The Comparison of the Effectiveness of Stress Inoculation Training and Lazarus Multimodal Therapy on Loneliness and Quality of Life in Older Adults

Abstract
Background: Later life is a stage that can significantly influence individuals’ physical and psychological health and may also lead to changes in lifestyle. Consequently, loneliness and reduced quality of life are relatively common among older adults. In this context, the use of psychological interventions and addressing these issues can enhance the overall well‑being of this population. Therefore, the present study aimed to compare the effectiveness of Stress Inoculation Training (SIT) and Lazarus Multimodal Therapy (LMT) on loneliness and quality of life among older adults attending a daytime care center.
Method: This study employed a quasi‑experimental design with a pretest–posttest control group. The statistical population consisted of adults aged over 65 who attended a daytime care center for older adults in Sari in 2023. From this population, 45 participants were selected through convenience sampling based on the study’s inclusion and exclusion criteria and were randomly assigned to three groups of 15 participants each. Data were collected using the UCLA Loneliness Scale developed by Russell and colleagues and the Quality-of-Life Questionnaire developed by WHO researchers. In this study, the two experimental groups received eight 60‑minute sessions of SIT (Meichenbaum) and LMT, respectively, while the control group received no intervention. Finally, the collected data were analyzed using interactive regression analysis.
Results: The results indicated that both SIT and LMT significantly reduced loneliness among older adults. Bonferroni post hoc comparisons showed that loneliness scores were significantly lower and quality-of-life scores were significantly higher in both intervention groups than in the control group, while the difference between the two intervention groups was not statistically significant.
Conclusion: Based on the findings of the present study, SIT and LMT appear to reduce loneliness and improve quality of life among older adults by enhancing psychological flexibility. Therefore, the application of these interventions may be beneficial in promoting psychological well‑being in later life.
EXTENDED ABSTRACT
 Introduction
Aging is a multifactorial process and one of the most complex biological phenomena, representing a major risk factor for mortality and various diseases. Advances in nutrition, technology, and medical science have substantially increased average life expectancy. However, age‑related problems and their consequences have become important public health concerns and may play a significant role in functional limitations among older adults. In recent years, the cost of living for this population has also increased, including expenses related to medical care, housing, food, and health and pharmaceutical products. Loneliness is one of the common challenges associated with later life and can have a substantial impact on the health of older adults. It has been linked with a variety of physical and psychological disorders. In addition, quality of life (QOL) refers to an individual’s overall well‑being and life satisfaction, encompassing feelings, circumstances, and personal experiences. It reflects satisfaction with personal values, goals, and lifestyle. Improving QOL among older adults can be facilitated through educational programs, as they promote skill development, knowledge exchange, and behavioral modification. The use of psychological interventions alongside medical treatments may help older adults improve their individual and social functioning and enhance their ability to manage life challenges. Therefore, the present study aimed to compare the effectiveness of Stress Inoculation Training (SIT) and Lazarus Multimodal Therapy (LMT) in loneliness and QOL among older adults.
Method
The present study employed a quasi-experimental design with a pretest–posttest control group. The statistical population consisted of adults aged over 65 who attended a daytime care center for older adults in Sari in 2023. From this population, 45 participants were selected using convenience sampling and were randomly assigned to three groups of 15 participants each. The inclusion criteria were: (1) age between 65 and 85 years; (2) obtaining the required scores on the study questionnaires; (3) ability to attend training sessions; (4) relative psychological stability; (5) relatively good physical health; (6) minimum literacy at the level of reading and writing; and (7) no prior participation in similar training programs. The exclusion criteria included: (1) age below 65 years; (2) failure to obtain the required questionnaire scores; (3) absence from more than one session; (4) onset of acute illness during the study; (5) presence of severe physical illnesses such as cancer; (6) illiteracy; (7) unwillingness to continue participation; and (8) withdrawal from the study due to circumstances such as death, illness, travel, or transfer to another center. Data were collected using the UCLA Loneliness Scale by Russell et al. and QOL questionnaire developed by WHO. In this study, the two experimental groups received eight 60-minute sessions of SIT (Meichenbaum) and LMT, respectively, while the control group received no intervention. The data were analyzed using interactive regression analysis and Bonferroni post hoc tests in SPSS-26.
