Document Type : Original article
Authors
1 Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
2 Mental Health Research Center, Tehran Institute of Psychiatry- School of Behavioral Science and Mental Health, Iran University of Medical Sciences, Tehran, Iran
3 Medical School, Iran University of Medical Sciences, Tehran, Iran
Abstract
Keywords
Introduction
Desirable quality of life is an indicator that has been increasingly studied in the present century (1,2). Marital satisfaction is an aspect of quality of life (3). Many psychologists and family experts believe that marital satisfaction is the most important factor for achieving and maintaining peace of mind, growth and improvement of family members (4). According to Hawkins’ definition, marital satisfaction is defined as “the subjective feelings of happiness and pleasure experienced by a spouse when considering all current aspects of his/her marriage” (5). Larson and Holman consider quality of marital life as a dynamic concept, since the nature and quality of relationships between people change over time (6). Researchers believe that the quality of marital life is a process determined by the degree of marital conflict, satisfaction, closeness and agreement in decision-making (7). Marital satisfaction has an effect on mental health, physical satisfaction, life satisfaction, success in job, and social communication and is one of the most important indicators of life satisfaction (8). Couples’ relationship quality is the strongest predictor of marital satisfaction (4). Based on the results of numerous studies, communication problems are the most common problem for couples (4). Although communication difficulties are not considered as the only cause of marital discord, they are a major cause of distress in couples’ relationships and exacerbate the existing problems (9). The quality of marital relationships depends on how couples interact and cope with stressful situations in life (10). This is due to the fact that inefficient communication results in unresolved issues and repetitive conflicts in the relationship, which then gradually wreck the couple’s compatibility (11).
Communication skills in establishing positive interactions and constructive conflict management are directly and significantly associated with relationship satisfaction, sense of trust and mutual control, and love and affection (12). In addition, from a cognitive point of view, factors such as false beliefs, prejudices, and negative attitudes make a relationship inefficient, causing misinterpretation of communicated messages (4). Cognitive skills training appears to be effective in reducing irrational communication beliefs (13). Couples who use appropriate functional methods and regulated styles such as communication skills, role-playing, and conflict resolution enjoy higher marital adjustment (14), establish more positive communication with each other, and experience a more stable life (15). Conflict resolution in marital relationships also determines the level of empathy and satisfaction in couples (16). As a result, improving relationship enhances the quality of marital relationships, increases marital adjustment, enhances empathy, cohesion and agreement, increases satisfaction and reduces self-centeredness, reduces violence, and increases marital agreement (3,17). Therefore, communication skills training is the main approach of many researchers in performing interventions. According to studies, communication skills training appears to be effective in increasing marital satisfaction, increasing family efficiency in solving problems and identifying roles and family function in general (4,11,17-19). To achieve this, marriage empowerment training programs have been designed in many countries to reduce marital conflicts and dissatisfaction (20).
Intervention strategies in many of such countries are conducted in three areas: premarital marriage preparation programs, post-marriage enrichment programs, and marriage counseling for incompatible spouses. Some researchers argue that it is superior to pay more attention to the role of prevention in marital research in improving marital adjustment and decreasing divorce rate (20). Prevention and couples’ relationship improvement programs refer to any intervention in which destructive relationship behaviors are reduced and improved relationship behaviors are enhanced, thus preventing interpersonal problems (21). If preventive programs are implemented effectively, the economic costs imposed on the individual and the community for therapeutic interventions will be highly reduced (22,23). In addition, according to studies, the probability of maintaining the marital relationship in recently married couples with a number of destructive behavioral patterns who participate in preventive programs is higher than couples who have lived with negative relationships for many years and only currently want to improve their relationship with traditional couple therapy (21). In Iran, training interventions in the area of communication and conflict resolution skills have been carried out and the effectiveness of these interventions has been assessed through various tools (3,18,19,24-26). This study was a part of a project of the social and mental health and addiction office of the Ministry of Health and Medical Education and this office had selected Kermanshah for this project because of significant divorce rate and noticeable suicide rate of married women in this province. Therefore, the present study was conducted to investigate the effect of training intervention on communication skills and conflict resolution methods through Enrich questionnaire and conflict tactics scale designed and implemented among married women in Kermanshah.
