1. Background
Marriage is a major social tradition that meets people’s emotional, psychological, and social needs. However, marriage expectation failure can cause marital conflicts and divorce (1). Statistics indicate an upward trend in divorce among Iranian families (2), and the marriage-to-divorce ratio (4: 1) indicates one divorce out of four marriages (3). According to studies, marital confusion has been the most relevant type of emotional dissatisfaction, classified as a subcategory of emotional disorders (4). Thus, clinical examinations showed that the prevalence of emotional disorders (e.g., mood and anxiety) is five-to-six times higher in emotionally divorced couples (EDCs) than in normal couples (5). The extent of these coincidences has made couples therapists more sensitive to pathological symptoms in developing treatment models and schemes (6).
Emotion regulation is among the variables of relationship distress and emotional divorce in marital satisfaction, family functions, and harm from marriage defects, which attracted couple therapists in the last two decades (7). Couples face many marital crises, which provoke their emotions (8). Attempts by couples to manage their feelings and thoughts have a significant role in coping with severe reactions (9). In other words, failure in emotion regulation can lead to sadness and even psychological harm, disrupting the continuity of an intimate relationship (10, 11). Cognitive flexibility is another factor in preventing emotional divorce (12).
Cognitive flexibility refers to the ability to learn from external and internal experiences, which varies in people and determines how they react to new experiences. Cognitive flexibility requires connecting with the present moment and separating from internal psychological experiences and thoughts (13). Cognitive flexibility enables people to appropriately cope with pressures, challenges, and other problems in life (14, 15). Some researchers have defined cognitive flexibility as changing cognitive cues and adapting to changing stimuli (16). Cognitive flexibility entails an extensive range of human capabilities, from detecting and adapting to demands for changing behavioral approaches when these approaches endanger people’s personal and social functions (17)—being cognitively flexible means staying aware of the environment and committing to behaviors in accordance with one’s values in all areas of life. Individuals with higher levels of cognitive flexibility are more responsible for personal and family interactions than less cognitively flexible ones. Therefore, cognitively flexible couples are more likely to accept personal differences and handle marital conflicts appropriately (18, 19).
Evidence shows that couples in today’s society often seek treatment solutions to recreate relationship trust and satisfaction, especially in emotional bonds with their beloved people (20). Therefore, developing effective and empirically supported approaches to couples therapy is essential. Integrative behavioral couple therapy (IBCT) can be considered a treatment solution, which helps couples reduce their conflicts by integrating acceptance and change and is known as context-based behavioral therapy (21). Couples easily accept each other’s differences at the beginning of a relationship, and when they cannot accept such differences easily, they see each other as imperfect instead of different. Ultimately, couples start complaining about each other and try to change each other, leading to compulsive and negative behaviors such as lying, avoidance, and criticism (22). Integrative behavioral couple therapy is based on four broad methods for improving the emotional acceptance of couples: Empathic joining regarding the problem, unbiased unity to assess the problem, increasing tolerance in coping with an annoying problem, and growing self-care skills against unsolvable problems. Integrative behavioral couple therapy uses axial change techniques like behavioral exchange, communication training, and problem-solving (23). Previous studies have indicated that IBCT effectively improved family functions and marital intimacy (24-27).
The broad range of family and couple problems and a growing divorce rate have necessitated more effective treatments. In this regard, IBCT is among the integrative therapies, which attracted the attention of family and couple therapists in recent decades.
2. Objectives
According to this background, the present study aimed to evaluate the effects of IBCT on emotion regulation and cognitive flexibility among EDCs.
3. Methods
This experimental research adopted a pretest-posttest design with follow-up. The statistical population included 20-50-year-old EDCs visiting Ramshir County, Khuzestan, Iran’s counseling centers in 2022, who were selected by purposive sampling. The study included 12 couples (24 individuals) based on G*Power software (effect size = 0.96, alpha = 0.05, and test power = 0.90). The inclusion criteria were couples diagnosed with an emotional divorce based on a clinical interview and a score higher than the average on the emotional divorce scale, and couples married more than two years, couples with at least a middle school degree, and couples without acute psychiatric disorders and drug/alcohol addiction. The exclusion criteria included addiction of at least one spouse to drugs and alcohol, severe verbal and physical violence, and having psychiatric disorders. Overall, 12 eligible participants were enrolled and answered the questionnaires in the pretest and posttest stages. In addition, the participants responded to the research tool again in a follow-up period of 45 days to evaluate the continuity of the intervention effect. The couples gave their informed consent before conducting the research, and they were assured that their data would remain confidential with the researchers.