Results
At the preliminary stage, the normality of the distributions of loneliness and quality of life (QOL) scores was examined separately across the three groups, namely the control group, the Stress Inoculation Training (SIT) group, and the Lazarus Multimodal Therapy (LMT) group, using the Shapiro–Wilk test. Since all p-values were greater than .05, the assumption of normality was not rejected, and therefore parametric statistical methods were used.
Each group consisted of 15 participants. The descriptive statistics, including the means and standard deviations of loneliness and QOL scores at the pretest and posttest stages, are presented in Table 3. As shown in the table, loneliness scores decreased from pretest to posttest in both intervention groups, whereas QOL scores increased from pretest to posttest in these groups. In contrast, the control group showed no substantial difference between pretest and posttest scores.
To compare the effects of the interventions on loneliness, the assumptions of analysis of covariance were first examined. The homogeneity of variances across the three groups was confirmed by Levene’s test, F = 0.411, p = .666. However, the assumption of homogeneity of regression slopes was violated, as the interaction between group and pretest loneliness was statistically significant, SS = 10481.20, df = 3, MS = 3493.73, F = 208.03, p = .0009, η² = 0.938. Therefore, classical ANCOVA was not used for this variable, and a regression model including the group × pretest interaction term was applied. The results of this regression model showed that the main effect of group on posttest loneliness was not statistically significant, SS = 55.43, df = 2, MS = 27.72, F = 1.71, p = .195, η² = 0.081. However, the effect of pretest loneliness was statistically significant, SS = 149.65, df = 1, MS = 149.65, F = 9.22, p = .004, η² = 0.191, and the group × pretest loneliness interaction was also statistically significant, SS = 284.02, df = 2, MS = 142.01, F = 8.75, p = .010, η² = 0.310.
To further examine the significant group × pretest loneliness interaction, adjusted group means were compared at three relative levels of baseline loneliness, defined as low baseline loneliness (one standard deviation below the mean, 51.10), moderate baseline loneliness (the sample mean, 58.93), and high baseline loneliness (one standard deviation above the mean, 66.76). At the low level of baseline loneliness, Bonferroni comparisons showed significant differences between the control group and the LMT group (mean difference = 26.04, p < .001) and between the control group and the SIT group (mean difference = 24.09, p < .001), while the difference between the LMT and SIT groups was not statistically significant (mean difference = 1.95, p = 1.000). At the moderate level of baseline loneliness, significant differences were again observed between the control group and the LMT group (mean difference = 33.71, p < .001) and between the control group and the SIT group (mean difference = 31.63, p < .001), with no significant difference between the two intervention groups (mean difference = 2.07, p = .937). At the high level of baseline loneliness, significant differences were found between the control group and the LMT group (mean difference = 41.38, p < .001) and between the control group and the SIT group (mean difference = 39.18, p < .001), while the difference between the LMT and SIT groups remained non-significant (mean difference = 2.20, p = 1.000). Overall Bonferroni pairwise comparisons for loneliness also indicated that both intervention groups differed significantly from the control group, with mean differences of 31.640 (p < .001) for SIT versus control and 33.719 (p < .001) for LMT versus control, whereas the difference between the two intervention groups was not statistically significant (mean difference = 2.08, p = .937).
For QOL, the assumptions of analysis of covariance were also examined. Levene’s test confirmed the homogeneity of variances across the three groups, F = 0.12, p = .886. A preliminary test of the group × pretest QOL interaction was statistically significant, SS = 10151.02, df = 3, MS = 3383.67, F = 55.76, p = .0009, η² = 0.803; therefore, a regression model including group, pretest QOL, and the group × pretest interaction term was applied. The results of the final regression model showed that the main effect of group on posttest QOL was statistically significant, SS = 1521.87, df = 2, MS = 760.94, F = 30.71, p = .0009, η² = 0.612, whereas the effect of pretest QOL was not statistically significant, SS = 36.70, df = 1, MS = 36.70, F = 1.48, p = .231, η² = 0.037, and the group × pretest QOL interaction was also not statistically significant in the final model, SS = 1.57, df = 2, MS = 0.78, F = 0.03, p = .969, η² = 0.002. Bonferroni post hoc comparisons for QOL showed that both intervention groups differed significantly from the control group, with mean differences of 30.516 (p < .01) for SIT versus control and 35.507 (p < .01) for LMT versus control, while the difference between the two intervention groups was not statistically significant (mean difference = 4.99, p = .324).