Materials and Methods
Population, sample and method of implementation
This study was conducted as a trial in Kermanshah during the year 2017. At first, 134 women who registered to participate in a project designed to increase marital satisfaction were selected through a convenience sampling method. Considering α=5%, β=20%, d=3 and σ=5, the sample size was calculated to be 43 and taking into account the possibility of lost follow up, individuals were recruited in intervention and control group of equal size. The inclusion criteria of the study included living with a spouse in the first five years of marriage and minimum reading and writing literacy, and the exclusion criterion included not completing and returning research questionnaires. Trained mental health professionals working in the health centers of Kermanshah University of Medical Sciences collaborated in selecting the sample, completing the questionnaires and training the participants in the study. The marital satisfaction package designed by the social and mental health and addiction office of the Ministry of Health and Medical Education was used as a training source for the participants. The educational content of this package included the following items: Training the participants’ effective communication skills, expectations of marital living, education on sexual health, and conflict resolution training.
The participants were educated by trained mental health professionals during two courses of the marital satisfaction and facilitation workshop at the Kermanshah Health Network.
At the beginning of the study, participants received instructions on how the plan was going to be implemented and they were assured about the confidentiality of the completed information. The questionnaires used in the study were completed by the participants. All participants were randomly divided into two groups of intervention and control (Each included 67 individuals). The intervention group attended two three-hr sessions of class and workshop on increasing marital life satisfaction. The intervention group completed the Enrich Couple Inventory and revised Conflict Tactics Scale in two time intervals: immediately after the training and a month post training. The control group completed the questionnaires before the intervention and a month later and did not receive any training.
Ethical consideration
This study was approved by the ethics committee of Iran University of Medical Sciences under the Ethics Code of “IR.IUMS.REC 1395.9311286006”.
Research tools
After explaining the study plan to all participants, they completed the questionnaires before starting the training intervention. After the training intervention, Enrich Couple Inventory and Conflict Tactics Scale were re-distributed among the intervention group. One month after the implementation of the training intervention, the questionnaires were re-completed by all participants in the two groups of intervention and control.
1. Demographic information questionnaire: It included questions on age, number of marriages, education level, job status, number of children and socio-economic status (Crowding index).
2. The Enrich Couple Inventory: It was designed by Fowers and Olson in 1989 (27) to assess potential problematic areas and to examine marital satisfaction in general. In a study on 5139 couples, it was found that this inventory could make a distinction between satisfied and unsatisfied married couples with 85-95% accuracy. The Enrich Marital Satisfaction Scale can also be used as a diagnostic tool for couples seeking marital counseling and pursuing strengthening of their marital relationship. The original version of the test has 115 questions with 12 subscales. The shortened version of this inventory has 35 questions, which was translated into Persian in 2010 by Asoudeh et al under the supervision of Professor Olson. In this study, the shortened and 35-item version of Enrich Couple Inventory was used. This short version is consisted of four subscales of marital satisfaction, communication conflict resolution and idealistic distortion. Cronbach’s alpha coefficient of the Persian version for the subscales was 0.62 to 0.78 (28).
3. Revised Conflict Tactics Scale (CTS2): It was developed based on the conflict theory of Straus et al (29). This scale examines the specific solutions and tactics that couples use when facing conflict with their spouse. The scale was reviewed in 1991 and 1996. The second version of the Conflict Tactics Scale (CTS2) is a modified and expanded version of CTS1 scale. The main advantage of the second version over the first version of this scale is the focus on objective methods of conflict resolution as well as a more extensive assessment of conflict resolution tactics. In addition, this scale shows the severity and persistence of spouses’ violence against each other. Another advantage of CTS2 is that it assesses both the performance of the participants and the behavior of their spouses. This scale assesses physical and psychological violence against each other over the last 12 months. This scale includes 5 subscales of negotiation, psychological violence, physical assault, sexual coercion and injury. This scale was translated by Panaghi et al into Persian language in 2011 (31). In the translated version of Panaghi, instead of the five factors of Straus, three factors of negotiation, psychological violence, and physical assault were used. The Cronbach’s alpha coefficient of the translated version was 0.66 to 0.86. To score the CTS2, the sum of the midpoint of the frequency mentioned in the category selected by the individual (Zero for not in the last year and before that, 2 for 2 times last year, 4 for 3-5 times last year, 8 for 6-10 times last year, 15 for 11-20 times last year, 25 for more than 20 times last year) was used. In this study, the total scores of the subscales of psychological violence and physical violence were calculated and evaluated as the total violence score.
