The Effectiveness of Integrative Behavioral Couple Therapy (IBCT) on Emotional Divorce of Couples: A Randomized Clinical Trial

Document Type : Original article

Authors

1 Department of Counseling, Abhar branch, Islamic Azad University, Abhar, Iran

2 Department of Psychiatry, Beheshti Hospital, Zanjan University of Medical Sciences, Zanjan, Iran

Abstract

Background: Some scientists consider emotional divorce as the first step in the divorce process, which means that the marital relationship is declining. Research shows the harmful physical and psychological effects of emotional divorce on couples. The present research was carried out to show the effectiveness of Integrative Behavioral Couple Therapy (IBCT) on emotional divorce among couples.
Methods: This was a quasi-experimental design study with a control group, including a pre-test, post-test and a 45-day follow up. The statistical population of this study was all couples referred to the family therapy clinic of Shahid Beheshti Psychiatric Hospital in Zanjan in 2020. Twenty couples were selected based on a score of eight or higher in a 24-item two-choice questionnaire on emotional divorce which was developed by Guttman in 1998. Next, participants were randomly divided into two groups of experimental and control. The experimental group received 11 weekly sessions of IBCT and each intervention session lasted for 120 minutes and the control group did not receive any intervention. Repeated measures ANOVA was used and data were analyzed by SPSS software V18.
Results: The results of ANOVA showed that there was a significant difference between the control and experimental groups in the pre-test, post-test and follow-up (p <0.001). Therefore, it can be concluded that IBCT has reduced the emotional divorce of couples in the experimental group.
Conclusion: Results suggest that IBCT can be used as a treatment of choice for reduction of emotional divorce.

