The Effect of Integrative Therapies Based on the Regulation of Cognitive, Emotional, and Behavioral Mediators on Marital Adaptation: A Systematic Review

authors:

avatar Ahad Solat Petloo 1 , avatar Shahram Vaziri ORCID 1 , * , avatar Farah Lotfi Kashani ORCID 1

Department of Psychology, Roudehen Branch, Islamic Azad University, Roudehen, Iran
Iranian Journal of Psychiatry and Behavioral Sciences: Vol.16, issue 1; e116680
published online: February 12, 2022
article type: Systematic Review
received: June 9, 2021
revised: December 7, 2021
accepted: December 30, 2021
DOI: https://doi.org/10.5812/ijpbs.116680

how to cite: Solat Petloo A, Vaziri S, Lotfi Kashani F . The Effect of Integrative Therapies Based on the Regulation of Cognitive, Emotional, and Behavioral Mediators on Marital Adaptation: A Systematic Review. Iran J Psychiatry Behav Sci. 2022;16(1):e116680. https://doi.org/10.5812/ijpbs.116680.

Abstract

Context:

Marital adjustment is necessary for ensuring the well-being and continuity of mutual relationships. It encompasses a wide range of experiences required for cohabitation, such as satisfaction, agreement, and expressing emotions. The importance of marital adjustment has been the focus of various therapeutic approaches, and it has been long considered by researchers in the context of communicative skills.

Evidence Acquisition:

Due to the inter-theoretical and multi-dimensional nature of marital communication and adaptation, this study was conducted to investigate the effectiveness of integrative therapies based on the regulation of the cognitive, emotional, and behavioral mediators on marital adaptation.

Data Sources:

In this systematic review, English articles published from March 2005 to March 2021 in databases including Google Scholar, ScienceDirect, PubMed, Web of Science, and Cochrane Library were extracted. Also, to find the articles published in Persian, databases including Scientific Information Database (SID) and Magiran were searched from January 2021 to April 2021.

Results:

A total of 20 studies were included for analysis. The results of the systematic review showed the usefulness of integrative couple therapies with the continuation of therapeutic effects in more than two months of follow-up.

Conclusions:

Although the effectiveness of integrative approaches in improving the couple's adaptation and communication components were confirmed in the reviewed studies, most of the studies provided no evidence regarding the effective variables in the therapeutic interventions and the related procedure. Therefore, more precise studies are required to make a more accurate judgment on their credibility.

1. Context

Undoubtedly, communication is one of the most basic needs of human beings, as well as one of the essential capabilities of his life (1); it also provides the necessary background for forming and giving meaning to interpersonal interactions. Communication is the main basis of the human participatory activities that are naturally formed in the context of mutual perception and shared social motivations (2). Gottman and Levenson (2000) considered three components for communication, including expectation/withdrawal, reciprocal avoidance, and constructive communication. They considered the reciprocal constructive model as healthy and reinforcing of the relationship, and considered the other two models as inefficient (3).

Naturally, addressing the marital adaptation issue has been long considered by researchers in the context of the communication issue. The study of marital adaptation has a history dating back to Hamilton's (1929) classic study. Since then, several measures have been developed to assess the dimensions of couples’ communication and marital adjustment (4). Four components of satisfaction, agreement, solidarity, and kindness expression can be considered as the main indicators of marital adaptation (5). Activation of these components in the relationship has contributed to adaptive role-playing and aligns with the responsibilities associated with cohabitation (6). It also provides the necessary backgrounds for changing and repairing the behavioral patterns and improving marital satisfaction; however, the opposite point of adaptation is inadaptation and marital conflicts that provide necessary substrates for continuous tensions, emotional isolation, and physical separation (7).

Global statistics have shown the instability of the family organization and the increasing divorce rate in the different societies (8). To prevent such a troubling process and find the related pathologies, various couples therapy approaches have been developed with the aim of examining the various dimensions of couples' experiences, understanding how stressors are formed, and how they affect marital dysfunction (9). In this regard, the existing gap is that why these treatments have not been able to achieve the expected success so far.

It seems that when a tendency or need is altered or distorted in the path of manifesting as an action or behavior, it is likely to be influenced by psycho-basic mediators such as cognitive, emotional, communicative, and behavioral mediators in its passage that act interactively and circularly and weaken or strengthen the relationship between these elements.

