated among children and adolescents, raising societal concerns due to the negative impacts on their psychological-emotional and social development. Consequently, child and adolescent mental health specialists underscore the importance of timely diagnosis of these issues and the provision of appropriate therapeutic approaches for treating psychological disorders. Early intervention in identifying mental health problems in children and adolescents is a key concern of mental health systems (Morley & Nati, 2019).

Research indicates that effective emotion regulation is associated with mental health, while ineffective emotion regulation is linked to various psychological and behavioral disorders in adolescents (Dehbozorgi & Davoodi, 2020; Vafapour, Karami, & Momeni, 2021). Gross (2001), in the emotion regulation process model, suggests that various emotion regulation strategies are engaged during the full expression of an emotional response. Before the full experience of an emotion, assessments of emotional cues are conducted. These cues can be evaluated from different perspectives, potentially initiating experiential, behavioral, and physiological responses (Gross, 2001). Each stage of the emotion generation process represents a potential target for regulatory efforts, where emotion regulation skills can be applied at different points. Gross's emotion regulation process model includes five stages, each involving a series of adaptive and maladaptive strategies (Kobylińska & Kosi, 2019). Individuals with emotional difficulties tend to rely more on maladaptive strategies such as rumination, avoidance, etc. (Borjali, A'zami, & Choupan, 2016). According to Gross's emotion regulation process model, the primary emotion regulation strategies include reappraisal (reconstructing an emotional situation as less emotionally intense) and emotion suppression (inhibiting the outward display of emotional states during emotional arousal). The main difference between reappraisal and suppression strategies lies in their timing; reappraisal is used before emotions are fully experienced, whereas suppression is employed after experiential, behavioral, and physiological responses have begun (Gross, 2002).

It appears that effective interventions and training during this period, and afterward, are more necessary than ever. Among these, "Reality Therapy," which emphasizes responsibility and choice principles, helps adolescents make appropriate choices and understand that they can control their lives, moving away from external control. Through appropriate choices, individuals assume responsibility for their behavior (Shishehfor, Kazemi, & Pezhvak, 2017). Reality Therapy comprises a set of methods and tools designed to assist individuals in transitioning from ineffective to effective behaviors, from destructive to constructive choices, and most importantly, from an unsatisfactory to a satisfactory lifestyle. In this approach, gaining control over one's choices and accepting responsibility for these choices and meeting needs are central to the therapeutic process (Glasser, 2019). Reality Therapy helps individuals confront the reality of their behaviors and choices, understand that they, not others or the world, play a role in their problems, and realize that they must move beyond denial and learn to reevaluate their desires and behaviors to make better choices for achieving life satisfaction. The primary goal of Reality Therapy is to change unsuccessful identity and foster responsible behavior, as irresponsible behavior leads to discomfort and mental health issues (Glasser, 2003).

A study titled "Examining the Effectiveness of Group Reality Therapy on General Health and Responsibility in Orphaned and At-risk Adolescents in Tehran's Welfare Centers" by Jabari, Saedi, Zohrabnia, and Rahmati (2020) demonstrated the effectiveness of Reality Therapy on general health and responsibility in adolescents. Another study by Rakh (2018) showed that after conducting Reality Therapy sessions, the therapy was effective in reducing emotion regulation difficulties and increasing self-efficacy compared to the control group. In another study by Ghorayshi and Behboodi (2016), titled "The Effectiveness of Group Reality Therapy on Emotion Regulation and Academic Self-Efficacy in Female Students in District 5 of Tehran Province," the results indicated the therapy's effectiveness in enhancing self-efficacy and emotion regulation in the experimental group compared to the control group. A study by Yazdizadeh, Hafezi, Ehteshamzadeh, Heydari, and Eftekhari Saadi (2023) found that Reality Therapy had a significant impact on reducing academic self-handicapping and emotion regulation difficulties in male high school students. These researchers concluded that Reality Therapy reduces academic self-handicapping and emotion regulation problems.

