Iran Red Crescent Med J. 2016 March; 18(3): e22424. doi: 10.5812/ircmj.22424
Published online 2016 March 06. Research Article
Evaluation of Quality of Life Therapy Effectiveness in Contrast to Psycho-Sexual Education on Sexual Self-Concept of Iranian Women
Mohammad Arash Ramezani,1,2 Khodabakhsh Ahmadi,1,* Afagh Ghaemmaghami,3,4 Somayeh Zamani,5 Seyed Hassan Saadat,1 and Seyed Peyman Rahiminejad4
1Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
2Family Research Institute, Shahid Beheshti University, Tehran, IR Iran
3Department of Counseling, Marvdasht Branch, Islamic Azad University, Marvdasht, IR Iran
4Behsa Family Clinic, Tehran, IR Iran
5Department of Psychology, Zahedan Branch, Islamic Azad University, Zahedan, IR Iran
*Corresponding Author: Khodabakhsh Ahmadi, Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-9123753252, E-mail: firstname.lastname@example.org
Received 2014 August 31; Revised 2014 September 14; Accepted 2014 October 21.
Background: Quality-of-life therapy (QOLT) is an integrative psychotherapy that was formed by adding positive psychology concepts to cognitive-behavior therapy (CBT).
Objectives: The aim of the current study was to evaluate the efficacy of QOLT on the sexual self-concept of Iranian women.
Patients and Methods: A double-blind randomized experimental study was done from February 2011 to January 2012. The study subjects were recruited from a mental health nongovernmental organization in Isfahan, Iran. They were assigned randomly to two groups. The first group was under ten sessions of QOLT, and the second, as a control group, was under psycho-sexual education (PSE). General Health Questionnaire-28 (GHQ-28), the Multidimentional Sexual Self-Concept Questionnaire, and the Female Sexual Function Index (FSFI) were completed for participants before and after the intervention. The ANCOVA model was used for analysis.
Results: The findings revealed no significant differences between the two groups in mental health (GHQ-28 scores) and female sexual dysfunction, but sexual self-concept changed. Two subscales of sexual self-concept, sexual monitoring (QOLT group = 6.3 ± 2.7 vs PSE group = 4.7 ± 3.1 P < 0.05) and sexual-problem management (QOLT group = 15.4 ± 3.8 vs PSE group=13.7 ± 3.9 P < 0.05), increased significantly during QOLT.
Conclusions: QOLT did not impact mental health, but it could change many dimensions of sexual self-concept.
Keywords: Quality of Life, Psychology, Well-Being, Sexuality, Self-Concept
Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
Quality of life (QOL) as subjective well-being has been an important index in health outcome assessment in studies. QOL is a multidimensional concept that includes physical, mental, emotional, and social aspects related to a disease or its specific therapeutic approaches (1, 2). However, in recent years, improving the QOL has surged to the forefront of human interest, and people are more interested in QOL issues (3). Improving the QOL of individuals is becoming an increasing goal in health care and psychology. This increased interest has brought an attempt to make the concept of QOL a more robust construct that can encompass a wide range of interests in its definition and investigation (4). Frisch utilized this construct with a glance to quality of life and innovated a new method for psychotherapy that combines positive psychology and cognitive behavior therapy known as “quality-of-life therapy” (QOLT) (5). According to Frisch, QOLT is a journey from cognitive therapy to positive psychology that guides people to more life satisfaction. The five-step model CASIO defines life satisfaction. CASIO stands for Circumstances or Characteristics of a definite area in QOLT; the person’s Attitude about, perception, and interpretation of an area in terms of his or her well-being; a person’s evaluation of fulfillment in an area based on the application of Standards of fulfillment or achievement; the value or Importance a person places on an area for overall happiness or well-being; and how these four components combine with a fifth concern of Overall satisfaction in other areas of life (5). Frisch has presumed sixteen effective items in a person’s QOL. These 16 areas of life are contained in 1, health, 2, self-esteem, 3, spiritual life, 4, money, 5, work, 6, play or recreation, 7, learning, 8, creativity, 9, helping, 10, love, 11, friends, 12, children, 13, relations, 14, home, 15, neighborhood, and 16, community (5).