In connection with this theoretical hypothesis, we assessed four main perspectives of integrative couple therapy.

1.1. Cognitive-Behavioral Couple Therapy

The basic premise of this perspective is that incorrect processing of cognitive information, misinterpretations or distortions due to misconceptions, along with adherence of their spontaneous thoughts provides the necessary backgrounds for couples' failure to identify and properly evaluate their cognitions in response to external and internal events (10). Cognition of behavioral therapists, especially Ellis (2000), introduces challenging of thoughts, re-evaluating the cognitive information, and correcting the irrational beliefs to reconstruct and change the cognition as the main elements of therapy (11).

The cognitive-behavioral couple therapy (CBCT) approach has a relatively rich research background, and most of its findings have confirmed the effectiveness of this treatment model in such areas as correction of communication patterns, problem-solving, emotional correlation, and behavioral control (12). Overall, meta-analysis results estimate the usefulness of this approach to 78% (13).

1.2. Emotionally Focused Couple Therapy

This treatment follows an adaptively based orientation of emotions and excitements by combining a structural systemic perspective and attachment theory. The overall goal of the emotionally focused couple therapy (EFCT) is to persuade couples to set aside the destructive patterns associated with repetitive conflicts and to avoid ineffective negative emotions. Then, they can focus on the reconstruction of mutual interactions and strengthen the shared emotional bonds (14). Experimental studies have examined the effectiveness of this approach in areas such as resolving communication problems, marital conflicts (15), and improving marital adaptation (16).

1.3. Self-regulation Couple Therapy

The main characteristics of this perspective are the change in cognitive, behavioral, emotional patterns and their reorganization based on goals and needs, with a focus on couples (17). Self-regulation couple therapy (SRCT) theorists believe that self-regulation can improve the coordination of a person's insights, attitudes, and actions and develop her/his psychological and communicational balance. Studies investigating the self-regulation-based therapy have confirmed its usefulness alongside other therapies. Also, studies have investigated the effect of this treatment method on improving satisfaction, reducing the couples’ stress and depression (18), vitality, and controlling the emotions of couples with psychological distress (19).

1.4. Common Factor Couple Therapy (CFCT)

In general, the theoretical basis of this perspective is based on the integration of the main or specific factors of different therapies with their common elements, and its goal is to increase the effectiveness of psychotherapy with the utmost usefulness in the shortest possible time (20). Consistent with this theoretical view, Vaziri and Lotfi Kashani (2015) introduced a therapeutic approach in which four factors, including creating hope, expectation of treatment, raising awareness, and behavior regulation (emotion, thinking, and function) were suggested as the common and systematic elements of various therapies (21). In this regard, various studies have provided strong theoretical and research support for the effectiveness of this therapeutic perspective (22-24).

2. Evidence Acquisition

Due to the serious effects of psychological interventions on marital adaptation and based on the four main perspectives of integrative couple therapy, this study aimed to investigate the effect of integrative therapies based on the regulation of cognitive, emotional, and behavioral mediators on marital adaptation.

3. Data Sources

In this systematic review, English articles investigating the effectiveness of integrative couple therapies on the components of marital communication and adaptation published from March 2005 to March 2021 in databases including Google Scholar, ScienceDirect, PubMed, Web of Science, and Cochrane Library were extracted. Also, to find the articles published in Persian, databases including Scientific Information Database (SID) and Magiran were searched from January 2021 to April 2021.

To retrieve the related articles, the following keywords extracted through the MeSH strategy were used: [“couple therapy” OR “couples therapies” OR “integrative couple therapy”] AND [“marital communication” OR “mutual communication” OR “personal communication”] AND [“psychological adaptation” OR “marital adjustment” OR “psychological adjustment” OR “adaptive behavior”] AND [“self-regulation” OR “emotional self-regulation” OR “emotional regulation”]; the Persian equivalents were also used in Persian databases. The final search was conducted from February 2021 to March 2021. Only studies published in English and Persian languages were searched and included in the study. The reference lists of the selected studies were also visually scanned to identify additional relevant articles.

4. Study Selection

In the first stage, articles related to the study title were searched through the mentioned keywords, and then a list of searched articles was included in the initial list. Two researchers (A. S. and Sh. V.) independently screened the titles and abstracts of the articles. If a study appeared to be relevant, the full text was obtained and reviewed for further assessment according to the inclusion and exclusion criteria.

