Introduction
Hypertension is one of the most critical risk factors for cardiovascular diseases [1, 2], and the most common cause of heart failure is stroke in many countries [3]. This chronic disease has been identified as a silent killer due to the lack of obvious symptoms [4] and it is a vital factor in increasing the death rate worldwide [5]. The prevalence of hypertension in Iran, like many countries in the world, is increasing for several reasons including rapid social changes such as urbanization and lifestyle change [6]. In a meta-analysis study in Iran, the overall prevalence of hypertension is estimated at 25% [7]. According to the importance of hypertension as a chronic disease on the one hand and the risk factor for other chronic diseases, on the other hand, prevention and control of this disease seem very necessary [8]. Self-care is an essential component of the treatment of hypertension [9] and is a practice in which people use their knowledge and ability to take care of their health independently [10]. The results of studies indicate that educational interventions significantly change the lifestyle of patients with hypertension [11]. A group of positive psychologists introduced mental health as equal to the positive function of psychology in recent years [12] and conceptualized it as “psychological well-being” [13]. Psychological well-being is defined as the existence of desirable cognitive and emotional psychological documents [14]. According to the study conducted by Ryff, one of the significant components of health is psychological well-being, which is defined as the development of an individual’s true talents [15]. According to Ryff, psychological well-being has components such as self-acceptance, feeling of autonomy, having a positive relationship with others, purposefulness, personal growth, and mastery of the environment [16]. In this regard, the research results indicate that religious beliefs and internal religious orientation have a positive effect on health, life satisfaction, and psychological well-being [12]. 
The way of perceiving the severity of symptoms by reducing the quality of psychological well-being in people with hypertension seems to have disabling interactions for this group, which has attracted the attention of physicians and psychologists at the same time. The conventional non-pharmacological therapies for improving the disease and further stabilization of blood pressure have emphasized the combination of various methods such as muscle relaxation, cognitive rehabilitation, effective coping training, training self-care skills, and lifestyle modification [17]. In this regard, self-healing is one of the new approaches that was formally introduced by Loyd (psychologist and complementary medicine therapist), and Johnson (cancer specialist) in the United States under the title of healing codes in 2011 [18]. The self-healing approach includes memory retrieval skills, recognizing problematic personality traits, reducing harmful actions, training self-healing skills, praying, and practicing healing codes [19]. Loyd, Johnson, and Lipton, cellular and molecular biologists, believe that 95% of all physical and non-physical problems originate from stress [20]. This type of stress causes diseases and illnesses that are not based on the external conditions of the person (which can be changed) but a hidden and very deep stress that is inside and completely independent of the current conditions of the person [21]. According to Lipton, the causes of physiological stress are patterns of unhealthy cellular energy, unreasonable fears, false images, and beliefs stored in the body and mind [22]. Loyd believes that the negative emotions and beliefs caused by destructive cellular memories cause mental imbalance and weakens the body’s immune system against diseases and consequently increase chronic physical disorders, including hypertension [23].
The positive effects of the healing approach are significant in the results of foreign studies. Frolich et al. [24]conducted an online self-healing program for Canadian young adults suffering from both alcohol abuse and emotional problems such as anxiety and depression and concluded that executing this program has increased the quality of life and reduction of anxiety and depression in addition to reducing alcohol consumption in the experimental group. Wetse et al. [25] implemented a self-help program for refugee women to reduce their psychological distress and increase their psychological well-being. Also, other researchers in Iran reported that the effectiveness of self-healing training on various variables such as burnout, quality of life, emotional resilience of social emergency personnel [26], self-compassion, concern for body image, improvement in cancer [27], depression in people with chronic headaches [28], distress tolerance, psychological capitals, the headache of spouses of addicted people [29], and psychological empowerment of drug-dependent men [30] have been beneficial and effective.
This research and the experimental gap are strongly seen in previous studies and it is required to conduct a study on the effectiveness of this approach in promoting the psychological well-being of women with hypertension to determine the results scientifically to be used as a type of low-cost and new treatment to help patients with blood pressure. In Iran, Latifi and Marvi in 2017 localized this approach, prepared the relevant protocol, and used it with Loyd’s approval [31]. According to the issues raised, the main question of the researcher is whether self-healing training can affect the psychological well-being of female patients with hypertension.
Materials and Methods 
