1. Introduction
Hospital staff is one of the most vulnerable social groups who need psychological support more than other social groups due to their special working conditions and physical and psychological pressures (Tracy et al., 2020).
Medical occupations due to factors, such as shift work, stress and long working hours, conflict with colleagues, observing the suffering and death of patients, professional responsibilities and issues related to the administrative system, lack of necessary facilities and technical equipment, lack of appreciation, short-time rest, role conflict, role ambiguity, etc. are faced with major job stresses. This type of stress in the long run leads to problems, such as job dissatisfaction, burnout, absenteeism, leaving the job, reduced quality of patient care, and reduced mental health of medical staff (Johnson et al., 2021). The category of mental health affects all aspects of human life and has both material and immaterial or intrinsic values for the individual and society. 
According to the World Health Organization (WHO), mental health is one of the important axes of assessing the health of different communities and a state of health of each individual that causes the realization of potential talents, coping with normal stresses of life and doing useful work, and feeling productive and the ability to participate with society (Rostami, Ghezelsofloo, Mohammadloo & Ghorbanian, 2015). The concept of mental health includes the inner feeling of well-being and self-confidence, self-reliance, competition capacity, intergenerational dependence, self-fulfillment of potential intellectual, and emotional abilities, etc. A person with mental health is able to adapt to the environment while gaining individuality (Bell & Wade, 2021).
Another occupational factor whose maintenance and promotion are important for the medical staff is psychological capital (Fernández-Valera, de Pedro, De Cuyper, García-Izquierdo & Soler Sanchez, 2020). It is a positive psychological state, which is defined by characteristics, such as belief in one’s ability to achieve success, perseverance in pursuing goals, creating a positive self-image, and enduring difficulties. In recent years, many studies have been conducted on the relationship of psychological capital with some occupational and organizational problems, such as being absent from work (Guo et al., 2021). Psychological capital is mainly obtained from theory and research in the field of positive psychology and has been used in the field of occupation (Broad & Luthans, 2020). Hope, optimism, self-efficacy, and resilience are the components of psychological capital (Luthans & Youssef-Morgan, 2017). 
Today, different treatment methods are used to increase and promote mental health and psychological capital. One of these methods is Transference-focused Psychotherapy (TFP). It is a structured modified psychodynamic treatment, and is derived from the object relations model of borderline personality disorder (Gaztambide, 2019). TFP aims to help individuals endure the turbulent and sharp emotions using a structured environment and contract therapy, along with the use of techniques of clarification, confrontation, and interpretation by focusing on transference relationships in the here and now. Then, by maintaining a non-judgmental and neutral subject, provide a space to tolerate their representations and communications or attachment patterns. The key features of this contemporary treatment model of object relations are: (a) Determining the treatment framework by setting an oral contract, (b) Focusing on disturbed interpersonal behaviors both in patients’ lives and in their relationship with the therapist, (c) Using the process of interpretation to correct internal representations of oneself and others, and (d) causing real-world changes in interpersonal behaviors, especially in the field of work and close/romantic relationships (Clarkin, Cain & Lenzenweger, 2018). 
In this method, through confrontation and exposure, patients are taught to deal with their worries for a long time by thinking about scary events. Exposure is done by calling up an image of a frightening expectation and focusing on it. Many studies have pointed to the high effectiveness of TFP in reducing the symptoms of anxiety disorders, but there is scant research on its effectiveness in promoting mental health and psychological capital. TFP reduced self-destructive behaviors and traumatic personality traits (Verheugt‐Pleiter & Deben‐Mager, 2006). Clarkin, Levy, Lenzenweger and Kernberg (2007) compared TFP with dialectical behavioral therapy and supportive modified psychodynamic psychotherapy and showed that all three treatments had different effectiveness in reducing depression and anxiety and in improving overall functioning and social adjustment. Levy et al. (2006) considered structural improvements to be specific to TFP. Gelso (2014) and van Asselt et al. (2008) compared three years of TFP and schema therapy. The effectiveness of TFP was demonstrated in reducing disturbance symptoms, although the rate of withdrawal and its effect size were higher and lower than those of the schema therapy, respectively. In another study, although TFP, dialectical behavioral therapy, and supportive psychotherapy were effective in reducing depression and anxiety and improving overall performance, adaptability to stressful conditions, and resilience (symptom changes), it was only the TFP that always significantly reduced aggression and personality (structural changes) in the form of maintaining increased attachment after one year of treatment (Diamond & Hersh, 2020).
Another effective treatment approach in promoting mental health is Acceptance and Commitment Therapy (ACT). In this therapy, instead of emphasizing the correction of inefficient cognitions and beliefs, patients are taught to accept their emotions and to have more flexibility (at the present) (Hayes, 2019). In this regard, the patient is taught that trying to avoid or control his/her disturbing mental experiences is ineffective or has the opposite effect and exacerbates them and s/he should try to accept them completely. In the next step, the present-moment awareness of the patient is emphasized and the patient becomes aware of his/her mental and physical status, thoughts, feelings, and behavior in the present moment. In the third step, the patient is taught to separate herself/himself from these mental experiences (Cognitive Defusion) and act independently of these experiences. The fourth step focuses on trying to reduce the excessive focus on the self-embodiment of the life story (such as being a victim) that patient has created in her/his mind. In the fifth step, the patients are helped to recognize the personal values and can practically turn them into specific behavioral goals (clarifying values). Finally, the patient is motivated to take action committed to the goals and values set, while accepting mental experiences (Narimani & Vahidi 2014). 
ACT as one of the third generation therapies, has more effectiveness than many other therapies due to the emphasis on functional cycles and consideration of motivational aspects along with cognitive aspects. A study showed the effectiveness of ACT along with coping techniques in reducing the severity of symptoms of a generalized anxiety disorder (Zhang et al., 2018). Another study on nurses working in Imam Sajjad Hospital in Tehran showed that ACT significantly reduced burnout and experiential avoidance in nurses (Bahrainian, Khanjani & Masjedi Arani, 2016). Findings of a study on patients with esophageal cancer showed that the ACT increased the psychological capital of these patients (Barghi Irani, Zare & Abedin, 2015). Bastami, Goodarzi, Dowran and Taghva (2016) showed that ACT can be effective in reducing the severity of depressive symptoms in military personnel with type 2 diabetes.
TFP is one of the new approaches that little research has been done on its effectiveness in the form of short-term interventions, especially in the hospital environment in Iran. On the other hand, the ACT is one of the relatively new approaches of third-wave cognitive-behavioral therapies that emphasizes helping people to have a more satisfying life, even in the presence of undesirable thoughts, emotions, and feelings (Thompson, Destree, Albertella & Fontenelle, 2021). 
Recently, psychological research has studied ACT and its important applications in adapting to stressful conditions (coronary conditions) and promoting mental health (Xu, Shen & Wang, 2021). The main advantage of this method over other psychotherapies is to consider the motivational aspects along with the cognitive aspects, in order to make the treatment more effective and continuous. The novelty of this treatment method and the high applicability of this treatment approach in promoting the mental health of hospital staff are among the reasons for choosing this treatment approach. As a result, more research is needed on the deeper dimensions of these treatments.
We found no research in Iran on the effectiveness of TFP on mental health promotion. On the other hand, no study has been conducted to compare the effectiveness of the TFP and ACT on the mentioned variables. In this regard, and considering the protective role of variables, such as mental health and psychological capital against job stress of hospital staff during the COVID-19 pandemic, which doubles the importance of using the most effective approaches in the promotion of mental health and psychological capital, such as hope, resilience, and optimism, this study was done to compare the effectiveness of TFP and ACT in promoting mental health and psychological capital of hospital staff.