Self-concept, the integrity of every person, contains two components: 1, the I-self, including a) self-awareness, an appreciation for one’s internal states, needs, thoughts,
Ramezani MA et al.
2 Iran Red Crescent Med J. 2016;18(3):e22424
and emotions, b) self-agency, the sense of authorship of
one’s thoughts and actions, c) self-continuity, the sense
that one remains the same person over time, and d) selfcoherence,
a stable sense of the self as a single coherent,
bounded entity; 2, components of the me-self, including
the “material me,” the “social me,” and the “spiritual me,”
which in contemporary models translates into new domains
of the self-concept as well as global self-esteem (6).
One part of self-concept in humans is sexual self-concept.
Sexual self-concept is a combination of sexual attitudes,
behaviors, and feelings, as well as beliefs about
one’s attractiveness and self-worth (7).
QOLT concentrates on self-concept as belief, emotion,
and behavior because it follows cognitive behavior therapy
(CBT). CBT impresses on self-concept (8). It has many
components that predict sexual behaviors and intimacy
between couples. Sexual life in Iran is very ambiguous
because of its socio-cultural context, and for this reason,
there is not any information regarding sexual self-concept
in Iran. We decided to intervene in this area through
QOLT for healthy Iranian women.
Our research question regarded the effectiveness of
QOLT as a new psychotherapy for improving Iranian sexual
self-concept and compared it to psychosexual education
as a routine alternative method. The current study
describes the results of this intervention on sexual selfconcept.
3. Patients and Methods
A double-blind randomized trial was conducted from
February 2011 to January 2012. The study design is shown
in Figure 1. The study was approved by the research council
and ethical committee of Baqiytallah University of
50 women was
25 women on QOLT
first evaluation on
20 women recieved
all participants (20)
were present in all
last evaluation 11
5 participants were
missing due to pull
out the study more
than 3 sessions
25 women on
psycho - sexual
first evaluation on
22 women recieved
psycho - sexual
all participants (22)
were present in all
last evaluation 11
3 participants were
missing due to pull
out the study more
than 3 sessions
Figure 1. Schematic Diagram of Study Process
Ramezani MA et al.
Iran Red Crescent Med J. 2016;18(3):e22424 3
Participant recruitment: We needed a representative
sample from the general population. Thus, we recruited
a sample from a mental health nongovernmental organization
(NGO) in Isfahan, Iran. Isfahan is in the center of
Iran, and its population has homogeneity with the general
Iranian population. We selected participants with a
simple random sampling from all members of this NGO.
Its members were representative of the Isfahan population.
The sample size was calculated based on two mean
comparison formulas. The variance was calculated based
on previous study (SD2 = 0.4, with a = 0.05 and b = 0.2, d =
0.4 SD2). The sample size was calculated with 20 women
in each group. However, 50 women were recruited for
study before random allocation. Every person was selected
based on the following inclusion criteria:
1) married women with active sexual issues during their
life, 2) women age 20 - 60 years, and 3) willing to engage
Exclusion criteria were 1) access to any unexpected
stressful events like grief, accidents, and so on 2) absence
from more than 2 treatment sessions, and 3, immigration
from one study group to the other.
For the first step, a researcher conducted an eligibility
check using the above criteria and explained the goal of
the study to the participant, who then provided a written
After that, participants were allocated to two groups by
using a random digit table. Only one of the researchers
knew the code of allocated individuals. Interventions
and evaluations were done by other investigators who
were blinded regarding allocation.
In the beginning, all participants undertook a psychiatric
interview and the mental health inventory General
Health Questionnaire-28 (GHQ-28), which was standardized
for the Iranian population and has been used for
the general population (9). After randomization, the first
group underwent QOLT. Ten sessions were regulated based
on Frisch’s guideline and has been ordered in Table 1 (5).
