1. Background
Parents of children with intellectual disability are exposed to various challenges and stressors that can cause serious problems for the whole family (1). These parents need to be highly accountable individuals, given their children’s various daily life restrictions and chronic medical condition (2). Generally, as the primary caregivers, mothers play an essential role in caring for their children and meeting their needs (3).
The birth of a disabled child is a devastating event for the family because it has complex effects on the entire family (4), as well as the marital life of couples. For example, parents of autistic children have reported less satisfaction with their marital relationship compared to other parents (5). Over the past 10 - 15 years, the birth of children with different types of developmental and neuropsychiatric disorders and syndromes, also known as children with special healthcare needs (CSHCN), has dramatically increased. This increasing trend has been accompanied by a parallel increase in the frequency of divorce and separation among the parents of these children (6).
Generally, taking care of CSHCN requires special parenting skills, high levels of supervision, dedication of significant amounts of time to children’s medical care and education, and consultation with mental health experts (7). Studies have reported that these caregivers may experience various negative consequences, such as physical, social, and financial problems, which often lead to marital failure and separation (7).
According to the official statistics published in the last decade, almost 25% of all marriages in Iran lead to divorce (8). According to Gottman, the main reason for more than half of the divorces is marital dissatisfaction and conflict between spouses over different issues (9). As reported by Olson, marital satisfaction is an essential predictor of the duration of marital life, as it reflects the spouses’ satisfaction with the functioning of their marital relationship (9).
Marital satisfaction is defined as a feeling of happiness or pleasure in partners considering all aspects of the marriage. It is a multidimensional phenomenon, which is assessed based on the couple’s interactions and relationship, such as mutual interests, caring for and accepting one another, having common interests in activities (e.g., leisure activities), sharing responsibilities, sexual relationship, expression of emotions, and communication quality (10). Numerous factors can reduce marital satisfaction and increase marital conflict between couples, including financial problems, unemployment, lack of the necessary communication skills to respect personal freedoms, extended use or misuse of social media and its subsequent problems for the family and the couple, increased belief in the equal rights of women and men in social roles among young couples, educational and cultural inequality of the couple (9), psychological and personality disorders in one or both partners, and maladaptive disorders in one or both partners (11).
Conflict between couples commonly arises from personality disorders. According to statistics, about 70% of people experience a type of personality disorder, which can lead to marital conflict (12). Overall, the learnings, experiences, memories, and interactions of the family with the child shape the child’s future personality traits. Primary maladaptive schemas and attachment styles are also formed during childhood, influencing an individual’s beliefs, behaviors, attitudes, and emotions during adulthood. Activation of these maladaptive schemas in adulthood may lead to the person’s misinterpretation of events, which can cause psychological conflicts between individuals (couples) in the form of misunderstandings, misconceptions, and unrealistic goals and expectations (11).
The marital satisfaction of parents, especially mothers of children with intellectual disability, can be affected by a number of factors, including the child's special care needs that are mainly addressed by the mother as the primary caregiver, housekeeping and child care roles, lack of time to fulfill all parental responsibilities, and feelings of stress and tension (13). There is ample evidence suggesting the effectiveness of marital counseling interventions in increasing the couples' adaptation, preventing depression, encouraging positive behaviors and communication, controlling anger, developing problem-solving skills, and resolving marital conflict (6).
The schema therapy approach, introduced by Jeffry Young, has been shown to be useful in increasing marital satisfaction in couples. This approach suggests that when the basic emotional needs of individuals are not adequately met in the family, it can lead to the formation of schemas in mind. According to these schemas, individuals appraise their spouse's behaviors, appearance, and attitudes; a relationship can be only successful if the spouse fulfills these criteria. Overall, schemas are important determinants of a person's coping with communication problems (14).
Studies on the effectiveness of schema therapy in resolving marital conflict and improving marital satisfaction have suggested the effectiveness of this approach in resolving the couple’s individual and interpersonal problems (15).
In a previous study, Arntz (16) investigated the effectiveness of schema therapy in treating type C personality disorder and found a reduction in the patients’ symptoms. Moreover, Reiss et al. (17) confirmed the effectiveness of schema therapy in reducing maladaptive schemas, alleviating the symptoms of borderline personality disorder (e.g., tendency to control the partner, impulsivity, and anger), and improving marital satisfaction. Moreover, in a study by Mahour and Farzinfar (18), schema therapy promoted the psychological well-being of mothers of deaf children.