2. Materials and Methods
This is a quasi-experimental study with a pre-test/post-test design. The study population consisted of the personnel working in the hospitals covered by social security in Tehran Province. From nurses, paramedics, and physicians who had direct contact with COVID-19 patients and worked in three hospitals (Milad, Fayyaz Bakhsh, and Kashani), 120 were selected using a purposive sampling method. The sample size was determined to be 40 for every three groups using GPower software and considering an effect size of 0.5, α=0.05, a test power of 0.8, and given that the minimum sample size in previous similar studies was 15 for each group. The samples were randomly (by drawing lots without replacement with new samples) assigned to two experimental groups and one control group (40 in each group). Inclusion criteria were working in social security hospitals in Tehran Province, age between 18 and 55 years, having at least a diploma, no hospitalization or suffering from severe psychological disorders, no addiction to drugs or alcohol, not on the verge of divorce, willingness to participate in research, the relevance of education to occupation, and not attending other counseling and psychotherapy sessions. Exclusion criteria were suffering from physical and mental illnesses that can affect the results, absent for more than two sessions for various reasons, such as relapse, unwillingness to continue participation, not performing home tasks, and occurrence of unforeseen events (such as illness, death of a loved one, etc.).
First, 230 staff in three hospitals, including nurses, paramedics, and physicians, voluntarily answered the questions of the Mental Health Questionnaire (Symptom Checklist-90-R (SCL-90-R)) of the Psychological Capital Questionnaire (PCQ). Then, 125 people with lower scores on these questionnaires were selected from them and randomly assigned to the experimental and control groups. Before starting the treatment process, one of the subjects due to personal problems and four people due to coronary heart disease were excluded, and eventually, 120 subjects were divided into three groups.
All three groups answered the SCL-90-R and PCQ in the pre-test phase. Then, both TFP and ACT groups received interventions in eight sessions, while the control group did not receive any intervention. At the end of the intervention, all three groups completed the questionnaires again.