Data analysis method
Data were entered into IBMSPSS STATISTICS version 22 software and analyzed. All quantitative variables were reported as mean±SE and qualitative variables were reported as percentage. Data analysis was performed using Student T-Test and repeated measures. A value less than 0.05 was considered as a significance level.
Results
In the end, 67 subjects in the intervention group and 64 subjects in the control group remained in the study among which 3 subjects were excluded from the study. In terms of demographic characteristics, the mean age of the participants (±0.48) was 26.08 years and majority of them (93.9%) were in their first marriage. About 84.7% of participants were housewives and level of education in 42% was below the high school diploma. In general, there was no significant difference between the two groups of intervention and control in any of the demographic characteristics.
The results of the Conflict Tactics Scale-2
The mean scores of the sub-scales of the Conflict Tactics Scale-2 in intervention and control groups and their comparison is shown in table 1. In the pre-intervention stage, the mean scores of the Conflict Tactics Scale-2 in general and in each of the subscales in both intervention and control groups did not show any significant difference between the two groups. By examining and calculating the mean scores of the Conflict Tactics Scale-2 one month after the intervention in general and in each of the subscales in intervention and control groups, it was observed that the intervention group showed significantly higher scores than the control group in negotiation, aggressor negotiation, and victim negotiation. Other scales did not show a significant difference in two groups at this stage.
The trajectory of changes in the mean scores of the Conflict Tactic Scale-2 in the two groups and their comparison is shown in table 2. By evaluating the changes in the scores of the scales through analyzing the repeated measures, it was found that the changes in the scores in most of the subscales of the Conflict Tactic Scale-2 in the intervention group were significant. In the intervention group, changes in general violence, negotiation, psychological violence, aggressor negotiation, victim negotiation, aggressor psychological violence and victim physical violence were significant, and changes in other subscales were not significant. In addition, in the control group, changes in the scores of general violence, negotiation, aggressor general violence, aggressor negotiation, victim negotiation and aggressor psychological violence were significant. Comparison of changes in scores in the two groups of intervention and control through analyzing the repeated measures did not show a significant difference between the two groups in any of the scales.
Investigating the results of Enrich Couple Inventory
The mean scores of the Enrich Couple Inventory in the pre-intervention stage and then in both groups is shown in table 3. Based on the results in the pre-intervention stage, investigating the mean scores of the Enrich Couple Inventory in general and also in each of the subscales in both intervention and control groups showed no significant difference between the two groups. In addition, after observing the mean scores of the Enrich Couple Inventory in general and in each of the subscales one month after the intervention in both intervention and control groups as well as comparing the two groups, no significant difference was found between the two. Examining the changes in the scores of the scales through repeated measures analysis showed that the changes in the scores of Enrich Couple Inventory were not significant in any of the intervention and control groups. By analyzing and calculating the mean scores of Enrich Couple Inventory one month after the intervention in general and in each of the subscales in both intervention groups and control and comparing the two, no significant difference was observed between the two groups. These findings are shown in table 2.