Additionally, a study by Nooroney et al. (19) showed that schema therapy and mindfulness-based schema therapy improved women’s conflict resolution skills. Besides, Pourfaraj Omran and Esmailzadeh (20) found that schema therapy was effective in increasing sexual self-efficacy and marital satisfaction and reducing primary maladaptive schemas in couples with marital conflict. Nozari et al. (21) also reported that schema therapy increased the marital satisfaction of mothers of children with autism spectrum disorder.
2. Objectives
Considering the effect of schema therapy on primary maladaptive schemas and marital satisfaction and conflict, the present study aimed to investigate the effects of this therapeutic approach on marital satisfaction and conflict in mothers of children with intellectual disability.
3. Methods
3.1. Study Design
This quasi-experimental study had a pretest-posttest, control group design. The independent variable was schema therapy, while dependent variables included marital satisfaction and marital conflict in mothers of children with intellectual disability.
3.2. Statistical Population
The statistical population of this study included the mothers of children with intellectual disability covered by the Social Welfare Organization of Qarchak in southeast of Tehran, Iran. Among the eligible individuals, 30 women were selected by convenience sampling and randomly assigned into two equal groups of experimental and control (n = 15 per group). Considering 80% power of test, 95% confidence level, and standard deviation and minimum score difference (d = 20), the total sample size was calculated as 30 individuals. Accordingly, the sample size was determined as 25 individuals in each group. Finally, considering the conditions of therapeutic groups, evidence in some valid sources (22), establishing the possibility of using educational and therapeutic interventions and consulting with supervisors, as well as the attrition rate, 15 individuals were considered for each group.
The inclusion criteria were as follows: Being married; having only one mentally disabled child; having high school education or higher; not receiving any type of psychotherapy during the study, and regular attendance of training sessions. Also, individuals missing more than two training sessions or using psychotherapeutic medications (or narcotics) were excluded.
3.3. Data Collection Tools
Enrich Marital Satisfaction (EMS) Questionnaire: It is a 115-item questionnaire designed by Olson (1998). It consists of 12 scales, including idealistic distortion, marital satisfaction, personality issues, conflict resolution, financial management, leisure activities, sexual relationship, children and parenting, family and friends, role relationship, and spiritual beliefs. This tool assesses responses based on a five-point Likert scale, with scores of one to five (completely agree, agree, undecided, disagree, and completely disagree). A 35-item version of this questionnaire was prepared by Asoodeh (23) with four subscales. The Cronbach’s alpha coefficients were 68%, 78%, 62%, and 77% for the subscales of marital satisfaction, communication, conflict resolution, and idealistic distortion, respectively. In the present study, the total marital satisfaction score was reported, and the subscale scores were not measured separately.
Marital Conflict Questionnaire (MCQ): It is a 42-item tool developed by Sanaei (24) to assess marital conflict. It includes the subscales of decreased cooperation, decreased sexual relationships, increased emotional reactions, attracting children’s support, increased interaction with one’s own relatives, decreased interaction with the spouse’s relatives and friends, and financial separation. In this study, the total score of marital conflict was measured, while the subscales were not addressed. Each item of the questionnaire was scored on a five-point Likert scale, with higher scores indicating a more severe conflict, and vice versa. The total score of the questionnaire ranged from 42 to 210. Its reliability (0.52) was measured by Sanaei among 111 couples with conflicts, visiting a family court (53 men and 53 women), along with a control group of 108 individuals. Besides, Dehghan and Farahbakhsh reported the reliability coefficients of 0.72 and 0.69, respectively (24).
3.4. Study Protocol
After coordination with the Qarchak Social Welfare Organization, we reviewed the records of children covered by the organization (792 files). A total of 120 cases were identified to be eligible for the study. These people were contacted by the researchers, and after giving the necessary explanations, they were invited to participate in the study. Finally, 30 eligible women were randomly selected. The participants completed the questionnaires after obtaining informed consent.
The participants were randomly allocated into two equal groups of experimental and control (n = 15 in each). While the experimental group received schema therapy, the control group received no intervention. The intervention was provided for the experimental group weekly as ten 120-minute group sessions. All participants in both groups were requested to complete the questionnaires in the posttest phase again.