The inclusion criteria were: psychological interventional studies related to the research topic; articles published after 2005, non-duplication of studies; Persian and English studies published in valid and scientific journals; and studies with randomized controlled trials, pilot randomized controlled trials, and quasi-experimental designs. Irrelevant studies, articles not published in the desired period, and studies conducted on couples with psychiatric disorders were excluded from the study.

The full texts of the selected articles were read carefully, and the required information was extracted and summarized in a descriptive table and cross-checked by one of the authors (FE). Disagreements were resolved in group discussions between the authors.

5. Data Extraction

A checklist including such information as first author, country, publication year, research method, sample size, sampling method, and data collection tool was prepared. After initial assessment of the included studies by the researcher, the related articles were included in the systematic review.

5.1. Quality (Risk of Bias) Assessment Tool

The research team decided to assess the methodological quality (risk of bias) of the trials through the modified Jadad Scale (25, 26). This validated tool is being widely used to evaluate the quality of randomized controlled trials, and it has two sections. The first section includes three direct statements, including “description of randomization of the study with appropriate methods”, “description of the double-blind study”, and “description of withdrawals and dropouts”. For the first statement, 1 point is assigned to a study if randomization has been mentioned, and if the method of randomization has not been mentioned, an additional point can be awarded. For the second statement, if the study has mentioned “blinding”, 1 point is allocated and an additional point is given if the appropriate method of blinding has been declared in the study. For the third statement, if withdrawals or dropouts have been described in the study, 1 point is given. The overall score of the first section of the Jadad Scale ranges from 0 - 5, and a higher score indicates a high-quality study (26, 27).

The second section of the modified Jadad Scale contains three additional statements about “a clear description of inclusion and exclusion criteria”, “a description of research method used to assess adverse effects”, and “a description of statistical analysis methods”. If the three statements have been cited, the study receives 1 point; otherwise, the score of zero is given. The overall scoring of this tool for each article ranges from 0 (as the lowest quality) to 8 (as the highest quality). Thus, studies with scores ranging in 4-8 represent good to excellent quality (i.e., high-quality) and those with scores ranging in 0-3 represent poor or low quality (27, 28) (Table 1).

Table 1.

Quality Assessment of the Included Studies Using the Modified Jadad Scale

First Author (Year)Was the Study Randomized? (Yes:1, No: 0)Was the Method of Randomization Appropriate? (Yes: 1, No: -1, Not Described: 0)Did the Study Have a Blinding Design? (Yes: 1, No: 0) Double-Blind Got 1 Score)Was the Method of Blinding Appropriate? (Yes: 1, No: -1, Not Described: 0)Was There a Description of Withdrawals and Drop-Outs? (Yes: 1, No: 0)Was There a Clear Description of The Inclusion/Exclusion Criteria? (Yes: 1, No: 0)Was the Method Used to Assess Adverse Effects Described? (Yes: 1, No: 0)Were the Approaches of Statistical Analysis Described? (Yes: 1, No: 0)Total Score
Kalkan and Ersanli (2008) (29)000000011
Nazari et al. (2011) (30)000001012
Azimi et al. (2016) (31)100000012
Bélanger et al. (2014) (32)110001014
Shahadati Maleki and Noroozzade (2015) (33)100001013
Dalgleish et al. (2015) (34)110011015
Ziaolhagh et al. (2012) (35)100011014
Javidi et al. (2013) (36)100001013
Poursardar et al. (2019) (37)000001012
Wiebe et al. (2017) (38)111011016
Halford et al. (2007) (17)000011013
Roshan et al. (2012) (39)100000012
Wilson et al. (2005) (40)000001012
Okabayashi (2020) (41)100011014
Khaleghkhah et al. (2016) (42)100000012
Mehdinezhad Qoushchi et al. (2016) (43)100011014
Modaresi Asem et al. (2017) (44)100000012
Su (2018) (45)100011014

6. Results

6.1. Search Results

After the initial search process, 147 articles were retrieved. Following the removal of studies with no therapeutic intervention and studies examining the unrelated dependent variables, 103 articles remained. In the next stage, abstracts of all the selected articles were screened, which resulted in a total of 61 articles. In the final screening stage, after removing the duplicate studies and considering the priority of publication year, 20 articles were included (Figure 1).

Flowchart of included articles in the systematic review.
Flowchart of included articles in the systematic review.
Figure 1.