The findings of these studies indicate the effectiveness of Reality Therapy on general health and emotion regulation across various populations. However, the information in this area is scattered. Additionally, research has shown gender differences in mental health issues, particularly in depression, anxiety, physical functioning, and interpersonal functioning during adolescence, which coincide with the onset of premenstrual disorders (Lee, Jiang, Haldorsdottir, Zhu, Burton Johnson, et al., 2023; Yoon, Eisenstat, Liria, & Dighton, 2023). Mental health issues are the leading cause of disease burden worldwide, with women and girls globally suffering from higher levels of mental health problems (Campbell, Bann, & Patalay, 2021). Considering the mental health challenges in adolescents, exploring newer treatment options, especially for adolescent girls at the onset of menstruation, is essential. Therefore, a research gap is evident in this area, emphasizing the importance and necessity of the present study. The aim of this study was to determine the effectiveness of Reality Therapy training based on Choice Theory on mental health and emotion regulation in female middle school students.

Methods and Materials

Study Design and Participants

The research method was quasi-experimental with a pre-test, post-test, follow-up, and control group design. The statistical population included all female middle school students in District 11 of Tehran during the 2021-2022 academic year, from which 30 individuals were selected through purposive sampling and randomly assigned to two groups: intervention and control. Referring to Cohen's table, considering the number of groups (u = 2), 95% confidence level, a test power of 0.8, and an effect size of 0.4, the sample size was determined to be 12 participants per group. Considering a 20% dropout rate, 15 participants were assigned to each group. Inclusion criteria included scoring above the mean cutoff in the General Health Questionnaire, age 13 to 15 years, living with both parents, absence of parental divorce, and no chronic physical illnesses, other psychological disorders, or simultaneous use of psychiatric medications and psychotherapy. Exclusion criteria included lack of cooperation in sessions, more than two absences, and withdrawal from participation.

Based on the inclusion criteria, 30 volunteers were selected, all of whom, along with their parents, consented to participate in the study. These 30 individuals were randomly assigned to experimental and control groups. Prior to the sessions, permission was obtained from the Tehran Education Department. After completing the legal procedures and obtaining permission, it was agreed with the school principal that the experimental group would use the school facilities for the training workshops. On July 1st, both the experimental and control groups attended the school, where pre-tests were administered at two different times by completing the research questionnaires. The schedule for the training sessions was coordinated with the experimental group. The control group was assured that if they wished, the educational sessions would be conducted for them after the intervention period. Each session lasted approximately 90 minutes and was conducted twice a week starting from the first week of July. Consequently, the Reality Therapy training based on Choice Theory was conducted in 12 sessions of 90 minutes each for the experimental group. The sessions concluded in mid-August. Notably, one participant from the experimental group was excluded due to more than one absence, reducing the experimental group to 14 participants. The control group remained at 15 participants until the end of the study. At the end of the training sessions, both the experimental and control groups were asked to complete the questionnaires again. A three-month follow-up period was planned, and in November 2022, both groups completed the questionnaires again.

Measures

Mental Health

Goldberg's General Health Questionnaire (1978) consists of 28 items divided into four subscales: physical symptoms (items 1 to 7), anxiety and insomnia (items 8 to 14), social dysfunction (items 15 to 21), and severe depression (items 22 to 28), measured on a 4-point Likert scale ranging from 0 to 3. The minimum score on this instrument is 0, and the maximum is 84. A score of 0 to 22 indicates no mental health problems, a score of 23 to 40 indicates mild problems, a score of 41 to 60 indicates moderate problems, and a score of 61 or higher indicates severe mental health issues. Goldberg and Hiller (1979) reported convergent validity for the General Health Questionnaire, with correlations ranging from 0.21 to 0.73 between the subscales and physical symptoms, anxiety and worry, and depression. Behroozi, Mohammadi, and Omidian (2018), in a sample of high school students in Ahvaz, reported Cronbach's alpha coefficients of 0.618, 0.696, 0.719, and 0.853 for the physical symptoms, anxiety and insomnia, social dysfunction, and severe depression subscales, respectively, and 0.86 for the entire questionnaire. Behroozi et al. (2018) also used confirmatory factor analysis to determine the construct validity of the General Health Questionnaire, with fit indices of GFI = 0.715, AGFI = 0.663, and RMSEA = 0.077, indicating a good fit of the data with the measurement model and the construct validity of the instrument. In this study, Cronbach's alpha coefficient for this instrument was 0.83.