In the end, the difference of scores before and after intervention in study subjects was calculated and comparison between study groups was done by independent T-Test. The result showed that the only significant difference between two groups was the psychological violence of victim (p value= 0.035)
Table 1. Comparison of the mean scores of the Conflict Tactic Scale-2 in the intervention and control groups in pre-intervention and one month after intervention stages
Scale |
Subscale |
Pre-intervention |
One month after intervention |
||||
Intervention group |
Control group |
*p value |
Intervention group |
Control group |
*p value |
||
Conflict Tactic Scale-2 |
General violence |
80.12±15.41 |
16.6±71.22 |
0.198 |
51.3±27.12 |
64.3±30.13 |
0.839 |
Negotiation |
86.11±46.121 |
14.11±17.112 |
0.570 |
48.11±58.90 |
70.7±78.55 |
0.013 |
|
Psychological |
75.4±69.21 |
84.3±92.16 |
0.439 |
17.3±89.10 |
14.3±56.11 |
0.882 |
|
Physical |
51.8±46.19 |
06.3±80.5 |
0.135 |
59.0±37.1 |
62.0±73.1 |
0.674 |
|
Aggressor |
75.4±78.12 |
60.1±19.7 |
0.276 |
98.0±86.3 |
09.1±97.3 |
0.944 |
|
Aggressor |
84.5±28.63 |
84.5±70.57 |
0.501 |
74.5±66.45 |
13.4±95.29 |
0.028 |
|
Aggressor psychological violence |
99.1±06.8 |
57.1±70.6 |
0.596 |
87.0±36.3 |
95.0±56.3 |
0.874 |
|
Aggressor physical |
15.3±72.4 |
15.0±48.0 |
0.184 |
35.0±51.0 |
22.0±41.0 |
0.811 |
|
Victim general |
16.9±37.28 |
22.5±53.15 |
0.226 |
95.2±40.8 |
87.2±33.9 |
0.823 |
|
Victim negotiation |
24.6±18.58 |
61.5±47.54 |
0.660 |
94.5±92.44 |
95.3±83.25 |
0.008 |
|
Victim psychological violence |
29.3±63.13 |
72.2±21.10 |
0.428 |
61.2±54.7 |
42.2±00.8 |
0.897 |
|
Victim physical |
12.6±75.14 |
04.3±31.5 |
0.170 |
42.0±87.0 |
54.0±33.1 |
0.500 |
*Comparison of the mean scores of two intervention and control groups in each stage of pre- intervention and one month after the intervention using the Student T-Test statistical test, p <0.05
Table 2. Comparison of the trajectory of changes in the mean scores of Conflict Tactics Scale-2 and the Enrich Couple Inventory in the intervention and control groups in all three stages
Scale |
Intervention group (n=67) |
Control group (n=64) |
|
||||||
|
|
Stage 0 |
Stage 1 |
Stage 2 |
p value* |
Stage 0 |
Stage 2 |
p value* |
**p value |
(Mean±SE) CTS-2 |
Marital |
80.12±15.41 |
20.4±03.14 |
51.3±27.12 |
0.039 |
16.6±71.22 |
64.3±30.13 |
0.044 |
0.319 |
Communication |
86.11±46.121 |
92.7±90.61 |
48.11±58.90 |
0.001 |
14.11±17.112 |
70.7±78.55 |
<0.001 |
0.094 |
|
Conflict |
75.4±69.21 |
93.1±86.8 |
17.3±89.10 |
0.034 |
84.3±92.16 |
14.3±56.11 |
0.059 |
0.663 |
|
Idealistic distortion |
51.8±46.19 |
47.2±36.5 |
59.0±37.1 |
0.067 |
06.3±80.5 |
62.0±73.1 |
0.165 |
0.162 |
|
Marital |
75.4±78.12 |
97.0±98. 3 |
98.0±86.3 |
0.095 |
60.1±19.7 |
09.1±97.3 |
0.036 |
0.338 |
|
Communication |
84.5±28.63 |
00.4±12.32 |
74.5±66.45 |
<0.001 |
84.5±70.57 |
13.4±95.29 |
<0.001 |
0.112 |
|
Conflict |
99.1±06.8 |
74.0±20.3 |
87.0±36.3 |
0.013 |
57.1±70.6 |
95.0±56.3 |
0.031 |
0.729 |
|
Idealistic distortion |
15.3± 72.4 |
3.0±77.0 |
35.0±51.0 |
0.407 |
15.0±48.0 |
22.0±41.0 |
0.737 |
0.185 |
|
Marital |
16.9±37.28 |
62.3±06.10 |
95.2±40.8 |
0.051 |
22.5±53.15 |
87.2±33.9 |
0.120 |
0.378 |
|
Communication |
24.6±18.58 |
10.3±78.29 |
94.5±92.44 |
0.014 |
61.5±47.54 |
95.3±83.25 |
<0.001 |
0.091 |
|
Conflict |
29.3±63.13 |
44.1±48.5 |
61.2±54.7 |
0.156 |
72.2±21.10 |
42.2±00.8 |
0.233 |
0.678 |
|
Idealistic distortion |
12.6±75.14 |
30.2±58.4 |
42.0±87.0 |
0.0496 |
04.3±31.5 |
54.0±33.1 |
0.168 |
0.218 |
|
ENRICH (Mean±SE) |
Marital |
93.0±59.35 |
95.0±89.35 |
0.85±35.89 |
0.736 |
82.0±20.35 |
92.0±53.35 |
0.626 |
0.74 |
Communication |
04.1±82.33 |
01.1±35.33 |
33.07±0.95 |
0.315 |
85.0±20.32 |
97.0±31.33 |
0.126 |
0.58 |
|
Conflict |
78.0±98.30 |
74.0±56.30 |
31.09±0.82 |
0.896 |
69.0±75.29 |
74.0±06.31 |
0.054 |
0.51 |
|
Idealistic distortion |
51.0±56.17 |
48.0±11.18 |
0.55±17.79 |
0.586 |
52.0±51.17 |
62.0±39.17 |
0.786 |
0.75 |
* Comparison of mean changes in three stages of pre- intervention, immediately after the intervention and one month after intervention in both groups using repeated measure statistical test, and the significance level of p <0.05