Flowchart of included articles in the systematic review.

6.2. The Characteristics of the Included Studies

After screening the retrieved articles, 20 articles were included in the systematic review. The included studies had been conducted in countries, including Australia (17, 40), Turkey (29), Canada (34), USA (32, 38, 45, 46), Norway (47), Japan (41) and Iran (30, 31, 33, 35-37, 39, 42-44). Of 20 included articles, five studies used the CBCT approach, five studies used the EFCT approach, five studies used the SRCT approach, and five other studies specifically used the CFCT approach. The reviewed cases included adaptation components (n = 7), communication components (n = 6), marital conflicts (n = 3), self-regulation and common factors (n = 2), happiness (n = 1), and self-evaluation (n = 1). The total sample size in 20 included studies was 1981 individuals. The results of the systematic review are summarized in Table 2.

Table 2.

The Characteristics and Results of the Included Studies in the Systematic Review

First Author/ Publication Year/ CountryTitle of StudyType of Study (Research Method)Sample Size and Sampling MethodData Collection ToolResults
Kalkan and Ersanli, 2008, Turkey (29)The effect of marriage enrichment program based on the cognitive behavioral approach on the marital adaptationQuasi-experimentalN = 30; ConvenienceMarital Adjustment Scale (MAS) Tutarel-KishlakComparison of the mean scores in pre-test and post-test showed the effectiveness of the CBCT on increasing marital adaptation (P < 0.05).
Nazari et al., 2011, Iran (30)Comparison the effectiveness of enriched CBCT and IBCT in increasing the marital satisfactionSingle caseN = 16; ConvenienceDyadic Adjustment Scale (DAS)Comparison of the mean scores among two interventional methods showed that IBCT was more effective than CBCT. The mean score of pre-test in CBCT group was 64.25 and post-test was 98.55. Also, the mean scores of pre-test and post-test in IBCT were 60.12 and 108.1, respectively.
Azimi et al., 2016, Iran (31)The effectiveness of CBCT on increasing the marital adaptation and the quality of life among couples seeking divorceQuasi-experimentalN = 40; ConvenienceDAS, World Health Organization Quality of Life Instruments (WHOQOL-BREF)The Results of multivariate covariance analysis showed the effectiveness of the CBCT intervention on increasing the marital adaptation (P < 0.01, F = 17.297) and quality of life (P < 0.01, F = 14.537)
Bélanger et al., 2014, USA (32)The effect of cognitive-behavioral group marital therapy on marital happiness and problem-solving self-appraisalQuasi-experimentalN = 132; PurposefulProblem-Solving Inventory (Heppner, Petersen), The Marital Happiness Scale (Azrin, Naster, Jones)Therapy was effective in improving global couple adaptation (P < 0.0001) and problem-solving self-appraisal (P < 0.0001)
Shahadati and Noroozzadeh, 2015, Iran (33)The effect CBCT on the couples' communication patternsQuasi-experimentalN = 24; VolunteerCommunication Patterns Questionnaire (CPQ)The results of covariance analysis showed the effect of the intervention on the components of mutual constructive communication, mutual avoidance, and expectation/withdrawal (P < 0.05).
Dalgleish et al., 2015, Canada (34)Predicting change in marital satisfaction throughout EFCTHierarchical Linear Modeling (HLM)N = 64; ScreeningDAS, Experiences in Close Relationships—Relationship Specific (ECR-RS)The results of the intervention showed a significant improvement in marital satisfaction among 20 couples (64.5%), no significant change in nine couples (28.1%), and decreased marital satisfaction in two couples (6.3%) (effect size: d = 81%).
Ziaolhagh et al., 2012, Iran (35)The effect of emotionally focused couple therapy in marital adaptationQuasi-experimentalN = 20; ConvenienceDASThe results showed the effectiveness of the EFCT on marital adaptation (P < 0.001). However, the results of the two-month follow-up did not confirm the durability of the therapeutic effects.
Javidi et al., 2013, Iran (36)The effectiveness of EFCT to improve communication patterns in couplesQuasi-experimentalN = 60; ConvenienceCPQThe results of the covariance analysis showed a significant mean difference between the post-tests in the two groups (P < 0.05).
Poursardar et al., 2019, Iran (37)The effectiveness of EFCT and IBCT on restructuring communication patterns in couples with marital conflictThe non-congruent multiple baseline experimental single caseN = 12; ConvenienceDAS, CPQThe EFCT intervention led to reconstruction of the communication patterns in the post-treatment (50.66 %) and follow-up (53.27%). Also, in IBCT, the scores were 80.38 and 41.21 in post-treatment and follow-up stages, respectively, indicating the relative superiority of the effectiveness compared to the EFCT.