Emotion Regulation

The Gross and John Emotion Regulation Questionnaire (2003) consists of 10 items that assess two subscales: thought suppression and reappraisal, measured on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Gross and John (2003) reported Cronbach's alpha coefficients ranging from 0.68 to 0.82, and the correlations of thought suppression and reappraisal with Trapnell and Campbell's (1999) Rumination Scale were 0.19 and -0.29, respectively. Lotfi, Bahrampouri, Amini, Fatemi Tabar, Birshak, et al. (2019), in a sample of 412 adolescent girls, reported concurrent correlations of the reappraisal and thought suppression factors with the positive and negative affect, anxiety, and depression subscales as an index of convergent validity for the instrument, and Cronbach's alpha coefficients of 0.79 and 0.68 for the reappraisal and thought suppression factors, respectively, as an index of the internal consistency of the instrument. In this study, Cronbach's alpha coefficients for the emotion regulation strategies of thought suppression and reappraisal were 0.73 and 0.81, respectively.

Intervention

Reality Therapy Training Based on Choice Theory

The training was based on Glasser's (2003) book "Reality Therapy for Parents and Adolescents" and was conducted over 12 sessions of 90 minutes each. A summary of the sessions is as follows:

Session 1: Establishing Rapport and Setting Program Goals

In the first session, the primary focus is on building rapport among participants and introducing the elements of the educational program, including the counselor, group members, and the program framework. The session aims to create a comfortable environment where members can connect with each other. Participants are encouraged to reflect on the concept of responsibility and its significance in their lives.

Session 2: Understanding Key Concepts and Their Impact on Life

This session introduces the theoretical concepts of Reality Therapy, explaining the reasons behind our behaviors and how they function. The session emphasizes the importance of responsibility and psychological well-being. Participants engage in exercises that help them understand the role these concepts play in their lives. As an assignment, each participant is asked to create a list of tasks they believe they cannot accomplish and goals they feel are unattainable.

Session 3: Exploring Human Needs

In the third session, the five basic human needs are comprehensively introduced, and participants are guided in prioritizing these needs. The session encourages participants to think about how their fundamental needs are being met. The homework involves reflecting on the strategies they use to fulfill these essential needs in their daily lives.

Session 4: Learning Behavioral Choices

This session focuses on familiarizing participants with the four components of total behavior (thinking, acting, feeling, and physiology) using the "behavioral car" analogy. The group learns that by adjusting the steering wheel—representing thoughts and actions—they can manage their behavior more effectively. Participants are tasked with practicing behavioral choices in real-life situations, emphasizing personal life scenarios.

Session 5: Emphasizing Responsibility for Behaviors

In this session, participants explore the concepts of internal and external control, understanding how these influences impact their behaviors. The group discusses the significance of taking responsibility for one's actions. As an assignment, participants create a list of behaviors under their internal and external control and develop strategies to manage these behaviors.

Session 6: Identifying Destructive and Constructive Behaviors

Participants are introduced to various destructive and constructive behaviors, learning to recognize these patterns in their key life interactions. The session encourages the identification of personal destructive and constructive behaviors. Participants are assigned to list their own destructive and constructive behaviors in real-life situations.

Session 7: Moving Toward Positive Choices

This session focuses on aligning participants' desires with reality, helping them assess whether their chosen goals are achievable. The group works on practical steps to achieve their desires, and participants are supported in taking actionable steps toward their goals.