Conclusion
The effectiveness of SIT and LMT may be related to their influence on established cognitive and emotional patterns. SIT emphasizes adaptive self-statements, cognitive restructuring, coping skills training, and the enhancement of perceived control. Through these processes, older adults may reconsider maladaptive interpretations related to loneliness, rejection, or feelings of uselessness and shift from a passive stance toward a more active psychological orientation. LMT adopts a comprehensive approach by addressing multiple dimensions of functioning, including behavior, affect, sensation, imagery, cognition, interpersonal relationships, and biological factors. This multidimensional framework allows intervention across several components of the loneliness experience. In addition to modifying maladaptive beliefs, it addresses interpersonal patterns, social skills, and behavioral activation, thereby helping to reduce emotional and interpersonal isolation. In SIT, the emphasis on cognitive restructuring, active coping strategies, and increased mastery over stressful situations may help older adults move away from focusing on limitations and instead attend to their personal strengths and internal resources. Such cognitive shifts may enhance components of life satisfaction and perceived meaning. Similarly, the multidimensional nature of LMT may facilitate changes in daily behavior, social interaction, and emotional regulation, which may contribute to improvements in individuals’ evaluation of their QOL.
Ethical Consideration
Ethical Code
Ethical approval for this study was obtained from the Ethics Committee of the Islamic Azad University, Semnan Branch (Code: IR.IAU.SEMNAN.REC.1403.064).
Financial Support
This study did not receive support.
Authors’ Contributions
M.S.T: Conceptualization, Methodology, Data Curation, Software, Formal analysis, Writing-Original Draft; K.A: Conceptualization, Methodology, Validation, Writing-Review & Editing, Supervision; H.E: Writing-Review & Editing
Conflict of Interest
The author had no conflicts of interest.
Acknowledgments
The authors would like to thank the Vice‑Chancellor for Graduate Studies and the Vice‑Chancellor for Research at the Islamic Azad University, Semnan Branch, the supervising and advisory professors of this research, all participating older adults, and everyone who contributed to the completion of this study.
References
Ameli Rezaei, L., Amir Mazaheri, A. M., & Haghighatyan, M. (2020). The effect of passive music therapy on the quality of life of the elderly living in nursing homes in Tehran (A case study of nursing homes in Tehran). Journal of Social Work Research, 7(24), 1–35. https://doi.org/10.22054/rjsw.2021.58517.473 [Persian]
Amini, S., Dehghani-Champiri, A., Salehi, A., & Soltanizadeh, M. (2019). The role of experiential avoidance and psychological capitals in predicting feeling loneliness by mediating meaning in life in the elderly. Psychological Science, 18(74), 223–234. https://www.sid.ir/paper/92866/fa#downloadbottom [Persian]
Andersen, G. K., Bauer, E. H., Bhavsar, R. P., Jensen, H. I., Ahrenfeldt, L. J., Hvidt, N. C., & Stroem, T. (2024). Assessment of quality of life for frail elderly patients’ post-ICU discharge: A protocol for a scoping review. BMJ Open, 14(1), 1–6. https://doi.org/10.1136/bmjopen-2023-076494
Baruah, M. (2023). Old age people and human rights: A socio-psychological perspective. Journal of Pharmaceutical Negative Results, 14(3), 592–597. https://doi.org/10.47750/pnr.2023.14.03.074
Charoenkiatkan, C., Khositditsayanan, N., & Wannupatam, B. (2024). Training curriculum to enhance the quality of life for the elderly. Education and Learning (EduLearn), 18(3), 616–623. https://doi.org/10.11591/edulearn.v18i3.21336
Delavar, A. (2016). Research methods in psychology and educational sciences. Roshd Publications.
De Magalhães, J. P., Abidi, Z., dos Santos, G. A., Avelar, R. A., Barardo, D., Chatsirisupachai, K., Clark, P., de Souza, E. A., Johnson, E. J., Lopes, I., Novoa, G., Senez, L., Talay, A., Thornton, D., & Ka Po To, P. (2024). Human ageing genomic resources: Updates on key databases in ageing research. Nucleic Acids Research, 52(1), 900–908. https://doi.org/10.