3.1. Instruments
Gottman Emotional Divorce Scale: This 24-item scale was developed by Gottman and Levenson (28). The items are responded to by "yes" and "no”. The number of "yes" responses (≥ 8) indicates marital dissatisfaction and emotional divorce. In this case, the marriage is broken, and there are signs of divorce. Mirzadeh Koohshahi et al. (29) reported this instrument’s Cronbach alpha coefficient of 0.97.
Emotion Regulation Questionnaire: This 36-item scale was developed by Gratz and Romer (30) with six subscales (i.e., rejecting emotional responses, difficulty in purposive behaviors, difficulty in impulse control, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity) to assess emotion regulation. Each subscale is scored on a 5-point Likert scale from 1 “never” to 5 “always.” The minimum and maximum scores are between 36 and 180, respectively. Higher scores indicate better emotion regulation. Zolfaghari Kahkesh et al. (31) reported this instrument’s Cronbach alpha coefficient of 0.81.
Cognitive Flexibility Inventory (CFI): This 20-item self-report inventory was developed by Dennis and Vander Wal (32) to measure a specific form of cognitive flexibility required to replace inefficient thoughts with efficient ones. This inventory tries to measure three dimensions of cognitive flexibility: (A) Perceiving difficult situations as controllable situations; (B) the ability to understand multiple alternative explanations for life events and human behaviors; and (C) the ability to create multiple solutions and alternatives for difficult situations. This inventory is scored on a seven-point Likert scale ranging from 1 for "strongly disagree" to 7 for "strongly agree." The highest and lowest scores in CFI are 140 and 20, respectively. Higher scores indicate higher levels of cognitive flexibility. Cronbach’s alpha coefficient for the scale was 0.83 (33).
3.2. Intervention
Integrative Behavioral Couple Therapy: The structure and content of the therapeutic intervention program (consisting of ten 90-minute sessions) were developed concerning the IBCT model proposed by Christensen and Doss (23). The first three sessions focused on the couples’ assessment, and the remaining sessions included therapeutic interventions. Table 1 presents a summary of the sessions.
| Session | Content |
|---|---|
| 1 | Introducing and creating a feeling of empathy; therapeutic alliance and building trust with couples; problem assessment; teaching couples to use "my phrases" and talk about selves; examining couples’ expectations; teaching them to express feelings and expectations; exploring marital problems from the partner’s point of view; teaching couples to discover and list desirable changes in their partners. |
| 2 | Holding individual meetings with couples to help them express their views on the problem; evaluating the interaction styles; collecting information about each other’s opinions on the problem; assessing anxiety; teaching the principle of confidentiality and commitment to each other; listing conflicting situations. |
| 3 | Examining and discovering dysfunctional communication patterns among couples; focusing on their personality traits and facilitating the expression of feelings about dysfunctional relationships with those important to them; identifying interactive and communication patterns in recurring cycles, the anxiety behind these defensive styles, and how couples cope with them. |
| 4 | Reviewing previous sessions; training how to express the feelings and demands to those necessary to them; catharsis; talking about inefficient communication styles and self-destructive behaviors; training verbal and non-verbal communication, empathetic understanding, and active listening to couples; and practicing these skills at home. |
| 5 | Reviewing contents of the previous session; training other communicational skills; focusing on recurring interactive patterns; discovering defensive styles; training how to cope with conflicts; increasing positive reinforcements and behavioral exchange. |
| 6 | Discussing the correction of recurring cycles, latent tendencies, defensive styles, and anxiety of couples, training problem-solving skills, identifying boredom factors, reducing intimacy, and training problem-solving skills during the week. |
| 7 | Reviewing contents from previous sessions; externalizing treatment sessions, particularly for interpersonal relationships; training friendly interactions and taking responsibility; training to express feelings and expectations in and out of sessions; scheduling one-hour sessions for expressing feelings per day. |
| 8 | Reviewing relationships between couples and therapist during the sessions; examining and training techniques to maintain healthy relationships between couples and essential people; increasing conflicts, accepting vulnerabilities and intimacy fears; training to listen to and accept partner’s fears. |
| 9 | Examining cognitive factors and mistakes of couples; examining problems related to their emotional instability; identifying inefficient thoughts and methods; training to review, accept, and correct behavioral skills; creating intimacy; and practicing these skills during the week. |
| 10 | Reviewing previous sessions; examining couple relationships to facilitate finding new solutions for the existing problems; training to create a secure environment; identifying and using healthy interactive models; creating secure communicational models; unconditional acceptance; being accountable and accessible. |
An Overview of Integrative Behavioral Couple Therapy Sessions
3.3. Statistical Analyses
The pretest, posttest, and follow-up data were analyzed through descriptive statistics (i.e., mean and standard deviation) and inferential statistics (i.e., repeated measures ANOVA).