To analyze the data, descriptive (mean and standard deviation) and inferential (multivariate analysis of covariance) statistics were measured. SPSS software was used for data analysis, and the significance level was considered as P < 0.05. Table 1 shows the content of the sessions.
Table 1.The Content of Therapeutic Sessions in This Study
| Session No. | Content |
|---|---|
| 1 | The overall objective of this session was to familiarize the participants with the process, purposes, rules, and instructions of the schema-based training program. |
| 2 | Training on the core needs and developmental roots of maladaptive schemas and explaining their formation. |
| 3 | In the third and fourth sessions, five main schematic areas and 18 primary maladaptive schemas related to human communication problems were described. |
| 4 | In this session, training the primary maladaptive schemas continued, and their characteristics were discussed. |
| 5 | Implementation of cognitive techniques. To challenge maladaptive schemas, schema validity was introduced, and new evidence supporting or rejecting the core belief was presented. The advantages and disadvantages of coping styles were analyzed, and the ways of preparing educational cards were taught. |
| 6 | The participants were familiarized with the mechanisms involved in the persistence of maladaptive schemas and were introduced to maladaptive coping styles in response to these schemas. |
| 7 | Training of inefficient coping responses. This session aimed to educate the outcomes of inefficient coping responses. Coping responses include all responses in an individual’s behavioral repertoire against threats. |
| 8 | Modulation and mitigation of the effects of maladaptive schemas (use of experimental techniques): imagination, reparenting, chair work, writing letters to parents, and having imaginary conversations with them; and mental imagery of traumatic events. |
| 9 | The behavioral techniques were educated and practiced. |
| 10 | Summary, final appraisal, and end of the program: The goal of the final session was to summarize the program and prepare the mothers for its end. This session focused on three important points: (1) encouraging women to apply the achievements of the educational program in real life; (2) identifying women who need individual interventions and scheduling an individual counseling session for them; and (3) implementing a posttest. |
4. Results
According to the results, the mean age of mothers was 38.7 years in the experimental group and 36.8 years in the control group. The majority of women in the experimental group had a high school diploma (86.7%), while 6.7% had either middle school education or an academic degree (Table 2). Also, the majority of participants in the control group had a high school diploma (93.3%), while 6.7% had an academic degree. So, the variables were significantly different in this regard (P < 0.622).
Table 2.Comparison of Education Scores in the Experimental and Control Groups a
| Group | Education | Total | ||
|---|---|---|---|---|
| Middle School | High School /Diploma | Above High School | ||
| Schema therapy | 1 | 13 | 1 | 15 |
| Control | 0 | 14 | 1 | 15 |
| Total | 1 | 27 | 2 | 30 |
a ANOVA results: Sum of squares = 1.037; df = 2; mean square = 0.519; F = 0.483; Sig. = 0.622.
Table 3 presents the marital satisfaction and marital conflict scores of the experimental and control groups in the pretest and posttest phases. To evaluate the effects of schema therapy on the marital satisfaction and marital conflict of mothers of mentally disabled children, analysis of covariance (ANCOVA) was performed. Before this test, the slope of the regression line and homogeneity of variance were investigated using Hotelling’s trace, Wilk’s lambda, Pillai’s trace, and Roy’s largest root. These tests are generally used when there is more than one dependent variable in the multivariate analysis method.
Table 3.Comparison of the Mean and Standard Deviation (SD) of Marital Satisfaction and Marital Conflict Scores Before and After Schema Therapy in the Experimental and Control Groups and the Mean Score Changes in the Two Groupsa
| Variables | Before Intervention | After Intervention | Changes in Scores Before and After the Intervention |
|---|---|---|---|
| Marital satisfaction | |||
| Experimental group | 104.4667 (19.98) | 129.800 (9.74) | 25.3333 (15.069) |
| Control group | 107.1333 (19.95) | 107.4667 (16.16) | 4.514 (0.3333) |
| Marital conflict | |||
| Experimental group | 94.533 (20.53) | 62.40 (7.17) | 32.133 (15.851) |
| Control group | 105.066 (18.29) | 88.06 (22.16) | 17.00 (11.420) |
a Values are expressed as mean (SD).
The results of multivariate analysis of covariance (MANCOVA) test (Table 4) indicated a significant effect of schema therapy on the dependent variables, i.e., marital satisfaction and marital conflict (P < 0.001). Also, there was a significant difference between the two groups in at least one of the dependent variables (marital satisfaction and marital conflict). The effect size was equal to 0.82, and the statistical power of the test was equal to 1.