Measures
The SCL-90-R has 90 items and nine subscales, including somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism (Salimi, Azad Marzaabadi & Abedi, 2013). It has also seven other items, which are important clinically and added to assist with the classification of subscales. The items of this tool are rated on a 5-point Likert scale: 0=not at all, 1=a little bit, 2=moderately, 3=quite a bit, and 4=extremely. A high score on each subscale (≥3) indicates a person’s serious problem in that area. Its indices include Global Severity Index (GSI), Positive Symptom Total (PST), and Positive Symptom Distress Index (PSDI). A mean score ≥1 on these indices indicates positive cases, and a score ≥3 indicates a distressed state. It has been used in Iran and in other countries. Its validity in other languages ranges from 0.72 to 0.90 with reliability ranging from 0.36 to 0.73. For its Persian version, reliability of 0.27 to 0.66 has been reported (Salimi, Azad Marzaabadi & Abedi, 2013). 
The PCQ was developed by Luthans (2002) to measure psychological capital. It has 24 items and four subscales of hope, resilience, optimism, and efficiency. Each subscale contains six items rated on a 6-point Likert scale (1=strongly disagree, 2=disagree, 3=somewhat disagree, 4=somewhat agree, 5=agree, and 6=strongly agree). To obtain the PCQ score, first, the score of each subscale was obtained separately and then their average was considered as the total PCQ score. The results of factor analysis have confirmed the validity of the PCQ structure. The six-factor model of this tool has better fitting. The x2/df value of this test is 24.6 and the values of the Goodness of Fit Index (GFI) and model are 0.97 and 0.08, respectively. The reliability of PCQ in Iran using Cronbach’s alpha was reported 0.85 by Bahadori Khosroshahi et al. (2012).

Interventions
The ACT protocol was presented at eight sessions according to Hayes, Luoma, Bond, Masuda and Lillis (2006). The summary of ACT contents is presented in Table 1.

The short-term TFP was presented at eight sessions according to the protocol proposed by Caligor et al. (2007), which is shown in Table 2.

Data analysis
Data were analyzed by SPSS software. The Kolmogorov-Smirnov test was used to check the normality of data distribution in pre-test and post-test phases, and Levene’s test was used to check the equality of variances. In order to compare the mean scores of the experimental and control groups in pre-test and post-test, Multivariate analysis of Covariance (MANCOVA) was used.

