Introduction
Marital satisfaction is a couple's general subjective assessment of the marital relationship and the extent of the fulfillment of personal and joint demands, wishes, and desires in a relationship [Jorshari, 2015]. It is one of the comprehensive concepts utilized in evaluating happiness and stability in marriage [Khalatbari, 2013]. Marital satisfaction is strongly associated with marital intimacy [Dandeneau, 1994; Greeff, 2001; Schaefer, 1981].
Intimacy is a fundamental psychological need and one of the crucial aspects of marital communication that affects marital adjustment, and mental health decreases the risk of depression, and enhances well-being and happiness [Bischof, 2003; Boden, 2010; Dandurand, 2013; Moreira, 2010; Nainian, 2013; Ulker, 2008]. In opposition, the absence of intimacy is one of the most prevalent explanations of distress and failure among men and women. It negatively affects couples' relations and, by that, results in conflicts and incompatibility, causes stress, depression, and affective and mental disorders as well [Duffey, 2004; Yoo, 2014]. Furthermore, lack of intimacy and less marital satisfaction increase the possibility of divorce, and instability of marriage [Hirschberger, 2009; Shakerian, 2014; Weinberger, 2008]. Likewise, numerous researchers declare that intimacy, which is a critical factor of marital satisfaction, can be achieved by effective communication and reciprocal disclosure [Yalcin, 2007]. In this regard, various psychotherapies have been proposed for improving the couples' interactional style and consequently increasing marital intimacy and satisfaction [Farahani, 2018].
One of these approaches is the Imago relationship therapy (IRT) which was developed as an integrative, relational approach for couples based upon a combination of attachment theory, object relations, transactional analysis, developmental psychology, and behavioral change technique. IRT speculates that unconscious partner choice causes an opportunity to alleviate a connection that was lost in childhood through increasing empathy, understanding, and interaction with the romantic partner. IRT considers that development occurs in a relational pattern and underlines self-in-relation rather than the self-as-independent. In this regard, IRT strives to rectify developmental stumbling blocks and childhood injuries by reforming the relationship between partners through specific empathic dialogue skills, such as the couples dialogue, parent-child dialogue, caring behaviors, behavior change request dialogue, and Imago workup [Luquet, 2017; Martin, 2011; Muro, 2015; Zielinski, 1999]. Expressly, empathy is the most crucial construct of the IRT, and the fundamental element for couples to create relational bonds and maintain the quality of relationships subsequently, coupled with high levels of empathy report fewer marital complaints and high marital satisfaction [Davis, 1987; Hendrix, 2011; Muro, 2015; Rowan, 1995]. Several studies have shown that IRT improves marital relationships, and marital happiness, and improves the quality of the couples' lives [Cheraey, 2020; Gehlert, 2017].
Acceptance and Commitment Therapy (ACT) is the other effective treatment for marital problems that several studies have been proved its application [Amani, 2018; Azimifar, 2016; Peterson, 2009]. Through the ACT view, marital conflicts are formed by each partnerꞌs rigid and impracticable experiential avoidance strategies in the context of couple relationships. General avoidance strategies consist of avoiding interaction with one's partner because of the previous communications which have brought them into conflicts or emotional distance; avoiding expressions of emotional or physical intimacy on account of the fear of rejection, and avoiding common activities that lead to meaning creation and mutual memories. These avoidance behaviors may occasionally provide provisional relief and delay experiencing undesired thoughts and feelings but they eventually end up generating more pain, suffering, and relationship damage. Furthermore, there is a fusion of thoughts and feelings about the actions or lack of actions in the relationship, and believing such thoughts as actual as well as acting on them keeps couples' negative relationship patterns. ACT strives to create distance from schema-driven thoughts that draw partners into experiential avoidance behaviors and aids partners to free from schema-driven thoughts that act as roadblocks to values-based actions and so, decrease the impact of these thoughts on behavior. Generally, ACT aims to help couples to become mindful regarding their own cognitive and emotional responses/ behaviors, as well as their partner's. Also, make clear the values they hold related to their relationship, and pledge to act compatibly with these valued directions [Lev, 2017; Peterson, 2009]. A review of 20 meta-analyses showed that ACT is effective on anxiety, depression, substance use, and pain [Gloster, 2020].