The participants in the other group, as a control, received
psycho-sexual education based on the content of Table 2.
Table 1. Ten Sessions of Quality-of-Life Therapy in Current Study
Sessions Contents Exercise
1 Introduce participants. Discuss the goal of the study. Set goals. Complete
What subjects increase QOL.
2 Discuss goals, values, and spiritual life. Sand-timer technique. Drive goal, objective in their life. Use sandtimer
technique. Pros-versus-con technique.
3 Describe self-esteem, self-confidence, and how to increase them. Success
path and log. Blessing, accomplishments, talents, traits, tenets (BAT)
BAT exercise. Success log exercise. Strengths
and weaknesses exercise.
4 Describe CASIO model on health. Describe triggers, actions, consequences
(TAC) of health.
TAC exercise. Relaxation.
5 Describe love triangle theory, emotion regulation, and principles of
Emotional expression with I statement. Take
6 Discuss couple relationship and family relationship. Take a letter. Tit-for-tat exercise. Couples
contract and rules. Empathy exercise.
7 Declare principle of human sexuality. Sex games, sex positions, emotional intimacy.
8 Talk about play and recreation. Prepare list of recreations. Prepare list of recreations with family
members. Prepare plan for play.
9 What is creativity? Problem-solving creative model, in- session exercise. Creative homework, building creation with
family. Creative sexual behavior exercise.
10 Summation session and post-test questionnaire.
Table 2. Ten Sessions of Psycho-Sexual Education in Current Study
Sessions Contents Exercise
1 Introduce participants. Discuss goal of study. Set goals. Complete
Free discussion for next session.
2 Discuss beliefs that boring. Drive automatic thought.
3 Describe self-esteem, self-confidence. Letter to herself.
4 Describe ABC. Relaxation.
5 Free discussion about love. Bring love map.
6 Free discussion about emotions. Emotion expression I
7 Learn human sexual anatomy. Writing about sexual life.
8 Free discussion about time. Prepare list of daily activity.
9 Talk about parenting and sexual training. Discover parenting style.
10 Summation session and post-test questionnaire.
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4 Iran Red Crescent Med J. 2016;18(3):e22424
In addition to Frisch’s quality-of-life index, each participant
completed the following questionnaires.
The Multidimensional Sexual Self-Concept Questionnaire
(MSSCQ) is a 100-item questionnaire that provides
20 subscales, including:
1) Sexual anxiety, defined as the tendency to feel tension,
discomfort, and anxiety about the sexual aspects
of one’s life;
2) Sexual self-efficacy, defined as the belief that one has
the ability to deal effectively with the sexual aspects of
3) Sexual consciousness, defined as the tendency to
think and reflect about the nature of one’s own sexuality;
4) Motivation to avoid risky sex, defined as the motivation
and desire to avoid unhealthy patterns of risky sexual
behaviors (e.g., unprotected sexual behavior);
5) Chance/luck sexual control, defined as the belief that
the sexual aspects of one’s life are determined by chance
and luck considerations;
6) Sexual preoccupation, defined as the tendency to
think about sex to an excessive degree;
7) Sexual assertiveness, defined as the tendency to be assertive
about the sexual aspects of one’s life;
8) Sexual optimism, defined as the expectation that the
sexual aspects of one’s life will be positive and rewarding
in the future;
9) Sexual problem self-blame, defined as the tendency
to blame oneself when the sexual aspects of one’s life are
unhealthy, negative, or undesirable in nature;
10) Sexual monitoring, defined as the tendency to be
aware of the public impression that one’s sexuality
makes on others;
11) Sexual motivation, defined as the motivation and desire
to be involved in a sexual relationship;
12) Sexual-problem management, defined as the tendency
to believe that one has the capacity/skills to effectively
manage and handle any sexual problems that one
might develop or encounter;
13) Sexual esteem, defined as a generalized tendency
to evaluate positively one’s own capacity to engage in
healthy sexual behaviors and to experience one’s sexuality
in a satisfying and enjoyable way;
14) Sexual satisfaction, defined as the tendency to be
highly satisfied with the sexual aspects of one’s life;
15) Power other sexual control, defined as the belief that
the sexual aspects of one’s life are controlled by others
who are more powerful and influential than oneself;
16) Sexual self-schemata, defined as a cognitive framework
that organizes and guides the processing of information
about the sexual-related aspects of oneself;
17) Fear of sex, defined as a fear of engaging in sexual relations
with another individual;
18) Sexual-problem prevention, defined as the belief
that one has the ability to prevent oneself from developing
any sexual problems or disorders;
19) Sexual depression, defined as the experience of feelings
of sadness, unhappiness, and depression regarding
one’s sex life; and
20) Internal sexual control, defined as the belief that the
sexual aspects of one’s life are determined by one’s own
personal control (10-12).