Wiebe et al., 2017, USA (38)Two-year follow‐up outcomes in EFCT: An investigation of relationship satisfaction and attachment trajectoriesHLMN = 64; ConvenienceDAS, ECR-RSThe results showed a significant growth pattern in increasing marital satisfaction (P < 0.001) and decreasing the couple's attachment anxiety (P < 0.001).
Halford et al., 2007, Australia (17)Does working at your marriage help? Couple relationship self-regulation and satisfaction in the first 4 years of marriageLongitudinalN = 382; PurposefulDAS, Behavioral Self-Regulation for Effective Relationships Scale (BSRERS)In this 5-year study, although the results showed a different coefficient of variation (P < 0.001), it was not able to predict a positive gradient as a continuum in the long term.
Roshan et al., 2012, Iran (39)The effectiveness of SRCT on enhancing marital intimacy of the couples with marital problems attending counseling centerQuasi-experimentalN = 32; ConvenienceDASThe results showed the effectiveness of SRCT (P = 0.0001). The effects of SRCT on improving other components of adaptation such as understanding (P < 0.001), attraction (P = 0.034), satisfaction (P = 0.002), and emotions expressing (P = 0.048) were relatively confirmed.
Wilson et al., 2005, Australia (40)Assessing how much couples work at their relationship: The behavioral self-regulation for effective relationships scaleLongitudinalN1 = 187; N2 = 97; N3 = 61; RandomDAS, Depression Anxiety Stress Scales (DASS)The results of factor analysis performed on three groups showed that self-regulation is an important part of the satisfaction variance in marital relationships. Also, it was a strong predictor of marital quality and marital satisfaction.
Okabayashi, 2020, Japan (41)Self-regulation, marital climate, and emotional well-being among japanese older couplesHLMN = 49; RandomSelective optimization with compensation (SOC)The results predicted a positive relationship between couples' self-regulation with well-being, high satisfaction, and low depressive symptoms (P < 0.001). The results also showed that individuals who positively interpreted life's unfortunate events, had high satisfaction and low depression.
Khaleghkhah et al., 2016, Iran (42)The effectiveness SRCT in marital satisfaction and expression of positive feelingsQuasi-experimentalN = 48; ConvenienceIndex of Marital Satisfaction (IMS), Positive Feeling Questionnaire (PFQ)Covariance analysis showed the significant differences and treatment effect in the studied variables (P < 0.001).
Mehdinezhad Qoushchi et al., 2016, Iran (43)Effect of common factors couple therapy paradigm on capability of couples to engage in effective dialogueQuasi-experimentalN = 32; ConvenienceEffective Dialogue Questionnaire (EDQ)The results showed the effectiveness of the intervention on improving the ability of the experimental group in verbal and non-verbal skills scales compared to the control group (P < 0.001).
Laska et al., 2014, USA & Norway (47)Expanding the lens of evidence-based practice in psychotherapy: A common factors perspectiveLibrarianN = 344; Targeted samplingDatabases, internet resources and previous studiesThe results showed the effect size of the therapeutic alliance (57%), empathy (63%), common therapeutic goals (72%), originality and coordination (49%), positive attention and approval (56%), and therapist (46%), indicating the relatively high effect size of therapeutic interventions.
Modaresi Asem et al., 2017, Iran (44)The effectiveness of four-factor therapy: The relationship of therapy, therapy expectation, increasing awareness and ordered behavior on reducing marriage conflictsQuasi-experimentalN = 52; ConvenienceMarriage Conflicts Questionnaire (MCQ)The results of one-way analysis of variance and multivariate covariance showed the effect of therapeutic methods on eight components related to marital satisfaction. Also, correlated t-test confirmed the stability of the results (P < 0.05).
Su, 2018, USA (45)The effect of common factor therapist behaviors on change in marital satisfactionQuasi-experimentalN = 48; ConvenienceTherapist's General Clinical Skills/Qualities (TGCSQ), DAS, Emotion Focused Therapy-Therapist Fidelity Scale (EFT-TFS)The results showed that out of 14 common factors studied, 13 factors had no significant relationship with any change in marital satisfaction, and only the therapist empathic factor was a strong predictor in this regard.
Harbison, 2018, USA (46)Therapist common factors, influence on client constructive communication and conflict resolution in couple therapySecondary analysis of previous studies by correlational methodN = 82; ConvenienceCPQ, Styles of Conflict Inventory (SCI), Marital Interaction Coding Scale-Global (MICS-G)The results of the Pearson correlation coefficient showed that the therapist's common therapeutic factors had a positive relationship with changes in the constructive and reciprocal relationship between couples. However, the direction of this relationship was reversed in the situation of using individual system techniques, especially in female therapists.