This present study is a quasi-experimental research with two groups (experimental and control) in three stages (pre-test, post-test, and follow-up). The statistical population of the study included all women with hypertension who referred to public health centers in Isfahan province. In the present study, after coordination with the provincial deputy of treatment and obtaining the ethical code IR.PNU.REC.1398.071 to follow the principles of research ethics from the National Committee for Ethics in Biomedical Research, female patients with hypertension were invited to attend the researcher’s initial briefing during the installation of a public announcement in public health centers for patients with hypertension file who referred to check their blood pressure once a week or every 15 days, accompanied by a doctor’s diagnosis and a health expert. A total of 30 people who wanted to participate in this research project were selected as a sample using the convenience method and set in two experimental and control groups of 15 people based on the inclusion and exclusion criteria and using random placement (to strengthen matching). The inclusion criteria were female gender, having symptoms of hypertension for three years, age range 40 to 65 years, not receiving concomitant psychological treatment, having at least a diploma, and completing the informed consent form. The exclusion criteria were acute or chronic mental disorders (with the diagnosis of a clinical psychologist), use of psychiatric medications, other specific and obvious chronic physical illnesses (such as asthma, epilepsy, and gastrointestinal diseases), the occurrence of stressful events, lack of cooperation during training, lack of doing homework presented in sessions, and being absent more than 2 sessions. The participants in the present study were matched in terms of gender, age, and duration of the history of hypertension. The experimental group participated in a self-healing training course (once a week for 90 minutes) in the health center for 14 sessions after selecting the sample, while the control group was placed on a waiting list after the intervention. It is significant to pay attention to some points for ethical considerations such as conscious willingness to participate in the research, ensuring the confidentiality of the subjects’ information (the principle of confidentiality), and respecting the human rights of the participants.
The sessions were held by two specialists who were proficient in the self-healing approach and one health center expert to control the participants’ blood pressure. In all sessions, all members of the group were asked to participate in the discussion actively and share their personal experiences with others while emphasizing confidentiality. Self-examination and finding destructive cellular memories and how to reduce the adverse effects of these memories were the main items of the sessions to be performed using various techniques appropriate to everyone’s taste. It was required that the participants do the exercises individually in the session and between sessions, and answer the instructor’s reflection questions. Having privacy and thinking about self was an essential part of the exercises. Participants were asked to begin training with family members or two friends at the same time to better understand the content, and to discuss the challenges in the session. In each session, the topics of the previous sessions were reviewed and it was emphasized to do homework. The instructors emphasized the basic role and will of the individual in improving himself for healing and inner pain. 
The following instruments were used in the present study:
Ryff’s Scale of Psychological Well-Being
Ryff designed psychological well-being scales for adults in 1989 to measure the structures of psychological well-being (self-acceptance, autonomy, positive relationships, purposeful living, individual growth, and mastery on the environment). After the initial review, the original version of the psychological well-being scale, which contains 84 questions, was prepared. Due to the length of this test, a 54-item version of the psychological welfare scale was designed. This questionnaire evaluates 6 main components of the psychological well-being model. Each subscale contains 9 terms. The answers given to each of the test items are specified on a 6-point Likert scale (1=strongly disagree to 6=strongly agree). 
Scores on this scale range from a minimum of 84 to a maximum of 504. A higher score indicates better psychological well-being. In another study conducted by domestic researchers, the reliability coefficient by re-testing the psychological well-being scale of Ryff was obtained 0.82 and the reliability coefficient of subscales of self-acceptance, positive relationships with others, autonomy, mastery on the environment, purposeful life, and individual growth were obtained 0.71, 0.77, 0.78, 0.77, 0.70 and 0.78 respectively which were statistically significant. The correlation between the psychological welfare scale and the life satisfaction scale, the Oxford happiness questionnaire, and the Rosenberg self-esteem questionnaire was 0.47, 0.58, and 0.46, respectively [32]. In the present study, Cronbach’s alpha coefficient was calculated in the range of 0.79 to 0.83 showing the reliability of the questionnaire and the positive correlation of psychological well-being scales with several well-being tools to indicate the validity of this questionnaire. 
In the current study, research tests were performed before the intervention, after the training sessions (post-test), and 60 days after the last session (follow-up). A summary of the training sessions is provided in Table 1. 