Table 4.The Results of Multivariate Analysis of Covariance (MANCOVA) on the Marital Satisfaction and Conflict Scores of the Experimental and Control Groups
| Test | Value | F | df Hypothesis | df Error | Effect Size | Statistical Power | P-Value |
|---|---|---|---|---|---|---|---|
| Pillai’s trace | 0.828 | 29.063 | 2 | 39 | 0.828 | 1 | < 0.001 |
| Wilk’s lambda | 0.724 | 29.063 | 2 | 39 | 0.828 | 1 | < 0.001 |
| Hotelling’s trace | 0.671 | 29.063 | 2 | 39 | 0.828 | 1 | < 0.001 |
| Roy’s largest root | 0.671 | 29.063 | 2 | 39 | 0.828 | 1 | < 0.001 |
To determine the differences between the two groups regarding the dependent variables, one-way ANCOVA and MANCOVA test were conducted (Table 5). The results of one-way ANCOVA were significant for both marital satisfaction (F = 116.129, P < 0.001) and marital conflict (F = 37.787, P < 0.001). According to the effect size, the training intervention could explain 73% and 48% of the variance in the marital satisfaction and marital conflict between the two groups, respectively. Also, the statistical power was equal to 1.
Table 5.The Results of ANCOVA Test in the Context of MANCOVA Regarding the Mean Posttest Scores of Marital Satisfaction and Marital Conflict in the Experimental and Control Groups
| Variables | Sum of Squares | df | Mean of Squares | F | Effect Size | Statistical Power | P-Value |
|---|---|---|---|---|---|---|---|
| Marital satisfaction | 4514.129 | 1 | 4514.129 | 116.129 | 0.739 | 1 | < 0.001 |
| Marital conflict | 4129.920 | 1 | 4129.920 | 37.787 | 0.480 | 1 | < 0.001 |
5. Discussion
This study aimed to investigate the effectiveness of schema therapy in improving marital satisfaction and reducing marital conflict in the mothers of children with intellectual disability. The results revealed that schema therapy improved marital satisfaction and reduced marital conflict in these mothers compared to the control group. The present findings were consistent with the results reported by Yousefi et al. (25) Khatamsaz et al. (26), Mokhtari et al. (27), Bahmani et al. (28), Hatami and Fadayi (29), and Nooroney et al. (19).
The effectiveness of schema therapy has been confirmed in the treatment of disorders, such as depression, chronic anxiety, and eating disorders, as well as mitigation of marital conflict and common problems in maintaining an intimate marital relationship (30). Several studies have investigated the relationship of schemas with marital satisfaction, marital conflict, and mental disorders (12). In this regard, Weissman showed that triggering each couple’s schemas during therapeutic sessions could be useful in assessing their satisfaction or dissatisfaction with the marital relationship (31). Moreover, Nooroney et al. found that schema therapy reduced the mothers’ marital conflict (19). Besides, Nozari et al. reported that schema therapy increased marital satisfaction in mothers of autistic children (21). According to the theory proposed by Young et al. (30), schema therapy can lead to changes in the cognitive, experiential, emotional, social, and behavioral aspects of an individual’s life. This therapeutic approach seems to be effective in weakening maladaptive schemas and responses and replacing them with positive thoughts and responses.
Generally, maladaptive schemas lead to an individual’s misinterpretation of events, which can present as misunderstandings, misconceptions, and unrealistic expectations. Mothers of children with intellectual disability have certain misconceptions, which can result in inappropriate behaviors, regardless of the possible consequences. This mindset is commonly triggered when an issue is of high sensitivity to the individual, leading to disturbing emotions, avoidance responses, or harmful behaviors.
Schema therapy can help individuals identify their maladaptive schemas and become aware of the factors that contribute to their persistence (e.g., extreme avoidance, submission, and compensation). In the present study, by using experimental techniques that trigger emotions associated with maladaptive schemas, we tried to improve the mothers’ responses and satisfy their unfulfilled needs. Moreover, by using the mental imagery technique, in which schemas are transferred from the logical realm to the emotional realm, we attempted to help women find the link between the developmental roots of their schemas and their current life problems, such as having a mentally ill child and its associated problems (e.g., medical expenses, care and nursing, and marital conflict), so that they can communicate with their spouses more effectively.