6.3. Quality Assessment of the Included Studies

Of 20 included articles, 18 articles were systematically assessed through valid quality assessment tools, the results of which are presented in Table 2. Since two studies were review studies, we excluded them from the quality assessment process (46, 47).

7. Discussion

This study aimed to investigate the effectiveness of integrative therapies based on cognitive, emotional, and behavioral mediators on marital adaptation. For this purpose, 20 related articles were reviewed according to the four main approaches of integrative couple therapy.

7.1. CBCT

In this section, five studies were reviewed. Based on the extracted results, the usefulness of the CBCT in the studied variables with different ratios was confirmed. Bélanger et al. (2014) showed the effectiveness of this therapy on improving the couples’ adaptation, self-assessment, and problem-solving skills. Also, the results of this study showed that the individual's problem-solving skills depend on the methods of his/her evaluation and perception of problems (32). In a consistent manner, the results of another study indicated that relationship enrichment based on the CBCT approach was effective in strengthening marital adaptation (29). However, despite such achievements in this approach, a noteworthy issue in this regard was the unspecific borders between various psychological components, including emotion, behavior, and cognition. Therefore, it is not clear whether unconditional validation has a defensible and strong base for conceptualizing the individual's intrapersonal and extra-personal actions following the cognitive and behavioral elements. Although the experts of this approach have recently attempted to resolve the mentioned defects by expanding the scope of its domain through combining the emotion with cognition and behavior factors (48), this orientation results in another inter-theoretical problem entitled entanglement with the emotionally focused perspective. Regardless of these issues, the CBCT approach has strong individual and comparative research supports. In a study that compared two enriched CBCT and IBCT approaches (30), similar results were reported. One of the specific characteristics of the CBCT is structural and rich educational-therapeutic protocols, which provide extensive research incentives.

Various studies showed the usefulness of CBCT in marital adaptation and couple's quality of life (31), improvement of marital communication patterns (33), emotional correlation and satisfaction, behavioral control, communication components, and problem-solving (12, 49). In general, based on the results of the studies, it can be stated that the usefulness of CBCT-based therapeutic interventions in the components of couple's adaptation and communication is mainly clear. However, more precise and controlled studies are needed to judge the level of its effectiveness.

7.2. EFCT

The five assessed studies in this regard mainly examined the components of marital adaptation, marital satisfaction, couple's conflict, and communication patterns. One of the included studies evaluated the effectiveness of EFCT on increasing marital adaptation; despite significant results of the intervention, the continuation of therapeutic effects was not confirmed in the two-month follow-up phase (35). In contrast, another study that examined the effectiveness of EFCT and integrative behavioral perspectives in reducing marital conflict showed not only the usefulness of post-therapeutic interventions, but also its continuity in the two-month follow-up phase (37). The results of this study are consistent with the results of Dalgleish et al. (2015); both studies showed the effectiveness of EFCT on increasing satisfaction, emotional control, and attachment security in the post-therapeutic and follow-up stages (34). Javidi et al. (2013) also confirmed the effectiveness of this therapeutic method in improving couples' communication patterns. The persistence of therapeutic effects in the long-term follow-up is an important issue in this model and other therapeutic approaches (36).