Emotion-Focused Couple Therapy (EFCT), the other couple psychotherapy that has been applied in this study, is an attachment-based psychotherapy that develops on humanistic and systemic assumptions to help couples make their interactions better by forming a more secure and validating emotional bond in their relationship [Johnson, 2004; Johnson, 2012]. EFCT considers relational conflicts as the cycle of negative interactional patterns that are evoked by underlying emotional processes related to attachment needs and emotions are regarded as a series of responses that help in predicting, understanding, and responding to individual experiences [Girard, 2017; Greenberg, 2007]. EFCT is aimed at identifying emotions and interpreting them into understandable messages and productive behaviors. The failure to transfer the affective conditions may result in conflicts in interpersonal relationships [Girard, 2017; Greenman, 2013]. Overall, EFCT aided to ameliorate the interactional style and skill of the partners; this would sequentially conduce to the improvement of marital satisfaction because communication is a fundamental skill mandatory for the relationship to work [Burgess Moser, 2016; Vazhappilly, 2016; Vazhappilly, 2018; Woldarsky Meneses, 2017] that is to say, couples with more affirmative patterns of interaction would experience a high level of satisfaction and favorable quality of the marital relationship [Campbell, 2008; Najafi, 2015]. A meta-analysis found EFCT to be highly effective in couplesꞌ problems [Forouzanfar, 2019].
It has been suggested that marital conflicts are a risk factor for psychological and physical health [Choi, 2008]. Marital dissatisfaction is related to emotional distress, depressive symptoms, and mental disorders [Røsand G.-M, 2012]. Therefore, it is very important to resolve marital conflicts in clinical psychology. Given the high rate of divorce in Iran, increasing marital intimacy and satisfaction in couples improve their interpersonal relationship pattern which consequently reduces divorce. There is relatively more research on the effectiveness of couple therapies on marital satisfaction and intimacy [Akhavan Bitaghsir, 2017; Etemadi, 2006; Heidari, 2017; Karimzadeh, 2018; Khalili, 2017; Peterson, 2009; Rostami, 2014; Soltani, 2013]. Nevertheless, in the research literature, there was not any study to compare the effectiveness of these three couple therapies on marital satisfaction and intimacy to determine which is the most effective. This study hypothesizes that EFCT, ACT, and IRT can lead to improved marital satisfaction and intimacy in married women.
Method
Study design. This is an experimental study in which three groups received Emotion-Focused Couple Therapy (EFCT), Acceptance and Commitment Therapy (ACT), and Imago Relationship Therapy (IRT). This study has been approved by the Ethics Committee for Research at Mazandaran University of Medical Sciences (IR.MAZUMS.REC.1396.2695). We received written consent from all participants after explaining the objectives and assured them that they could leave the study at any time.
Participants. The population of the study was forty-five married women but six of them dropped out of treatment in the first and second sessions (one subject of EFCT, one subject of ACT, and four subjects of IRT). The sample was selected among all married women who were referred to Tehran Psychiatric Institute Clinic for psychotherapy. The marriage was a civil and religious marriage in this study. All participants had nuclear families. The sample size was based on previous studies and considering the test power (0.80) and the significance level (0.95), 15 patients were selected in each group.
Procedure. All subjects were completely randomly assigned into EFCT, ACT, and IRT groups after signing an informed consent form and based on the inclusion and exclusion criteria. The inclusion criteria include the age between 20 and 50 years old, the ability to read and write, conflicts, and marital problems. Exclusion criteria include any current psychological treatment, substance abuse, personality disorders, and absence of more than two sessions in the treatment process. A structured Clinical Interview for DSM-IV Disorders-2 (SCID-II) was used to investigate the exclusion criteria. Considering the individual sessions of the treatment, each subject of the sample was randomly assigned to a group by a person who did not know about the research. Then, pre-test data were collected from all the subjects in the first session. The subjects of each group were individually visited each week by a trained doctoral student who specialized in that treatment. The method of the intervention of IRT was based on the Imago Therapy Approach adapted from Hendrix and Hannah (2013), EFCT was designed according to instructions of Johnson [Johnson, 2012], and ACT was based on instructions of Peterson et al. [Peterson, 2009] which were respectively eight – 1 hour, eight – 90 min, and twelve – 45-min face-to-face individual therapy sessions.