1093/nar/gkad927
Dewi, C. F., Marlina, Y. F., & Dafiq, N. (2025). Family support and loneliness in the elderly: Their influence on quality of life. Keperawatan dan Kesehatan, 13(1), 68–74. https://doi.org/10.20527/jdk.v13i1.781
Dinarvand, N., & Barghi Irani, Z. (2021). The comparison of the effectiveness of metacognitive therapy and spiritual therapy on cognitive dissonance and feeling loneliness in the elderly living in nursing homes. Aging Psychology, 7(2), 181–197. https://doi.org/10.22126/JAP.2021.6334.1520 [Persian]
Eydivand, M., Arjmand-Siyapoush, I., & Haroon-Rashidi, H. (2025). The effectiveness of schema therapy on rumination and alexithymia in older adults. Aging Psychology, 11(2), 155–172. https://doi.org/10.22126/jap.2024.10521.1771 [Persian]
Farzin, M., Amiri Majd, M., & Ghamari, M. (2024). Comparing the effectiveness of guided imagery and Lazarus multimodal therapy on COVID-19 anxiety and life expectancy in people recovered from COVID-19. Journal of Practice in Clinical Psychology, 12(1), 53–66. https://doi.org/10.32598/jpcp.12.1.917.1
Falahi, F., Parandin, S., & Valizadeh, H. (2024). Comparison of the effectiveness of treatment based on acceptance and commitment therapy and mindfulness-based therapy on death anxiety and loneliness of the elderly. Modern Psychological Researches, 19(74), 221–232. https://doi.org/10.22034/JMPR.2024.59381.5949 [Persian]
Figueiredo, T., Midao, L., Rocha, P., Cruz, S., Lameira, G., Conceicao, P., Ramos, R. J. G., Batista, L., Corvacho, H., Almada, M., Martins, A., Rocha, C., Ribeiro, A., Alves, F., & Costa, E. (2024). The interplay between climate change and ageing: A systematic review of health indicators. PLOS ONE, 19(4), 1–17. https://doi.org/10.1371/journal.pone.0297116
Ghazi Mohseni, M., Soleimanian, A. A., & Heidarnia, A. (2016). Examining the effectiveness of hope-based group training on the quality of life of the elderly people. Salmand: Iranian Journal of Ageing, 11(2), 300–309. https://doi.org/10.21859/sija-1102300 [Persian]
Guner, T. A., Erdogan, Z., & Demir, I. (2023). The effect of loneliness on death anxiety in the elderly during the COVID-19 pandemic. Omega: Journal of Death and Dying, 87(1), 262–282. https://doi.org/10.1177/00302228211010587
Heravi-Karimooi, M., Rejeh, N., Garshasbi, A., Nikkhah, M., & Montazeri, A. (2016). A validation study of the Persian version of older people’s quality of life questionnaire (CASP-19). Payesh, 15(4), 432–442. [Persian]
Hojatkhah, S. M., Mesbah, I., & Azar, P. (2021). Effectiveness of group counseling based on Lazarus multimodal approach on psychological well-being of male students. Counseling Research, 20(78), 109–128. https://doi.org/10.18502/qjcr.v20i78.6786 [Persian]
IRNA. (n.d.). Islamic Republic News Agency. https://www.irna.ir/news/85309149/%DB%B9
Issalillah, F., & Aisyah, N. (2022). The elderly and the determinants of stress. Social Science Studies, 2(1), 9–12. https://doi.org/10.56348/jos3.v2i1.19
Jafari, A. (2019). Effectiveness of counseling based on Lazarus multimodal theory on possible selves, locus of control, and decrease of opiate craving in addicts under pharmacotherapy. Quarterly of Applied Psychology, 13(4), 602–623. https://doi.org/10.29252/APSY.13.4.601 [Persian]
Jangi Jahantigh, L., Latifi, Z., & Soltani Zadeh, M. (2021). The effectiveness of self-healing education on the quality of life in the elderly. Aging Psychology, 7(4), 345–359. https://doi.org/10.22126/JAP.2022.6911.1561 [Persian]