Session 8: Emphasizing Personal Responsibility for Choices

In this session, participants review the content from previous sessions and deepen their understanding that they are responsible for their own behaviors and must take ownership of their lives. The session focuses on planning and implementing steps toward desired outcomes. Participants review their plans and programs to ensure they are on track to achieve their goals.

Session 9: Understanding and Managing Emotions

Participants are introduced to the concept of emotions and the basic human emotions, with examples provided for each. The session covers strategies for managing and regulating these emotions. Participants practice expressing and regulating their emotions, sharing their experiences with the group.

Session 10: Identifying Strengths and Self-Awareness Using Strength Cards

In this session, participants identify and evaluate their strengths using strength cards. They choose cards that represent their strengths and reflect on other strengths they wish to develop. The session aims to enhance self-awareness and personal growth.

Session 11: Goal Setting and Planning

This session focuses on helping participants understand the importance of having a life goal and how to plan and maintain behavior change until their goals are achieved. Participants are asked to think about how to achieve their goals by creating specific, measurable, attainable, realistic, and time-bound (SMART) plans.

Session 12: Reviewing Previous Sessions and Assessing Progress

In the final session, the group reviews the material covered in previous sessions and discusses the progress made. The session is designed to reinforce commitment to applying what has been learned to create better lives and relationships. Participants practice the skills they have acquired throughout the course with one another, solidifying their understanding and readiness to apply these skills in their daily lives.

Data analysis

In this study, descriptive data were analyzed using mean and standard deviation, and inferential data were analyzed using "Repeated Measures ANOVA" and "Fisher's exact test." Assumptions were tested using the "Shapiro-Wilk test," "Levene's test," and "Mauchly's sphericity test," with significance levels of 0.05 and 0.01. The data were analyzed using SPSS version 24.

Findings and Results

In the present study, within the Reality Therapy group based on Choice Theory, 3 participants (20%) were 13 years old, 10 participants (66.67%) were 14 years old, and 2 participants (13.33%) were 15 years old. In the control group, 5 participants (33.33%) were 13 years old, 6 participants (40%) were 14 years old, and 4 participants (26.67%) were 15 years old. In the Reality Therapy group based on Choice Theory, 4 participants (26.67%) were in the seventh grade, 9 participants (60%) were in the eighth grade, and 2 participants (13.33%) were in the ninth grade. In the control group, 7 participants (46.67%) were in the seventh grade, 6 participants (40%) were in the eighth grade, and 2 participants (13.33%) were in the ninth grade.

Table 1 shows the mean and standard deviation of the variables of mental health and emotion regulation in the Reality Therapy group based on Choice Theory and the control group across three stages: pre-test, post-test, and follow-up.

Table 1 demonstrates that the mean scores of mental health, emotion regulation, communication skills, and dependence on virtual space variables in the intervention groups changed in the post-test and follow-up stages.

Table 2 presents the results of repeated measures ANOVA for explaining the effect of Reality Therapy based on Choice Theory on mental health.

Table 2 shows that Reality Therapy based on Choice Theory in the intervention group resulted in a significant reduction in mental health problems compared to the control group (p = .001). The effect of time in Table 3 indicates that the mean mental health scores significantly differed across the study period and the three measurement points: pre-test, post-test, and follow-up (p = .001). The interaction effect in Table 2 reveals a significant difference in mean mental health scores over time between the intervention and control groups (p = .001).

Table 3 presents the results of repeated measures ANOVA for explaining the effect of Reality Therapy based on Choice Theory on the components of emotion regulation.

Table 3 shows that Reality Therapy based on Choice Theory in the intervention group led to a significant reduction in suppression and an increase in reappraisal compared to the control group (p = .001). The effect of time in Table 3 indicates significant differences in the mean scores of emotion regulation components across the study period and the three measurement points: pre-test, post-test, and follow-up (p = .001). The interaction effect in Table 4 demonstrates significant differences in the mean scores of emotion regulation components over time between the intervention and control groups (p = .001).