4. Results
The mean and standard deviation of the age of men and women participating in this study were 33.41 ± 4.27 and 29.64 ± 3.68 years, respectively. The average duration of cohabitation in the participants was 8.58 ± 2.41 years. Table 2 presents the means and standard deviations of emotion regulation and cognitive flexibility in the pretest, posttest, and follow-up.
| Variables | Mean ± SD | P (Within-Group) | ||
|---|---|---|---|---|
| Pretest | Posttest | Follow-up | ||
| Emotion regulation | 80.25 ± 7.92 | 124.88 ± 11.63 | 120.88 ± 8.70 | 0.001 |
| Cognitive flexibility | 60.50 ± 5.70 | 100.46 ± 6.33 | 98.13 ± 4.47 | 0.001 |
Mean and Standard Deviation (SD) of the Emotion Regulation and Cognitive Flexibility in the Pretest, Posttest, and Follow-up Phases
Before data analysis, research hypotheses were examined to ensure that the data met the repeated measurement ANOVA assumptions. The Kolmogorov–Smirnov test indicated the normality of data related to emotion regulation (Z = 0.74, P = 0.363) and cognitive flexibility (Z = 0.52, P = 0.397). The results of Levene’s test confirmed the homogeneity of covariance in emotion regulation (F = 0.09, P = 0.763) and cognitive flexibility (F = 2.11, P = 0.134).
In other words, there was an effective relationship between the different measurement stages in couples who received IBCT, at least for one of the emotion regulation and cognitive flexibility variables (F = 496.66, P<0.001, η2 = 0.99). The intragroup ANOVA test was conducted to determine which dependent variables were significantly affected by the intervention program. According to Table 3, IBCT has significant relationships with emotion regulation (F = 148.61, P < 0.001, η2 = 0.86) and cognitive flexibility (F = 373.00, P < 0.001, η2 = 0.96).
| Variables | SS | df | MS | F | P | η2 |
|---|---|---|---|---|---|---|
| Emotion regulation | 28656.36 | 2 | 14328.18 | 148.61 | 0.001 | 0.86 |
| Cognitive flexibility | 24142.02 | 1.94 | 12388.55 | 373.00 | 0.001 | 0.96 |
Repeated Measures ANOVA for Within-group Effects in the IBCT Group
The LSD test was adopted to distinguish different pretest, posttest, and follow-up stages in research variables. Table 4 shows a significant difference between the pretest and posttest in cognitive flexibility and emotion regulation (P < 0.001). The results showed that IBCT significantly improved emotion regulation and cognitive flexibility in EDCs. Since there were significant differences between the pretest and follow-up scores of emotion regulation and cognitive flexibility (P < 0.001), IBCT had long-lasting effects on emotion regulation and cognitive flexibility.