Kabirinasab, Y., Bahrainian, S. A., Ahi, G., & Mansouri, A. (2024). Comparison of the effectiveness of acceptance and commitment therapy and compassion therapy on death obsession and self-care ability in the elderly. Psychological Science, 23(142), 2519–2538. https://doi.org/10.52547/JPS.23.142.2519 [Persian]
Karami, A., Arian, S. Kh., Soltani Khorshid, H., & Khanabadi, M. (2012). Exploring the effectiveness of group training based on Lazarus multifaceted approach on women’s marital satisfaction. Woman & Society, 3(1), 21–39. [Persian]
Khalvati, M., Babakhanian, M., Khalvati, M., Nafei, A., Khalvati, M., & Ghafuri, R. (2021). Death anxiety in the elderly in Iran: A systematic review and meta-analysis. Salmand: Iranian Journal of Ageing, 16(2), 152–171. https://doi.org/10.32598/sija.16.2.862.2 [Persian]
Khodabakhshy, N., & Foroozandeh, E. (2022). Comparison of the effectiveness of Lazarus multifaceted treatment and matrix treatment on indications for treatment of drug abuse. Etiadpajohi, 16(63), 199–222. https://doi.org/10.52547/etiadpajohi.16.63.199 [Persian]
Kishikawa, Y., Miyabara, H., Uchinoura, M., Yamaguchi, Y., Nishimura, S., Shibata, S., Shibata, H., & Owada, H. (2023). Determinants of quality of life in elderly rehabilitation users at a day care service center. Journal of Physical Therapy Science, 35(1), 12–17. https://doi.org/10.1589/jpts.35.12
Kudelka, J., Ollenschläger, M., Dodel, R., Eskofer, B. M., Hobert, M. A., Jahn, K., Klucken, J., Labeit, B., Polidori, M. C., Prell, T., Warnecke, T., von Arnim, C. A. F., Maetzler, W., & Jacobs, A. H. (2024). Which comprehensive geriatric assessment (CGA) instruments are currently used in Germany: A survey. BMC Geriatrics, 24(347), 1–19. https://doi.org/10.1186/s12877-024-04913-6
Komada, Y. (2023). Sleep and body composition, physical function in older women. Sleep and Biological Rhythms, 21, 129–129. https://doi.org/10.1007/s41105-023-00443-7
Luo, J., Guo, Y., & Tian, Z. (2024). Loneliness or sociability: The impact of social participation on the mental health of the elderly living alone. Health & Social Care in the Community, 1–12. https://doi.org/10.1155/2024/5614808
Ma, J., Zhang, Z., Zheng, J., & Huo, Z. (2025). Can travel relieve the loneliness of the elderly? Journal of Sustainable Tourism.
McCormick, I. (2025). A qualitative study of client experiences using stress inoculation coaching. International Journal of Evidence Based Coaching and Mentoring, 23(2), 289–302. https://doi.org/10.24384/tg0c-yt11
Mehra, A., Agarwal, A., Bashar, M., Avasthi, A., Chakravarty, R., & Grover, S. (2024). Prevalence of loneliness in older adults in rural population and its association with depression and caregiver abuse. Indian Journal of Psychological Medicine, 46(6), 564–569. https://doi.org/10.1177/02537176241231060
Mirdrikvand, F., Panahi, H., & Hoseyni-Ramaghani, N. S. (2016). Loneliness of the elderly: The role of communication skills, social support, and functional disability. Aging Psychology, 2(2), 103–113. https://jap.razi.ac.ir/article_582.html?lang=fa [Persian]
Muhammad, T., Maurya, P., Selvamani, Y., & Kelekar, U. (2023). Mediation of pain in the association of sleep problems with falls among older adults in India. Scientific Reports, 13(221), 1–11. https://doi.org/10.1038/s41598-022-27010-3
Mutchler, J., Su, Y. J., & Roldan, N. V. (2023). Living below the line: Economic insecurity and older Americans, insecurity in the states, 2022 (pp. 1–15). University of Massachusetts Boston.