Wiebe et al. (2017) evaluated the two-year follow-up of the outcomes regarding the effect of EFCT on improving the attachment status and marital satisfaction; the results supported the stability of the changes during the investigation (38). Consistent with these results, other similar studies have also examined the effectiveness of EFCT on various aspects of couples' communication such as marital conflicts (15) and marital adaptation (16). But like CBCT perspective, in this approach, we are faced with a phenomenon called the uncertainty and unpredictability of its borders and specific domain. It should also be noted that the developers of this perspective showed low interest in an in-depth examination of the psychological interacting mediators, insights, dynamics, and motivations that operate in intrapersonal and extra-personal actions. Therefore, its implications may be reduced by inexperienced and superficial therapists to the repetitive application of few accessible, soothing, and transient therapeutic techniques. However, the overall outcomes of the systematic reviews showed that the usefulness of EFCT is acceptable in the post-therapeutic phase and relatively acceptable in the follow-up stage.

7.3. SRCT

Consistent with the structural principles of this approach, based on the correction and restoration of dysfunctional couple interactions, through the cognitive, emotional, communicational, and behavioral elements regulation, various studies have been performed to evaluate its effectiveness in the couples’ communicational and functional variables.

In this review study, five studies examined the therapeutic effects of self-regulation on elements such as adaptation, satisfaction, and communication patterns in marital communication. The results of multistage evaluations in a five-year longitudinal study confirmed the sustainable use of therapeutic intervention focused on the couples' self-regulation in improving marital communication and satisfaction (17); this result is inconsistent with other studies supporting the theoretical hypothesis of self-regulation perspective on the effectiveness of correcting multifactorial cognitive, behavioral, and emotional patterns in improving the quality of the marital relationships (40, 42).

In addition, studies evaluating marital adaptation (39), vitality and control of emotions among distressed couples (19), and the status of marital emotional communication (41) have also obtained similar results. Overall, it can be declared that the centralism of this approach on the capacities of the clients, as well as its theoretical flexibility are the significant characteristics highlighting the integrative nature of this approach more than most other integrative theories.

7.4. CFCT

Regarding the research related to the CFCT approach, we faced poor empirical studies but rich review studies. This might be related to factors such as the complexity of the therapeutic protocols’ formulation due to the expanded theoretical coverage, or other interfering elements. According to five included studies in this section, interpersonal interactions and marital communication were explored in the context of the CFCT approach. A study that evaluated the effectiveness of a CFCT intervention on improving communication patterns and skills showed the positive function of therapy in regulating the verbal and non-verbal skills of clients (43). This result is consistent with the theoretical basics of the CFCT approach that emphasizes the regulation of intellectual, emotional, and functional elements (21). Also, the results of various studies have confirmed the effectiveness of CFCT in reducing marital conflicts (44) and marital distress (22, 47, 50, 51). In contrast, two studies showed different results. A study indicated no significant relationship between the CFCT and the constructive relationship between female therapists participating in the treatment (46). In another study evaluating the effect of CFCT along with specific therapeutic systems, out of 14 common factors, only the “therapist empathy”

factor had a significant relationship with a change in the level of marital satisfaction (45). The heterogeneity of research outputs related to CFCT indicates the influential position of this approach in the field of theoretical and practical studies; it also explains the necessity for more scientific research in this regard.

Currently, it seems that the most convincing statement regarding the status of existing therapies in terms of their usefulness and effectiveness is the well-known phrase entitled “treatment is better than no treatment”. Although some studies have estimated the positive effect of couples therapy by nearly 70%, such estimates have uncertain credibility without presenting scientific and evidence-based responses.

In general, and based on the author's perception, in order to more accurately evaluate the therapeutic effects of the approaches reviewed in this study, it seems necessary to answer the following questions:

(1) How can the scope and effect of each of the specific treatment approaches be differentiated? In other words, how can it be understood whether the therapeutic agent affects only a certain range of cognition, insight, emotion, and behavior, or includes an inseparable set of these elements?

(2) By what mechanism can the contribution of factors such as therapist ability, treatment strategies, client's effort, treatment environment and other variables in the treatment process be measured?

(3) Do therapies really lead to the creation of new meanings, the discovery of fundamental solutions, and lasting change, or are they only able to provide temporary and unstable relief?

7.5. Conclusions

The results of this systematic review showed that different interventional approaches have been performed regarding the effectiveness of integrative therapies based on the regulation of cognitive, emotional, and behavioral mediators on marital adaptation. Also, the effectiveness of these approaches in improving the couple's adaptation and communication components has been confirmed. Since most of the studies provided no evidence regarding the effective variables in the therapeutic interventions and there are no sufficient explanations for questions about what, how, and why the client's treatment changes, therefore it seems that more precise studies are required to make a more accurate judgment about their credibility.

Acknowledgements

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