Measures
Structured Clinical Interview for DSM-IV Disorders-2 (SCID-II). Structured Clinical Interview for DSM-IV Disorders-2 (SCID-II) is a semi-structured interview, which is used to diagnose common axis II disorders according to the DSM-IV criteria and contains 10 personality disorders criteria. Inter-rater reliability coefficients ranged from 0.48 to 0.98 for categorical diagnosis, and from 0.90 to 0.98 for the intraclass correlation coefficient. Internal consistency coefficients were adequate, from 0.71 to 0.94 [Maffei, 1997]. The reliability coefficient of Farsi version of SCID-II obtained using the test-retest method within one week was 0.87.
ENRICH Marital Satisfaction Scale. This scale is a multidimensional self-report measure designed by Olson, Fournier, & Druckman [Olson, 1986] to identify potentially problematic areas or strengths and productive marital relationships. It contains 115 items and 12 subscales including idealistic distortion, marital satisfaction, personality issues, communication, conflict resolution, financial management, leisure activities, sexual relationship, children and parenting, family and friends, equalitarian roles, and religious orientation [Fowers, 1989]. Each statement includes three items rated on a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree). Like the original version, the Farsi version of the EMS includes 115 items and 12 factors. Internal consistency coefficients of the factors spanned from 0.50 to 0.87 and the test-retest reliability of the questionnaire for men, women, and the entire sample was 0.94, 0.94, and 0.94, respectively [Sanaei, 2008].
Intimacy Scale. The Intimacy Scale is a 17-item scale assessing general intimacy. Each item is rated on a scale of 1 to 7. A higher score indicates greater intimacy/affection. Walker & Thompson [Walker, 1983] reported good reliability of IS through Cronbachꞌs alpha, 0.91 to 0.97. The correlation of this scale with the Fear of Intimacy Scale (FIS) was reported as -0.58, which represents its divergent validity.
Statistical Analysis. All analysis was performed using IBM SPSS for Windows, v. 22.0 [IBM SPSS Statistics, 2020]. First, descriptive statistics for the participants' demographic data were calculated. Before examining the effectiveness of the interventions, Kolmogorov–Smirnov test was performed for assessing normal distribution and homoscedasticity. As shown in Table 2, to compare the difference between groups one-way ANOVA was conducted. Furthermore, the paired t-test was served to evaluate the difference between the pre-test and post-test, and the effect size of each sample. The level of statistical significance was set at α=0.05 for all statistics.
Results
Results of the demographic characteristics indicate that IRT's mean age was 34.82, ACT's – 34.00, and EFCT – 31.43. Most of the IRTs and ACT's educational level was the bachelor and for EFCT was a diploma and bachelor's (Table 1).
Table 1
Characteristics of sample based on research group
|
|
IRT n (%) |
ACT n (%) |
EFCT n (%) |
p |
|
Number |
14 (36) |
14 (36) |
11 (28) |
|
|
Agemean (SD) |
34.82 (1.89) |
34.00 (1.43) |
31.43 (1.43) |
0.05 |
|
Educational level |
|
|
|
|
|
Diploma |
0 |
3 (21.42) |
6 (42.85) |
|
|
Bachelor |
8 (72.72) |
10 (71.42) |
6 (42.85) |
0.09 |
|
Master Degree |
3 (27.28) |
1 (7.16) |
2 (14.30) |
|
|
Length of marriage |
6.5 (2.72) |
7.1 (2.21) |
6.7 (1.83) |
0.31 |
|
Children |
|
|
|
|
|
<1 |
10 (71.42) |
11 (78.57) |
9 (81.81) |
|
|
1-2 |
3 (21.43) |
2 (14.28) |
2 (18.19) |
0.12 |
|
>3 |
1 (7.15) |
1 (7.15) |
0 |
|
As shown in Table 2, normal distribution is achieved in both variables. Therefore, a one-way ANOVA was performed. The result of ANOVA demonstrated that no differences in the pre-test and significant differences were obtained between the groups in the post-test (Table 3).