Mobini, S. (2016). Stress inoculation training: Donald Meichenbaum. Roshd Publications. [Persian]
Montejo, C. P., Crespo, D. P., Rubio, C. M., & Montenegro-Pena, M. (2022). Loneliness in the elderly: Association with health variables, pain, and cognitive performance. A population-based study. Clínica y Salud, 33(2), 51–58. https://doi.org/10.5093/clysa2021a14
Mostafaie, A., & Oraki, M. (2020). The effectiveness of psychological immunization training on neuropsychological skills and behavioral symptoms (Attention deficit and impulsivity) of children with attention deficit hyperactivity disorder (ADHD) based on the Meichenbaum model. Neuropsychology, 6(21), 111–130. https://doi.org/10.30473/clpsy.2020.48949.1470 [Persian]
Motahari, N., & Torkan, H. (2025). The relationship between loneliness, distress tolerance, and resilience with spiritual well-being among older adults residing in nursing homes. Aging Psychology, 11(2), 213–230. https://doi.org/10.22126/JAP.2024.10521.1771 [Persian]
Naghdi, M., Taher, M., Aghaei, H., & Hossein Khanzadeh, A. A. (2023). Comparing the effectiveness of logotherapy and acceptance and commitment therapy on the loneliness of the elderly. Psychological Science, 22(128), 1663–1678. https://doi.org/10.52547/JPS.22.128.166 [Persian]
Oraki, M., Mahdizadeh, A., & Dortaj, A. (2019). The effectiveness of self-care empowerment training on life expectancy, happiness, and quality of life of the elderly in Iranian elderly care centers in Dubai. Salmand: Iranian Journal of Ageing, 14(3), 320–331. https://doi.org/10.32598/sija.13.10.670 [Persian]
Papadopoulou, S. K., Mantzorou, M., Voulgaridou, G., Pavlidou, E., Vadikolias, K., Antasouras, G., Vorvolakos, T., Psara, E., Vasios, G. K., Serdari, A., Poulios, E., & Giaginis, C. (2023). Nutritional status is associated with health-related quality of life, physical activity, and sleep quality: A cross-sectional study in an elderly Greek population. Nutrients, 15(2), 1–14. https://doi.org/10.3390/nu15020443
Russell, D., Peplau, L. A., & Cutrona, C. E. (1980). The revised UCLA loneliness scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology, 39(3), 472–480.
Sarkar, S. M., Dhar, B. K., Crowley, S., Ayittey, F. K., & Gazi, M. A. I. (2023). Psychological adjustment and guidance for ageing urban women. Ageing International, 48, 222–230. https://doi.org/10.1007/s12126-021-09467
Taher, M., & Mirzadeh, B. (2022). Evaluation of the effectiveness of Lazarus multidimensional treatment on self-esteem and adjustment of children with separation anxiety disorder. Educational Psychology Studies, 19(46), 85–99. https://doi.org/10.22111/JEPS.2022.6756 [Persian]
Tamannaeifar, M. R., Mansourinik, A., & Malekzade Kashani, F. (2024). Relationship between insecure attachment style and quality of life in chronic pain patients: The mediating role of alexithymia and moderating role of resilience. Health Psychology, 13(2), 45–62. https://doi.org/10.30473/hpj.2024.68731.5868 [Persian]
Valencia-Contrera, M. A., & Sanhueza-Alvarado, O. I. (2023). Diseases associated with loneliness in the elderly: A social challenge. Enfermería Global, 22(1), 642–668. https://doi.org/10.6018/eglobal.514761
Witham, M. D., Crighton, L. J., & MacMurdo, M. E. T. (2007). Using an individualised quality of life measure in older heart failure patients. International Journal of Cardiology, 116(1), 40–45. https://doi.org/10.1016/j.ijcard.2006.03.026
Xiong, Q., & Zhang, N. (2025). An interaction design study of horticultural healing resting appliance for alleviating loneliness among the elderly. In International Conference on Human-Computer Interaction (Vol. 15809). Springer. https://link.springer.com/chapter/10.1007/978-3-031-92707-2_24
Yongqi, X. (2023). Research on the influence of pension insurance on the Chinese elderly’s subjective well-being based on Maslow's hierarchy of needs. In Proceedings of the 6th International Conference on Economic Management and Green Development (pp. 198–203). Applied Economics and Policy Studies. Springer. https://www.springerprofessional.de/en/applied-economics-and-policy-studies/19570136
Zarei, S. (2018). The effectiveness of stress inoculation training on vocational stress of active elderly. Clinical Psychology Studies, 8(32), 151–173.