The MSSCQ was translated into Persian and normalized
for the Iranian population by the authors. The reliability
with Cronbach’s alpha was 0.8, and the validity has been
checked by factor analysis that explained 84% of the variance
with 28 factors loaded (13).
The Female Sexual Function Index (FSFI) was standardized
for the Iranian population with α = 0.81 for reliability
and factor analysis for validity with five factors loaded (14).
The Index of Sexual Satisfaction was designed by Hudson
in 1992 (15). It was translated by the authors, and the
internal consistencies were within the acceptable point
α = 0.87.
The first evaluation was done at the initiation of the
study to measure baseline data; the second evaluation
was done a maximum of one week after the end of the
3.4. Statistical analysis
A statistical analysis was performed using SPSS for
Windows (ver. 20, SPSS Inc., Chicago, IL, USA). Comparisons
between groups were done by t test for means and
chi-square test for nominal variable. Because of adjusting
first evaluation scores, we used the ANCOVA model
after attaining the presumptions. Prior to examining
treatment effects, Kolmogorov–Smirnov tests were conducted
to evaluate the distributional characteristics of
the primary outcome measures. The primary outcome
measures were found to be distributed normally, and no
transformations were necessary. P < 0.05 was considered
Ethical approval was obtained for this study by the appropriate
review boards (no = 340 - 22, March 7, 2012). All
subjects participated in this study voluntarily, and all
responses were kept confidential. Informed consent was
obtained from all study participants.
Forty-two women finished the study. Five women in the
QOLT group and three women in the control group were
pulled from the study because of absence from more
than three sessions of therapy. The demographic and
mental health characteristics of these participants were
no different from other subjects in the study.
The mean age of all participants was 42.8 ± 8.3 years old.
The demographic characteristics of the two groups of
women are shown in Table 3. There were no significant
differences between the two groups on any demographic
The baseline measurement of pre-test scores were evalRamezani
MA et al.
Iran Red Crescent Med J. 2016;18(3):e22424 5
uated and were the same in both groups without significant
differences. Pre-test scores are shown in Table 4.
The analysis of covariance presented no significant differences
between the two groups in mental health (GHQ-
28 scores), sexual satisfaction, and female sexual dysfunction.
Table 5 shows the ANCOVA findings.
Additionally as shown in Table 4, there were significant differences
in sexual self-concept scores as the main intervention
effects. Table 4 presents the mean score of sexual selfconcept
for pre- and post-treatment outcome measures.
Two subscales of sexual self-concept increased during QOLT:
sexual monitoring and sexual-problem management.
Table 3. Demographic Variables Distribution Separation by Two Study Groups
Variable Group, Mean ± SD Statistical
QOLT PSE t P
Age 43.9 ± 8.5 41.9 ± 8.2 0.801 0.428
Offspring 2 2 NA NA
Weight 67.4 ± 8 67.6 ± 14 0.054 0.95
Marital duration 22.2 ± 11 20.7 ± 10.2 0.439 0.656
Spousal age 51.2 ± 10.3 491 ±8.1 0.74 0.463
Abbreviations: NA, not available; PSE, Psycho-sexual education; QOLT, Quality-of-life therapy.