** Comparison of changes in the two groups of intervention and control using repeated measure statistical test, and significant level of p <0.05
Table 3. Comparison of the mean scores of the Enrich Couple Inventory in intervention and control groups in pre- intervention and one month after intervention stages
Scale |
Subscale |
Pre-intervention |
One month after intervention |
||||
Intervention group |
Control group |
*p value |
Intervention group |
Control group |
*p value |
||
Enrich |
Marital satisfaction |
93.0±59.35 |
82.0±20.35 |
0.754 |
35.89±0.85 |
92.0±53.35 |
0.781 |
Communication |
04.1±82.33 |
85.0±20.32 |
0.234 |
33.07±0.95 |
97.0±.33 |
0.862 |
|
Conflict resolution |
78.0±98.30 |
69.0±75.29 |
0.243 |
31.09±0.82 |
74.0±06.31 |
0.981 |
|
Idealistic distortion |
51.0±56.17 |
52.0±51.17 |
0.945 |
17.79±0.55 |
62.0±39.17 |
0.628 |
*Comparison of the mean scores of two intervention and control groups in each stage of pre- intervention and one month after the intervention using the Student T-Test statistical test, p <0.05
Discussion
In this study, the subscales of psychological violence in the intervention group decreased immediately after the intervention, yet increased slightly one month after the intervention. Overall, the intervention group showed a significant decrease compared to baseline. The change in psychological violence in the intervention group may be due to the fact that the initial effect immediately after the intervention significantly reduced the psychological violence between couples. Subsequently, with reduction of the initial effect of training over time, the level of psychological violence slightly increased again, though after one month, it remained still significantly below baseline. According to the meta-analysis results of Hawkins et al (31) and Pinquart and Teubert (32), in contrast to the immediate post-test, the magnitude of the intervention effect in long-term follow-up was not significant, indicating that the initial effects of the intervention fade over time. Though the results of other studies have challenged this conclusion, it is supported that even though the effect of intervention is reduced in the long term, its effect still continues to remain (33,34). Thus, the effect of short-term interventions on reducing violence appears to be significant. However, it is not yet clear whether or not the effects of interventions are long-lasting and it is suggested to look for means to prolong the effects of interventions (35). In order to achieve more accurate results, repeating the reminder intervention or developing deeper intervention can be recommended. Therefore, an emphasis on this issue for future studies is advised. It is crucial to note the cost of interventions in order to assess the feasibility of widely providing large-scale interventions at the community level. In addition, the consequences of domestic violence in the family and community are widely evident. Therefore, the result of this study indicates that short-term interventions can reduce the prevalence of violence which can be applied in macro planning.
In addition, a significant decrease in sub-scales of negotiation, aggressor negotiation, and victim negotiation was observed both in the intervention group and the control group compared to baseline level. A potential reason for a reduction in the level of negotiation can be attributed to the knowledge gained by subjects about the existing problems, developing an understanding of the current situation and an urge to improve it. It appears that the knowledge gained was the result of studying the questionnaires in both groups and receiving training in the intervention group. It is accepted that gaining knowledge of existing problems will lead to a search for solutions in the long term and ultimately will improve negotiation tactics. It is also understood that skill-based interventions, as a primary intervention, make couples subconsciously more sensitive to the skill deficiencies in their relationship (36).