For example, some of the beliefs and behaviors of mothers of children with intellectual disability, such as shame and embarrassment about having a disabled child, fear of other people’s opinions, humiliation by others (considering oneself worthy of humiliation), social pressure, and self-isolation, can present their defectiveness/shame schema. By explaining this type of schema -in which the person considers oneself and other family members to be imperfect and underestimates oneself- and describing its roots and coping styles for individuals, they will become aware of their avoidance behaviors and show alternate active behaviors (e.g., speaking in public and expressing the capabilities and strengths of oneself and one’s child and spouse); and this can lead to positive behavioral changes.
Regarding the schema of strict criteria, the parents’ awareness of their exhausting behaviors (e.g., continuous care of the disabled child, high cost of treatment and rehabilitation, allocation of time to regular visits to rehabilitation centers, and comparison of their disabled child with other children) along with their awareness of the developmental roots of their schemas (e.g., always wanting oneself and one’s family to be the best) encourage them to pay more attention to their own diverse needs, as well as the needs of their spouse and children. In other words, they accept the fact that people are mentally and physically diverse and that different people have different abilities and limitations. Moreover, these parents can make plans for other aspects of their lives (e.g., spending time alone or with their spouse) and increase their social interactions; this can subsequently improve marital relationship and satisfaction.
Moreover, mothers with a self-sacrifice schema spend most of their time caring for their children; however, excessive caring for mentally disabled children increases their dependence on them. In schema therapy, these mothers are trained to concentrate on their self-sacrifice schema. While prioritizing their own personal needs, they learn to allow their children to work on their functional, behavioral, and adaptation skills with perseverance and continuous practice. Another possible reason for the effectiveness of schema therapy in increasing marital satisfaction is training of skills, such as active listening to the spouse, explaining and paying attention to various emotional and psychological needs of individuals (especially one’s spouse), empathy, and promoting communication skills via mental imagery and role-playing techniques to mitigate the emotional deprivation schema. Overall, by changing the parents’ misconceptions about the reason for the birth of their disabled child (involving self-blame, guilt, feeling of being ill-fated, and feeling of extreme responsibility toward the child without the support of others), recognizing the schemas of oneself and the spouse, and finding strategies to increase marital satisfaction and quality of life, it is possible to increase the marital satisfaction of mothers of children with intellectual disability.
According to Young et al.’s theory (30), schema therapy is an approach, consisting of cognitive, behavioral, interpersonal, attachment, and experimental aspects in the context of an integrated therapeutic model. By employing cognitive, behavioral, communication, and experimental techniques, schema therapy can challenge maladaptive schemas, which are the main causes of irrational thoughts, and lead to the expression of repressed negative emotions, such as anger because of dissatisfaction of self-motivation needs and secure attachment to others in childhood. In other words, in schema therapy, behavioral assignments are designed and implemented to replace the person’s maladaptive behavioral patterns with appropriate coping responses.
During schema therapy, therapists try to satisfy the client’s unmet needs by drawing therapeutic boundaries, without deviating from ethical principles. In this study, women with disobedience schemas were asked to write a number of criticisms about the therapist and the therapeutic process. Also, those with a shame and embarrassment schema were encouraged to express themselves. They were asked to write down their spouse’s strengths, weaknesses, and positive or negative behaviors on a piece of paper and read them publicly in the next session.
Based on the findings, schema therapy promoted adaptive strategies and improved marital satisfaction in the mothers of children with intellectual disability. The results of this study, while approving the research hypothesis, showed that schema therapy plays an effective and important role in promoting the marital satisfaction of mothers of children with intellectual disability. Moreover, it enhances marital intimacy and the couple’s quality of life by assessing their core beliefs and modifying maladaptive schemas. Overall, modification of these schemas can be a suitable approach to improve the couple’s relationship. Also, it seems essential to pay attention to factors affecting the quality of life and marital satisfaction of mothers of children with intellectual disability who face many difficulties and challenges in everyday life. By screening the maladaptive schemas of these mothers and identifying their coping strategies, therapists can implement preventive and interventional programs to reduce their communication problems.
5.1. Limitations
One of the limitations of this study is that it was performed merely on the mothers of children with intellectual disability. Therefore, the results should be generalized to other mothers and families with caution. Also, we faced many challenges in obtaining the necessary permissions to hold the training sessions and accessing the mothers due to the high sensitivity of these families.