3. Results
Information about the demographic variables (gender, age, occupation, education, and work experience) of the respondents is summarized in Table 3.

The data in this table show that 69 participants in the study were women and 51 were men. The highest frequency of age is related to participants 49 to 35 years with 49 people (40.67%) and the lowest frequency with 29 people (24.47%) aged 50 years and more. Also, 33 participants in the study were paramedic staff, 68 were nurses, and 19 were physicians. Thirty-five participants in the study had a bachelor’s or master’s degree, 46 had a bachelor’s degree, 20 had a master’s degree, and 19 had a Ph.D. Finally, 37 people had 1 to 10 years of work experience, 61 people had 10 to 20 years of work experience, and 22 people had more than 20 years of work experience.
Table 4 presents the mean and Standard Deviation (SD) of the SCL-90-R and PCQ scores in two pre-test and post-test phases.

As can be seen, the mean post-test scores of SCL-90-R and PCQ in the two groups of ACT and TFP were higher than in the control group, and the mean post-test scores in the TFP group were lower than in the ACT group. MANCOVA was used to examine the research hypothesis that the effectiveness of ACT and TFP is different in improving mental health and psychological capital. Before using the test, its presumptions were examined. Kolmogorov-Smirnov test was used to check the normality of data distribution in pre-test and post-test phases. The significance level for the components of SCL-90-R and PCQ was greater than 0.05. Therefore, the distribution was normal. Levene’s test was used to check the equality of variances. The results showed that the F-statistic for experimental and control groups was not significant (P>0.05).
Table 4 presents the results of MANCOVA for comparing the effects of ACT and TFP on mental health. As can be seen, after controlling the effect of pre-test scores, there was a significant difference between all three groups in the components of anxiety (F=27.09, P<0.001), hostility (F=28.03, P<0.001), depression (F=15.39, P<0.001), interpersonal sensitivity (F=6.09, P<0.001), somatization (F=10.41, P<0.001), obsessive-compulsive disorder (F=16.67, P<0.001), phobic anxiety (F=20.20, P<0.001), psychoticism (F=23.48, P<0.001), and paranoid ideation (F=3.8, P<0.05). Therefore, it can be said that there was a significant difference between the three groups in terms of mental health components in the post-test phase. Tukey’s Post Hoc Test was used to determine between which groups these differences were reported. The results showed a significant difference between the ACT and TFP groups in the components of anxiety, phobic anxiety, psychoticism, and paranoid ideation (P<0.01), where the score of these components was lower in the TFP group than in the ACT group. No significant difference was reported between these two groups in terms of other mental health components (P>0.01).
Table 5 presents the results of MANCOVA for comparing the effects of ACT and TFP on psychological capital.

As can be seen, after controlling the effect of pre-test scores, there was a significant difference between all three groups in the components of hope (F=10.05, P<0.05), optimism (F=11.20, P<0.001), self-efficacy (F=9.57, P<0.001), and resilience (F=8.94, P<0.001). Therefore, it can be said that there was a significant difference between the three groups in terms of psychological capital components in the post-test phase. The results of Tukey’s post hoc test showed a significant difference between the ACT and TFP groups in all four components of psychological capital (P<0.01), where the scores of these components were higher in the ACT group than in the TFP group