| Variables | Phase A | Phase B | Mean Difference (A - B) | SE | P |
|---|---|---|---|---|---|
| Emotion regulation | Pretest | Posttest | - 43.83 | 2.74 | 0.001 |
| Follow-up | - 40.63 | 2.17 | 0.001 | ||
| Posttest | Follow-up | 3.21 | 3.44 | 0.360 | |
| Cognitive flexibility | Pretest | Posttest | - 39.96 | 1.38 | 0.001 |
| Follow-up | - 37.63 | 1.65 | 0.001 | ||
| Posttest | Follow-up | 2.33 | 1.86 | 0.222 |
LSD Test for Paired Comparison of the Emotion Regulation and Relationship Distress Across Time Series
5. Discussion
The present study aimed to investigate the effects of IBCT on emotion regulation and cognitive flexibility among EDCs. The research indicated the effectiveness of IBCT in improving emotion regulation, which was consistent with Najafi et al. (24). A significant part of the IBCT interventions and techniques facilitated access to emotions and basic needs. The early stages of a relationship are marked by an acceptance and tolerance of each other’s differences. In many cases, couples see each other’s differences as the source of attractiveness. Couples rarely regard these differences as threatening and problematic during the early days after marriage. Gradually, some couples’ acceptance and adjustment to each other’s differences reduced, which would no longer be the source of attractiveness, and attempts were ultimately made to change each other. A negative attitude, such as blaming, is an unfortunate outcome of these attempts (24). When these coercive patterns become frequent, couples see each other as imperfect instead of different people and finally start blaming each other. When the frequency of blaming increases, each spouse feels that he/she has the right to correct the other one’s behaviors (2). Therefore, these differences are potentially intensified, broadening the gaps between couples. Hence, these coercive and pressing behaviors -not the differences- lead to problems. In other words, some of these problems are due to the attempts made by some couples to alleviate differences (26).
Integrative behavioral couple therapy effectively improved cognitive flexibility in couples. These findings were consistent with those of Panahi et al. (27). Among the most critical factors mentioned earlier, IBCT is the effective management of stressful situations in life, such as the correct interpretation of marital life events. Adapting to these abilities is the main target of a cognitive-behavioral approach, which assumes that perception changes a person’s entire behavioral and emotional structure. In this therapeutic method, a person frees control of her/his psychological system from semi-conscious factors such as negative autonomous thoughts and consciously and actively explains the mood and behavioral system through direct control of the cognitive system (27). This assumption of cognitive-behavioral approaches has now been confirmed and agreed upon by mental health and family therapy theorists. Therefore, accepting this assumption leads to identifying and reducing ineffective cognitions, and replacing them with more efficient ones can improve overall mental health and cognitive flexibility (25).
Conflict-provoking issues and stressful circumstances are common in marriage, resulting in different reactions, even in emotional messages between couples. Behavioral couples therapy differs from IBCT in combining the opposite acceptance and change techniques. Change approaches are adopted to change some behaviors or compensate for the lack of behavioral skills (23). The husband’s criticizing behavior can be reduced, or the wife’s emotional behavior can be increased if efforts are made to make a change. In contrast, acceptance techniques are focused on accepting a behavior rather than adopting a behavior (22). Acceptance techniques can be employed to help a woman perceive her husband’s criticizing behavior when he is under excessive pressure or to help a husband empathize with his wife’s indifferent behaviors. Both acceptance and change techniques can mutually facilitate the change process (24). Couples who accept each other’s differences are more likely to change together. Once they accept change, they will accept each other more efficiently (21).
5.1. Limitations
The present study faced such limitations as using self-report instruments and analyzing a small sample size. The absence of a control group was another limitation of this study. Since the research was limited to Ramshir County, caution should be considered while generalizing the results.
5.2. Conclusions
Based on the results, IBCT improved emotion regulation and cognitive flexibility in couples experiencing marital conflicts and emotional divorce. Couples therapists can adopt IBCT workshops to enhance emotion regulation and cognitive flexibility. Future studies are recommended to compare IBCT with other family therapy and couples therapy approaches to measure the effectiveness of each technique in improving emotional regulation, cognitive flexibility, and other psychological variables. Moreover, cultural differences within Iran should be taken into account when conducting similar studies and analyzing whether cultural differences affect the effectiveness of this therapeutic approach.