Table 2
Descriptive statistics and Kolmogorov–Smirnov test of research groups
|
Variable |
Group |
Pre-test |
Post-test |
||||||||
|
df |
KS |
p |
M |
SD |
df |
KS |
p |
M |
SD |
||
|
Intimacy |
IRT |
2 |
0.70 |
0.699 |
3.52 |
0.15 |
2 |
0.73 |
0.663 |
4.17 |
0.16 |
|
ACT |
0.42 |
0.994 |
3.35 |
0.35 |
0.45 |
0.986 |
4.19 |
0.30 |
|||
|
EFCT |
0.58 |
0.885 |
3.37 |
1.27 |
0.53 |
0.935 |
4.79 |
0.68 |
|||
|
Marital Satisfaction |
IRT |
2 |
0.53 |
0.937 |
200.08 |
7.51 |
2 |
0.98 |
0.290 |
438.01 |
17.82 |
|
ACT |
0.37 |
0.999 |
202.11 |
16.29 |
|
0.50 |
0.965 |
208.71 |
13.66 |
||
|
EFCT |
0.91 |
0.373 |
203.70 |
14.88 |
0.88 |
0.500 |
273.33 |
8.26 |
|||
Table 3
ANOVA results for research variables
|
Variable |
Group |
Pre-test |
Post-test |
||||
|
M (SD) |
F |
p |
M (SD) |
F |
p |
||
|
Intimacy |
IRT |
3.52 (0.15) |
0.16 |
0.852 |
4.17 (0.16) |
7.85 |
0.001 |
|
ACT |
3.35 (0.35) |
4.19 (0.16) |
|||||
|
EFCT |
3.37 (1.27) |
4.79 (0.68) |
|||||
|
Marital Satisfaction |
IRT |
200.08 (7.51) |
0.81 |
0.211 |
438.01 (17.82) |
930.98 |
0.001 |
|
ACT |
202.11 (16.29) |
208.71 (13.66) |
|||||
|
EFCT |
203.70 (14.88) |
273.33 (8.26) |
|||||
According to Table 4, a significant difference was found between the pre-test and post-test in the intimacy variable for all interventions. In other words, the results indicated that all three couple therapies were effective in improving marital intimacy. For marital satisfaction, a significant difference was detected for EFCT and IRT between the pre-test and post-test. Hence, ACT was not effective in enhancing marital satisfaction based on the results. Considering Cohen's d, the effects of all three interventions were clinically significant on intimacy, and IRT was clinically the most effective therapy. Regarding marital satisfaction, IRT was clinically the most powerful treatment and ACT had a poor effect.
Table 4
Paired t-test and effect size of pre- and post-test scales for research variables
|
Variable |
Group |
Pair differences |
t |
p |
Cohenꞌs d |
r |
|
|
M |
SD |
||||||
|
Intimacy |
IRT |
-0.64 |
0.20 |
-10.44 |
0.001 |
-4.19 |
-0.90 |
|
ACT |
-0.83 |
0.38 |
-8.20 |
0.001 |
-2.57 |
-0.79 |
|
|
EFCT |
-1.42 |
0.86 |
-6.13 |
0.001 |
-1.39 |
-0.57 |
|
|
Marital Satisfaction |
IRT |
-237.92 |
15.72 |
-50.17 |
0.001 |
-17.40 |
-0.99 |
|
ACT |
-6.60 |
13.87 |
-1.78 |
0.098 |
-0.44 |
-0.21 |
|
|
EFCT |
-69.63 |
20.43 |
-12.74 |
0.001 |
-5.78 |
-0.94 |
|
Discussion
The purpose of the study was to compare the effect of Emotion-Focused Couple Therapy (EFCT), Acceptance and Commitment Therapy (ACT), and Imago Relationship Therapy (IRT) on marital satisfaction and intimacy. The results of the study corroborated the effectiveness of EFCT, ACT, and IRT on intimacy, while the IRT was the most effective therapy. The findings of this study were in line with the results of several researches [Etemadi, 2006; Fatemi, 2016; Heidari, 2017; Khalili, 2017; Khanjani, 2017; Mousavi Haghighi, 2022; Soltani, 2013; Tavakol, 2014; Zakhirehdari, 2019; Zanganeh Motlag, 2017]. However, to explain the high effectiveness of IRT it can be mentioned that in Imago Relationship Therapy couple's unhealed wounds in childhood and their impact on their current relationship are considered the main cause of the decrease in intimacy, hence IRT helps couples to form a secure position to attain empathy and validation through mirroring and deep listening [Khalili, 2017]. Empathy is the main concept of the IRT which plays a fundamental role in the development and maintenance of a couple's bonds [Rostowski, 2009]. Each partner expresses his emotional status through IRT techniques and enhances his listening skills which improve his empathic relationship and; in turn, ameliorates marital intimacy [Fatemi, 2016; Khalili, 2017].