Table 4. Mean and Standard Deviation Scores for Pre- and Post-Treatment Outcome Measuresa,b
Sexual Self-concept Subscales QOLT PSE P Value
Pre Post Pre Post
Sexual anxiety 5.6 ± 5 4.7 ± 4.5 5 ± 4 5.9 ± 4.9 .18
Sexual self-efficacy 15 ± 2.8 14.8 ± 4.2 14.7 ± 3.2 13.5 ± 4.6 .906
Sexual consciousness 15 ± 3.5 15.1 ± 4 15 ± 2.8 15 ± 4.3 .699
Motivation to avoid risky sex 16.4 ± 4 16.9 ± 4 18 ± 2.6 17.4 ± 3.6 .378
Chance/luck sexual control 3.5 ± 2.4 2.6 ± 2.4 3.7 ± 3.1 3.6 ± 3.4 .635
Sexual preoccupation 3.8 ± 3.2 4.9 ± 3.9 5.3 ± 4.3 5.1 ± 4 .897
Sexual assertiveness 10.7 ± 3.2 12.1 ± 4.2 10.5 ± 4.6 11.8 ± 4.7 .214
Sexual optimism 14.4 ± 3.4 14.4 ± 3.7 14.5 ± 2.8 14.7 ± 3.6 .68
Sexual problem self-blame 8.7 ± 2.6 7.7 ± 3.5 8.7 ± 3.4 7.9 ± 4.6 .209
Sexual monitoring 5.7 ± 3.3 6.3 ± 2.7 6.2 ± 3.5 4.7 ± 3.1 .034
sexual motivation 12.5 ± 2.3 13.4 ± 4 12 ± 4.3 12.2 ± 5.3 .36
Sexual-problem management 14.7 ± 2.9 15.4 ± 3.8 13.9 ± 3 13.7 ± 3.9 .017
Sexual esteem 14.1 ± 4.8 14.2 ± 4.8 14.5 ± 4.2 13.7 ± 4.9 .645
Sexual satisfaction 13.9 ± 4.6 13.4 ± 5.7 11.9 ± 4.6 12.7 ± 5.3 .37
Power–other sexual control 4.4 ± 3.1 4 ± 3.3 4.5 ± 3.5 3.5 ± 3.2 .277
Sexual self-schemata 17.8 ± 3 17.4 ± 4.2 17.3 ± 3.4 15.7 ± 6 .596
Fear of gender 5.9 ± 4.1 7.3 ± 3.4 7.3 ± 4.5 6.9 ± 4.4 .612
Sexual-problem prevention 16.3 ± 2.7 16.5 ± 4.1 16.3 ± 4.3 15.3 ± 4.3 .663
Sexual depression 4.6 ± 4.3 5.3 ± 4.5 5.6 ± 4.8 4.5 ± 4.3 .332
Internal sexual control 14.8 ± 3.4 14.3 ± 4 14 ± 2.9 13.5 ± 4.6 .62
Abbreviations: QOLT, Quality-of-life therapy; PSE, Psycho-sexual education.
aANCOVA test: F = 6.007, P = 0.034.
bANCOVA test: F =7.304, P = 0.017.
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6 Iran Red Crescent Med J. 2016;18(3):e22424
Table 5. Analysis of Covariance on Mental and Sexual Health
Variables F (ANCOVA) P Value
GHQ-28 Score .57 .816
Sexual Satisfaction .44 .528
Female Sexual Disorder
Desire .262 .621
Arousal (sensation) .956 .354
Arousal (lubrication) .109 .12
Arousal (cognitive) .383 .568
Orgasm .148 .71
Pain .411 .546
Enjoyment .001 .98
Data generated in this study responded to our research
question. Our findings revealed that QOLT had positive
influences on sexual monitoring and sexual-problem
management in sexual self-concept.