Discussion and Conclusion

The aim of the present study was to determine the effectiveness of Reality Therapy training based on Choice Theory on mental health and emotion regulation in female middle school students. The findings indicated that Reality Therapy training based on Choice Theory significantly improved the mental health of these students. These results are consistent with the findings of studies by Jabari et al. (2020), Rakh (2018), Ghorayshi and Behboodi (2016), and Yazdizadeh et al. (2023).

To explain the effectiveness of Reality Therapy training based on Choice Theory on mental health, it can be argued that Reality Therapy is rooted in the belief that humans have the ability to choose and can correct their errors in meeting their basic needs—such as belonging and social interest (love), achievement and power, freedom, fun, and survival—through self-evaluation. This control is learned, and if not acquired, psychological pathology begins, which manifests as unsuccessful satisfaction of these needs through the repetition of incorrect past choices. Therefore, gaining control over one's choices and accepting responsibility for those choices should be the focus of therapy (Robey, Berdan-Sky, Britzman, Crowell, & Kays, 2011). Reality Therapy helps adolescents confront the reality of their behaviors and choices, understand that they, not others or the world, play a role in their miseries, and recognize that they must move beyond denial and learn to reassess their desires and behaviors to make better choices that lead to life satisfaction. Ultimately, this leads to a more flexible, meaningful, and enjoyable life (Glasser, 2010). According to Choice Theory, failure to meet basic needs is what causes a person's behavior to deviate from the norms. What is termed "illness" is, in reality, the result of the numerous ways people choose to behave when they fail to satisfy their basic needs. If a person moves beyond denial and realizes that they must reassess their desires and behaviors to make better choices that lead to life satisfaction, they will ultimately achieve a more flexible, meaningful, and enjoyable life (Glasser, 2013). This theory emphasizes that because behavior is chosen, withdrawing from personal responsibility or blaming others or society for problems is unacceptable. Since behaviors are chosen as a way to solve the frustration stemming from an unsatisfactory relationship, more effective choices should be made when interacting with those necessary in one's life (Glasser, 2019).

The results of the present study also showed that Reality Therapy training based on Choice Theory significantly improved emotion regulation in female middle school students. These findings are in line with the results of studies by Jabari et al. (2020), Rakh (2018), Ghorayshi and Behboodi (2016), and Yazdizadeh et al. (2023).

In explaining the effectiveness of Reality Therapy training based on Choice Theory on emotion regulation, it can be said that Choice Theory posits that only the individual can act for themselves, and no one can do anything without their consent. Since hope is under the individual's control and stems from their decision to never see themselves as less than a unique being, a person gains hope by deciding to have it and simply decides not to let anything external to them destroy or diminish them. They take responsibility for their life, even if it is undesirable, and despite related risks, they carry out this responsibility (Glasser, 2010). Therefore, emphasizing concepts such as control, responsibility, and choice in Reality Therapy can impact coping strategies and individuals' locus of control, as Choice Theory is fundamentally the psychology of internal control (Glasser, 2001). Individuals feel responsible for what they make of themselves and, through better decision-making, organization, and reevaluation of events, they engage in cognitive development. Reality Therapy, in essence, focuses on problem-solving, better decision-making, and improved evaluation to achieve goals. In crisis situations, Reality Therapy helps adolescents make more effective decisions, assume responsibility, identify ineffective behaviors that do not significantly contribute to meeting their needs, replace them with more effective options, responsibly address their emotional needs, and reassess their behaviors, thereby reducing the likelihood of suppressing thoughts and emotions (Lennon, 2019).

Limitations & Suggestions

The results of the present study indicated that Reality Therapy training based on Choice Theory significantly improved the mental health and emotion regulation of female middle school students. Based on these results, it is recommended that Reality Therapy training based on Choice Theory be implemented for adolescent girls in schools. Like other studies, this research faced limitations such as the use of self-report tools and non-random sampling. Therefore, caution should be exercised in generalizing the results. Future researchers are encouraged to use other assessment methods, such as interviews, and random sampling techniques.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

This article is derived from the first author's doctoral dissertation. All authors equally contributed to this article.