The findings confirmed the effectiveness of EFCT and IRT on marital satisfaction, while the effectiveness of ACT was not statistically significant. The results of this study were consistent with the findings of other studies [Akhavan Bitaghsir, 2017; Dalgleish, 2015; Najafi, 2015; Rostami, 2014; Shakerian, 2014]. To explain the results of the study, it should be noted that couple international styles are straightly related to marital satisfaction [Walitzer, 2013], and negative interaction patterns are a strong predictor of marital dissatisfaction and marital conflicts [Kiecolt-Glaser, 2003]. Thus, couplesꞌ treatment mostly focuses on improving interaction and fostering their emotional relationship [Reibstein, 2013]. More specifically, EFCT focuses on recognizing the fears and needs of attachment and increasing the support and care of spouses [Naaman, 2005; Solomon, 2009] and aims to extend restricted emotional responses that provoke negative interactional patterns, reconstitute interactions so that couples become more attainable and responsive to each other, and reinforce positive caring cycles [Johnson, 2010] which increase safety and intimacy among couples and are the necessary elements for the maintenance of a satisfactory and successful marriage [Halchuk, 2010; Rostami, 2014]. Moreover, one of the main reasons for the effectiveness of IRT is its emphasis on empathy and caring behaviors. Empathy forms the main feature of emotional support; higher levels of empathic interaction increase the partner bond and positively influence the continued development of healthy partner communications, a strong association with relationship satisfaction [Cramer, 2010; Dijkstra, 2014; Rostowski, 2009].
Regarding the results, IRT was more effective than EFCT which was accordant with Sheydanfar et al. research [Sheydanfar, 2018]. For clarifying this result, it can be pointed out IRT's theoretical features and techniques. IRT emphasizes the relational paradigm, conflicts' origins, and early relationship effects, the role of relationships in healing childhood wounds. Overall, IRT focuses on growth and understanding between the couple [Holliman, 2016]. Furthermore, the couple's collaboration in getting involved in their own and their partner's internalized mental world may exceedingly change the couple's interactional patterns and consequently enhance marital satisfaction. As shown, the effectiveness of ACT was statistically insignificant but clinically was poorly effective on marital satisfaction which was inconsistent with some studies [Akhavan Bitaghsir, 2017; Moradzadeh, 2018; Peterson, 2009]. This inconsistency might be attributed to the sample of this study. In the previous studies, the samples were couples; however, in this study merely women were recruited. For this purpose, it is recommended that other studies should be performed on couples as well.
It may be that one method is more effective than other methods in a different context. Therefore, finding out which methods are more effective can help psychologists to choose a technique in different contexts. It is also necessary for researchers to study the effectiveness of different couple therapy methods depending on other variables affecting the psychotherapy process.
Limitations. Finally, like every other research, this study has some limitations. First, the sample was not sufficiently diverse which may hinder the generalizability of the results. Also, the subjects of the study were simply women who referred to Tehran Psychiatric Institute Clinic for psychotherapy thus single-gender subjects were the other limitation. Another limitation of this study was the absence of governing on intruding variables such as socioeconomic status and income of the sample.
Conclusions
Based on the findings of this study, the IRT, ACT, and EFCT enhance the intimacy and marital satisfaction of married women. Also, the results indicate that the impact of IRT on marital satisfaction and EFCT on the intimacy was more effective than other couple therapy methods in married women.