Research documents regarding QOLT are very scarce.
However, as Frisch previously described, QOLT is useful to
improve mental health and totally in health care system
Grant and colleagues have used QOLT in psychotherapy
of depression. They found QOL and self-efficacy improved
in depressive patients and were maintained in followup
(18). In other research, Rodrigue and co-workers suggested
that QOLT offers a psychological opportunity
to increase the quality of life of patients while they are
awaiting lung transplantation (19). These findings were
repeated for patients who were awaiting kidney transplantation.
QOLT could improve QOL, psychological functioning,
and social intimacy in these patients (20).
In the Iranian population, QOLT for parents of children
with obsessive-compulsive disorder (OCD) has been
found to decrease OCD and anxiety symptoms and increase
children’s satisfaction in the global, family, and
environment domains, as well as increase QOL for their
QOLT has decreased somatization and social dysfunction
in GHQ-28 questionnaire subscales. This is the finding
of Ghasemi and co-workers in the Iranian population
Padash and colleagues assessed QOLT on couple life
satisfaction. They used the ENRICH questionnaire, which
revealed QOLT was effective in marital satisfaction. In addition,
QOLT was effective in idealistic distortion, marital
satisfaction, communication, conflict resolution, leisure
activities, and religious orientation (P < 0.01), but there
was no significant influence on financial management,
sexual relationship, children and parenting, family and
friends, and equalitarian roles (23). In contrast to the
findings or Ghasemi (22) and Padash (23), our findings
did not show any significant difference in GHQ-28 subscales
and marital satisfaction.
There are many differences between the current research
and previous research in Iran. The first is the design of the
study. Our study was a randomized double-blind experimental
study. In contrast, both of the two previous studies
were quasi-experimental. The main goal of our study
was to evaluate QOLT on sexual self-concept. Yet, mental
health and marital satisfaction were evaluated parallel to
the sexual self-concept objective. The second difference is
in samples and interventions. QOLT in our study was done
as group therapy. The Ghasemi and Padash studies were
done as group therapy (22, 23), too, but in Padash’s paper,
the control group had no intervention, and in Ghasemi’s
research the control group was selected from a waiting
list. The control group in our study was with positive intervention,
and we used psycho-sexual education for control.
We considered ethical issues and principles for a doubleblind
randomized experimental study. In addition, our
samples were healthy women. Nevertheless, it seems QOLT
is useful for marital satisfaction and improvement of sexual
self-concept. According to Frisch, when feeling satisfied,
people may be more attractive to others (including potential
friends and mates) who can offer them marital aid and
social support. Life satisfaction and happiness also may
reflect a type of internal functioning that helps maintain
external functioning by giving people the motivation (e.g.,
sense of purpose, energy, confidence, hope, and compassion)
to persevere and to perform well in stressful, boring,
or even affectively neutral situations (16, 17).
Although the current study was the first in this regard
in Iran and was randomized, double blind, there were
some limitations in our study. QOLT was done by the first
author. He learned it from Abedi (21), and it was done exactly
by the Frisch model (5). However, it was used for the
first time for QOL group therapy.
We could not follow up with subjects after the end session,
thus we could not evaluate the long-term effect of
QOLT. CBT needs follow-up sessions for relapse prevention
We have many suggestions for future research. It is better
to compare QOLT with other CBT methods. Outcome
variables may be more, like different dimensions of life
satisfaction, emotion regulation, interpersonal issues,
and so on.
We give special thanks to Mrs. Padash for giving us her
information regarding QOLT. We appreciate the research
committee of Baqiyatallah University of Medical Sciences
for supporting us financially. This article has been derived
from Mphil thesis of Mohammad Arash Ramezani
in Baqiyatallah University of Medical Sciences.
Funding/Support:The research and ethical committee
Ramezani MA et al.
Iran Red Crescent Med J. 2016;18(3):e22424 7
of Baqiyatallah University of Medical Sciences approved
this research (no = 340-22, March 7, 2012).
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