Analysis of variance (ANOVA) with repeated measures applying SPSS software, version 24 was used to analyze the data. 
Results
 The sample size was 30 females with a Mean±SD age of 66.50±7.92. Regarding age, 10 participants were 40 to 45 years old (33%), 4 participants were 46 to 50 years old (10%), 8 participants were 51 to 55 years old (26%), and 8 participants were 56 years old (26%). Subjects in the sample were at least 40 and at most 63 years old. Among the sample members, 12 people had a diploma or less (40%), 9 people had an associate degree (30%), 4 people had a bachelor’s degree (13%) and 5 people had a master’s degree or higher (16%). The mean total scores for pre-test, post-test, and follow-up of systolic blood pressure in the experimental group were 122, 116, and 114, respectively, and it was 125.33, 126.66, and 124.00 in the control group. Also, the mean scores of pre-test, post-test, and follow-up diastolic blood pressure in the experimental group were 73.33, 64.66, and 65.33, respectively, and it was 74.00, 72.33, and 72.33 in the control group. 
Table 2 illustrates the mean and standard deviation of pre-test, post-test, and follow-up scores of the Psychological Well-Being Scale for two experimental and control groups. 


According to Table 2, the mean total score of the pre-test, post-test, and follow-up of psychological well-being scale in the experimental group was 213.20±23.31, 219.98±9.88, and 220.086±12.18 and it was 195.26±23.78, 197.33±23.10, and 200.24±06.62 in the control group. Assumptions of analysis of variance including the normalization of pre-test and post-test distributions are approved by the Shapiro-Wilkes test and a complete lack of correlation between covariates variables and homogeneity of variance is approved by Levene's test. According to the significance level of the scale which is not less than 0.05 and the null hypothesis of Levene's test based on homogeneity between covariates, dependent groups were confirmed and these pairs of groups are homogeneous with each other. As a result, another conditional assumption is provided for ANOVA of repeated measures. Repeated measures ANOVA were used to evaluate the effectiveness of self-healing training on psychological well-being. One of the assumptions of the statistical test is the repeated measure of Mauchly's sphericity test. 
According to the insignificance level of Mauchly's sphericity for psychological well-being, this hypothesis is confirmed (P<0.05). Table 3 shows the values ​​of the Wilkes' Lambda test. 


According to Table 3 and values of 0.53, 0.14, and 0.23 for intergroup, intragroup, and interactive effect, respectively, it was indicated that self-healing training was effective on the psychological well-being scale. Table 4 illustrates the results of intergroup and intragroup ANOVA for the effect of self-healing training on psychological well-being with three pre-test, post-test, and follow-up measurements.