4. Discussion
The purpose of this study was to compare the effectiveness of TFP and ACT on promoting the mental health and psychological capital of staff working in hospitals in Iran. The results showed a significant difference between the ACT and TFP groups in the components of anxiety, phobic anxiety, psychoticism, and paranoid ideation. They assessed the effectiveness of long-term TFP in people with depression, anxiety, and somatic disorders, and concluded that TFP significantly reduced the symptoms of mentioned diseases in patients. 
In TFP, active and relentless confrontation with the patients’ defenses forces them to experience their true feelings at every moment. Therefore, the effectiveness of TFP can be due to patients’ exposure to anxiety conflicts. Such exposure causes the reorganization of the self and letting go of the sick defenses. Gregory et al. (2010) showed that psychodynamic psychotherapy reduced pathological symptoms, including depression and anxiety. Svartberg et al. (2004) and Bateman and Funaji (2008) reported that TFP for 10-18 months produced lasting effects, including pathological reduction. Some other studies have also demonstrated the effectiveness of psychodynamic psychotherapy in reducing symptom severity and pathology and improving quality of life and interpersonal issues, and related the superiority of this type of treatment to its communication aspects. They suggested it as the most suitable method for people with borderline personality disorder, who have problems and emotional instabilities in interpersonal relations (Haskayne et al., 2014). 
Along with the effectiveness of psychodynamic psychotherapy, studies have shown that structured and tailored forms of these approaches, such as TFP can lead to better results (Paris, 2010). It has been shown that increasing the level of insight during treatment is associated with positive outcomes (Kulligan et al., 2000; Grand et al., 2003). For example, Leachnering et al. (2004) found that TFP has an effect size of 90% for mental disorders and 80% for social functioning. Abbass (2002) examined the effect of TFP on somatization disorder, anxiety, depression, and social adjustment. Their results showed that this treatment was effective in most disorders compared to the control group. Our results are consistent with the results of these studies. TFP focuses on rebuilding a person’s past relationships as well as his/her current relationships with family and others. 
In therapy sessions, the patient has the opportunity to get to know other members of the group, be exposed to a social situation, and be able to express anger, wants, and needs. This shows the subject’s motivation after a few sessions of treatment. Kernberg, Yeomans, Clarkin & Levy (2008) believes that TFP helps improve interpersonal relationships. In this method, attention is paid to the therapist’s evaluation of the patient’s behavior and how the therapist feels about what the patient is saying. The reason for the superiority of TFP over ACT is because of using psychoanalytic techniques mentioned by Gill and Hoffman (1982), such as interpretation, transference analysis, and technical neutrality. The use of interpretation, especially in the early stages, i.e. clarifying the patient’s subjective experience (clarifying what is in the patient’s mind instead of clarifying the information) and confrontation based on tactful attention to the contradictions in patient’s communication, between what the patient says at one point in contrast to another, between verbal and non-verbal communication, or between the patient’s communication and what is evoked in the countertransference. 
Non-verbal aspects of behavior are very important in TFP. In this method, the therapist’s overview of the patient’s total treatment and total life situations may determine that the patient introduces an issue arbitrarily and then, focuses on the development of transference. Technical neutrality is an appropriate technique that is widely used by therapists because it counteracts the tendency of patients to activate intrapsychic conflicts. The use of countertransference in psychotherapy sessions is considered as a main therapeutic method and as an important source of information about effective emotional issues of the patient. Anxiety and feeling guilty are common countertransference feelings that patients experience to learn to tolerate their emotions. Setting clear expectations of treatment reduces a therapist’s anxiety about what s/he can do for the patient and helps raise awareness of the feelings of countertransference. The treatment contract is useful because the responsibilities of the therapist and the patient are delineated (Kernberg et al., 2008). 
In short-term TFP, attention is paid to how people deal with stressors. According to psychodynamic theory, depression and anxiety are characterized by the use of certain maladaptive defensive mechanisms. In this therapy, active and relentless confrontation with the patient’s defenses forces him/her to experience his/her true feelings at every moment. This treatment tries to lead the patient to use more adaptive, more developed, and more rational defense mechanisms such as humor (Hersh et al., 2021). This type of developed defense makes the person accept the condition of the disease and experience less fear and anxiety. On the other hand, the emphasis of many short-term psychodynamic psychotherapies, including TFP, is on structured techniques and protocols, while the role of communication has been neglected. By the TFP, a space is created, in which in addition to awareness and insight into repetitive and unhealthy patterns, patients experience a new communication with the therapist that have not experienced before, and the barriers to the realization of their potentials are removed. 
In all psychodynamic therapies, common therapeutic elements are the processing of past relationships and the creation of new and positive interpersonal relationships, increasing awareness, and expressing emotions (Bernstein et al., 2015). In the present study, the therapist confronted the subjects with their repressed emotions and tried to provide the necessary ground for the expression and experience of the accumulated emotions (especially fear and anxiety) in the subjects during eight sessions of treatment. Regarding the greater effectiveness of TFP in reducing phobic anxiety, psychoticism, and paranoid ideation, it can be explained that TFP is effective in both neurotic people and those with borderline personality disorder according to Kernberg et al. (2008). also showed that TFP significantly reduced depression, anxiety, and somatization disorders.
In our study, there was a significant difference between ACT and TFP groups in the psychological capital components of hope, optimism, self-efficacy, and resilience, where the scores of patients in the ACT group were higher. This is consistent with the results of Jaafari et al. (2018) who showed the effectiveness of ACT in promoting hope in women with breast cancer undergoing chemotherapy, with the results of Valizadeh (2016) who showed the effectiveness of ACT in promoting resilience, with the results of who showed the effectiveness of ACT in improving the resilience of marines showing that ACT increased all communication variables in couples. The main goal of ACT is to maximize a person’s potential for having meaning in life. ACT helps accept what is beyond a person’s personal control and commit to something that enriches his/her life. The goal of ACT is to help patients to create a rich, complete, and meaningful life while accepting the suffering that life inevitably brings with it (Izadi et al, 2012). 
ACT can reduce experiential avoidance and help individuals to recognize and commit to pursuing valuable goals. It promotes resilience, hope, optimism, and self-efficacy by reducing experiential avoidance, getting rid of unpleasant thoughts, not judging, and being aware of the present moment (Reyes, Muthukumar, Bhatta, Bombard & Gangozo, 2020). In the ACT, a person learns to accept many of the hardships and thoughts, and feelings that come with his/her job, while setting goals and actions in line with his/her values with full awareness of his working conditions. Putting the thoughts and feelings aside increases one’s psychological flexibility and, consequently, resilience, optimism, and hope (components of psychological capital). This made this treatment be more effective in promoting psychological capital compared to TFP.
Lack of follow-up due to the COVID-19 pandemic and vaccination of medical staff (which could affect the results) was one of the limitations of the present study. Therefore, it is recommended that the results be followed up for two years after the interventions. The present study used group therapies; hence, it is recommended that the therapies are conducted individually and the results are compared with the results of group therapies. Finally, it is recommended that ACT and TFP be used in hospitals and medical centers to promote the mental health and psychological capital of staff, especially in the current COVID-19 pandemic.