Despite significant changes in both intervention and control groups in most subscales of the Conflict Tactics Scale, the differences between the two groups were similar and the comparison of the changes in the two groups showed no significant difference. The results of this study were reasonably consistent with the results of the “building strong families” and “supporting a healthy marriage” program. Reviewing the results of the intervention in the “ building strong families “ program demonstrated that the follow-ups did not show a statistically significant difference after the interventions. Although significant positive effects were observed in the sub-group of African-American participants, there was no significant difference in the three-year follow-up (37). In the results of the “supporting a healthy marriage” program, which was conducted to investigate the impact of skills-based training programs, the effectiveness of the intervention was insignificant (38).
In this study, despite changes in conflict resolution tactics, no change was observed in marital satisfaction sub-scales. Marital satisfaction is a rather complex concept, the associated changes are slow and time consuming, hence, such a result was expected. Further accurate examination of sub-scales of the Enrich Couple Inventory may require longer intervention, extensive sampling and comparison of different populations.
Despite significant changes in the subscales of Conflict Tactics Scale-2, it is not possible to confirm with certainty that the changes in the intervention group were due to the training provided. Therefore, it might be possible that there existed a common factor between the two groups, causing similar changes in both groups. For example, inviting people to participate in the study has attracted their attention to the discussed topics. In addition, the subjects in both intervention and control groups were placed in a group with a common problem and accordingly felt social support, encouraging a sense of hope in both groups. Another common factor is the completion of the questionnaire, which introduces important points of communication skills and conflict resolution for the couples as it encourages the couples to think, search for and create a solution to solve problems in relation to their spouse. The key point about the mentioned factors is that simple interventions can result in a significant impact. For example, in a 2013 study conducted on a group participated in video and conversational sessions on the relationship without any skill training showed a performance similar to groups participated in educational programs in 4 sessions (15 hr) in terms of stability and satisfaction. This study highlights the importance of cost-effective interventions such as the one carried out in the current study (36). Similarly, Finkel et al showed the potential of brief social psychological interventions in maintaining the quality of an intimate relationship (39).
The presence of common factors affecting both groups could potentially explain the lack of significant differences between the two groups. In addition, the effect of intervention could be masked by another affecting factor. For example, since the sampling of two groups was performed from similar small populations, the intervention group may have transferred the content of the training to the control group.
Another potential reason for the lack of significant difference between the changes in the two groups could be trainers’ skill inadequacy in providing training. This effect is evident in a meta-analysis of couple relationships training interventions as significant effect size was observed only in the groups guided by staff with professional clinical competency in comparison with less professional staff (32). Other reason could be the inaccurate completion of questionnaires which in itself could be due to length of the questionnaires, lack of clarity and simplicity of the questions for the target group, incompatibility with the education level and knowledge of this population as well as ambiguity of the questions due to cultural differences. However, by observing significant changes in the subscales of the Conflict Tactics Scale in each of the groups, the direct effect of above mentioned reasons diminishes.
Overall, it appears that intervention in this area has two levels, one is merely raising awareness and the other is further deeper interventions. It is thought that deeper interventions (With longer group sessions) result in stronger effects (35). This premise was confirmed in two meta-analyses: the effect of low-dose interventions (up to 7 to 8 hr) on couple satisfaction and communication was not found to be significant in long-term follow-up, and the effect of moderate-dose intervention (up to 20 hr) was found to be moderate to high (31,40). Based on the results of the present study, the content of the workshop by itself was not sufficient and the current intervention was effective only at the level of raising awareness. Further research on training materials and a review of content and its effectiveness is recommended.
Limitations
Low participation of women in the study and as a result, small sample size and also difficulty in comprehension and completing the questionnaires were some limitations of this study.
Recommendations
Based on the results of the present study, following recommendations for future studies are suggested: selection of a larger sample size from varied populations and examining intergroup correlation, using alternative assessment tools, thorough monitoring in completing the questionnaire and providing an expanded training course, compared to the present study.
Conclusion
In general, modification of beliefs and expectations from marital life and teaching communication skills in the form of short-term intervention can be effective in improving the methods of resolving conflict between couples. Since marital satisfaction is a complex concept, achieving more accurate results in this area requires more extensive studies.
Acknowledgments
The authors would like to acknowledge the support and contribution of the social and mental health and addiction office of the Ministry of Health and Medical Education and Ministry of Interior’s Social Injuries Council in conducting the study.