 According to Table 4 and the significance of the factors within the groups, the significant difference between the three measurements of pre-test, post-test, and follow-up for the psychological well-being scale was confirmed at the level of P<0.05. Also, according to the significance of the group source among the groups, there is a significant difference between the experimental group and the control group for psychological well-being at the level of P<0.05. Therefore, self-healing treatment has been effective in the psychological well-being of female patients with hypertension. 
Discussion 
This study aimed to evaluate the effectiveness of self-healing training on the psychological well-being of female patients with hypertension. Repeated measure ANOVA was used to analyze the data. The results indicated a significant difference between the three measurements of pre-test, post-test, and follow-up and the effectiveness of self-healing training in increasing psychological well-being among participants. These results were consistent with the results achieved from other studies in the field of improving psychological well-being variables in people with hypertension such as Ahrari et al. [1], Barati et al. [3], Mohammadian et al. [5], Hosseini et al. [11], Bagheri et al. [13], and Mohammadi et al. [14]. In addition, it was consistent with the results achieved by other studies on the effectiveness of the self-healing approach on variables such as the quality of well-being in elderly period [21], psychological capital and sense of cohesion [23], quality of life and emotional problems [24], psychological stress [25], job burnout, quality of life and emotional resilience [26], self-compassion, concern for body image and improvement in cancer [27], depression [28], distress tolerance, psychological capital and headache [29], and psychological empowerment.
Psychological problems have a significant impact on the occurrence, persistence, and even reduction of symptoms of cardiovascular problems, especially hypertension with its debilitating disorders. In explaining the above findings to increase psychological well-being, it can be said that since the main focus of self-healing training is the cognition of the individual and treatment of destructive cellular memories and these memories knowingly or unknowingly create stress in the body, change cells to the defensive state, exit the automatic nerve out of balance, and cause a sense of confusion, therefore, learning techniques such as forgiveness and releasing, resentment, stopping harmful actions, correcting believed lies, spiritual excellence, lifestyle and internal dialogue correction, learning to manage situational and physiological stresses, creative visualization and reverse retrieval memories, praying, and practical exercises of healing codes in participants help balance the autonomic nervous system and stop the unbalanced activity of the brain by creating calm that leads to increased management of blood pressure symptoms in the individual. On the other hand, psychological well-being requires an effective understanding and confrontation with the existential challenges of life, and this approach strongly emphasizes moral, religious, and human principles. In addition, a part of patients’ impatience with hypertension is due to wrong evaluations of its symptoms and consequences. These thoughts are recognized in self-healing training by recognizing unreasonable fears, believable lies, and unhealthy thoughts to reduce impatience and stress. In this regard, it seems that the creation and strengthening of healing codes such as codes of patience, forbearance, and continence as well as lifestyle modification such as adjusting sleep and wakefulness, nutrition, practical exercises, healing codes, meditation, and prayer increase peace of mind and high compatibility with these chronic symptoms, and ultimately strengthen the role of the individual in improving psychological function.
It is evident that all the approaches presented so far have been therapeutic and have necessarily been performed by the therapist. Therapists have tried to cure the patients from the outside; however, in this approach, an inner psychological transformation in the individual or the healing of psychological pains is considered from within instead of treatment from the outside which is a new paradigm in the world of psychology based on religious teachings. It explicitly states that the psychological problems of human beings, i.e., inner pains that have arisen over time, cannot be completely cured but can be healed. Healing is a process of inner transformation, a gradual, permanent process with the understanding of one’s emotions and the healing of inner pains by the individual. In fact, in the self-healing approach, a person is required to have silence and solitude in his introspection to discover his pains and sorrows during the continuous performance of spiritual meditation which is also one of the teachings of the Islam religion.
Conclusion 
The present study tried to examine the question of the effectiveness of self-healing training (healing codes) on the psychological well-being of female patients with hypertension in the framework of a valid methodology. The results of this study indicated that this program has been able to significantly increase psychological well-being among participants. In general, the possible causes of the effectiveness of self-healing (healing codes) are as follows: Highlighting patients’ role in reducing physiological stress by performing respiratory-muscular relaxation exercises, temple meditation and rose meditation, light body scan, and special healing code exercise that was trained practically by providing audio files and given homework, along with increasing the individual›s coping ability by creating a code of tolerance and increasing resilience which has been effective in increasing calmness. One of the limitations of this study is the participants’ gender, all of whom were female. Also, the researcher assumes that some members may sometimes use sedatives to control their blood pressure temporarily (once or twice during the course) despite the emphasis on not taking sedatives other than those used to control blood pressure during training. Another important limitation of this study was the assessment of outcomes based solely on a questionnaire tool without the use of other intervention evaluation methods. 
Practical Suggestions 
It is suggested that other therapeutic approaches along with the self-healing therapeutic approach be used to compare and evaluate the effectiveness of different therapeutic approaches in future studies. Also, according to the prevalence of psychosomatic diseases, it is suggested that the effectiveness of this method be examined on other diseases such as headache, gastric ulcer, gastrointestinal reflux, sleep disorders, chronic fatigue, low back pain, etc., particularly for specific diseases with an unknown origin for which definitive treatment has not been detected. 

Ethical Considerations
Compliance with ethical guidelines
The present study has been approved by the ethics code IR.PNU.REC.1398.071 of the National Committee for Ethics in Biomedical Research.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Writing the initial version and final review: Zohreh Latifi; Data interpretation: Reyhaneh Gharghani; Main idea: Zohreh Latifi; Study design and data collection: All authors. 

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
In the end, the researchers express their gratitude for the sincere cooperation of all the participants and staff of the Ghaemieh Clinic in Shahreza, Isfahan Province.


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