5. Conclusion
According to the obtained results, it can be said that the TFP led to a higher promotion of the mental health of the staff working in the hospitals covered by social security. According to the findings, it can be concluded that TFP was able to cause symptomatic changes in a short time and enhanced the mental health capacity of the subjects, especially improving the symptoms of anxiety, morbid fear, psychosis, and paranoia. TFP, as a form of structured psychodynamic psychotherapy, was associated with symptom improvement.
The results of the study showed that ACT improved psychological capital and its four subscales, namely self-efficacy, hope, resilience, and optimism. ACT is an evidence-based psychological intervention that combines acceptance and awareness strategies in a variety of ways with commitment and behavior change strategies. This is done with the aim of increasing psychological flexibility. The ACT group members learned that hardships and adversity in the path of life goals and values are inevitable. By applying appropriate skills, such as acceptance skills and cognitive assimilation, and by committing to the values ​of life, many problems and difficulties can be overcome, including the difficult conditions of COVID-19. The results of the present study provide support for TFP and ACT. According to the results of the present study, since in positive psychology, it is believed that the constructs of positive psychology, including hope and optimism, can protect people against the effects of stressful life events, it seems that preventive programs based on the ACT are helpful.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Islamic Azad University - Shahrood Branch (Code: IR.IAU.SHAHROOD.REC.1400.060).

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

Authors' contributions
All authors equally contributed to preparing this article

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The Authors would like to thank the supervisor Dr. Raheb Ghorbani, the Advisor Dr. Nemat Sotoudeh Asl, at Islamic Azad University, Semnan Branch, and Social Security Organization. 

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