Keywords


Abstract
Background: Some scientists consider emotional divorce as the first step in the divorce process, which means that the marital relationship is declining. Research shows the harmful physical and psychological effects of emotional divorce on couples. The present research was carried out to show the effectiveness of Integrative Behavioral Couple Therapy (IBCT) on emotional divorce among couples.
Methods: This was a quasi-experimental design study with a control group, including a pre-test, post-test and a 45-day follow up. The statistical population of this study was all couples referred to the family therapy clinic of Shahid Beheshti Psychiatric Hospital in Zanjan in 2020. Twenty couples were selected based on a score of eight or higher in a 24-item two-choice questionnaire on emotional divorce which was developed by Guttman in 1998. Next, participants were randomly divided into two groups of experimental and control. The experimental group received 11 weekly sessions of IBCT and each intervention session lasted for 120 minutes and the control group did not receive any intervention. Repeated measures ANOVA was used and data were analyzed by SPSS software V18.
Results: The results of ANOVA showed that there was a significant difference between the control and experimental groups in the pre-test, post-test and follow-up (p<0.001). Therefore, it can be concluded that IBCT has reduced the emotional divorce of couples in the experimental group.
Conclusion: Results suggest that IBCT can be used as a treatment of choice for reduction of emotional divorce.
Keywords: Couples therapy, Divorce, Marriage
Introduction
Marriage is the most important and supreme social tradition that has always been approved to meet the emotional needs of individuals (1). Although the concept of marriage is influenced by culture and varies from one society to another, it is an emotional and interpersonal relationship almost in all societies (2). Sometimes couples confront problems in marital relationships that lead to conflict between them. The level of satisfaction or dissatisfaction with the marital relationship is determined by the general assessment of the marital relationship and how to meet the needs, desires and aspirations of the individual and the couple (3).
Researches have shown that the non-fulfilment of marital expectations and its incompatibility with the realities of marital relations cause emotional coldness and marital dissatisfaction (4). The saddest problem of the twentieth century is divorce, which has been on the rise for the last 50 to 60 years. Unfortunately, the divorce rate has continued to increase unexpectedly in Iran, so that in 2011 compared to 2006, it increased by 45% and 153 divorces occurred per 1000 marriages (5). The official divorce rate does not fully reflect the level of failure of spouses in married life, because in addition to that, a larger number is dedicated to emotional divorces, i.e. silent lives and families where husband and wife live together coldly but do not seek legal divorce. The emotional divorce is a clear and obvious emotional distance between spouses who are both immature and indistinguishable in personality (6). Lack of empathy, trust, emotional needs, lack of time with each other, sexual dissatisfaction and communication problems are the factors that facilitate emotional divorce (4). Some scholars consider emotional divorce to be the first step in the divorce process, which means that the marital relationship is declining and is replaced by feelings of separation. When the needs of the couple in the family are not met and the traditional view of individuals to divorce is destroyed, the odds of emotional divorce will be intensified (7). In accordance with previous research, the harmful physical and psychological effects and consequences lead to emotional divorce of couples. Moreover, emotional divorce causes problems and psychological pressures such as depression, anxiety, low self-esteem, isolation, and physical and mental illnesses in women (8). Divorce is a phenomenon that not only poses a serious threat to the institution of the family but also affects the health of society (9). Integrative Behavioral Couple Therapy (IBCT) is an acceptance-based and tolerance strategy developed by Christensen and Jacobson as an integrated model of Traditional Behavioral Couple Therapy (TBCT) (10). Theorists of the IBCT do not consider the couples’ problems as merely lack of skills, but instead as differences between couples who have lost their tolerance to overcome obstacles. If these differences target each couple’s faults and foibles, it will be a source of serious emotional arousal. The intervention strategies of IBCT often emphasize on the couple’s emotional reactions to the differences and conflicts (11). The IBCT is a context based behavior therapy that helps couples reduce their incompatibilities by combining acceptance and change-based strategies (12). In the beginning, acceptance and tolerance of differences exist between couples, but when acceptance fades, couples see each other incomplete and begin to gossip and change, and these efforts often lead to forced and negative behaviors such as criticism and withdrawal (13). The IBCT originates from TBCT; in order to overcome some of the limitations of TBCT, emotional acceptance techniques have been used. It is assumed that acceptance-based interventions, along with acceptance, lead to spontaneous changes that are applied in four ways: (a) empathic connection regarding the problem, (b) the unit’s neutrality in examining the problem, (c) increase of tolerance in the face of an annoying problem, and (d) increase of self-care skills against unsolvable problems. It also maintains some of the axial change techniques including behavioral exchange, communication training, and problem-solving (14). According to study of Christensen et al, the IBCT was effective in reducing the chance and rate of divorce during the treatment and in the long run, respectively (15). Niazi et al in their research showed that IBCT improves the communication beliefs of incompatible couples (1). Moreover, the findings of Poursardar et al showed that IBCT improves the symptoms of emotional regulation in conflicting couples (16). Today, integrated therapies have strong advocates and therapists aim to access more effective treatments by combining different theories and approaches (17). Increased divorce rate and marital dissatisfaction and more importantly, the couple’s request to enrich marital relations indicate the need of spouses for specialized interventions and training in this field (18). Psychological interventions stabilize the marriage, increase the quality of life of the couple and prevent emotional divorce. With regard to the benefits of IBCT and the importance of reducing emotional divorce, this research evaluated the effectiveness of this model on couples’ emotional divorce in the target community. Therefore, the present study, while introducing the above model, sought to answer the basic question of whether IBCT reduces couples’ emotional divorce and whether this effect can be sustained in the follow-up phase.

Materials and Methods
The present study is quasi-experimental with a pre-test, post-test design including a control group. The statistical population of this study was all couples referred to the family therapy clinic of Shahid Beheshti Psychiatric Hospital in Zanjan in 2020. Twenty couples were selected from the community available and then, participants were divided randomly into two groups of experimental and control. Inclusion criteria included having minimum level of education (Holding diploma), minimum age of 20 and maximum of 50, at least one year of living together, and achieving a score of eight or higher in the emotional divorce questionnaire. The exclusion criteria included persons being under medical treatment and psychotherapy and referral due to addiction and infidelity. In order to observe ethical principles, some issues of study were explained to participants such as the purpose of the research, the possibility of leaving the study without disturbing the intervention, and confidentiality of personal information. Then, couples signed an informed consent form, which covered their participation in treatment. The subjects in the control group did not receive any intervention until the end of the research process and were placed on a waiting list. The experimental group received 11 weekly sessions of IBCT and each intervention session lasted for 120 minutes. At the end of eleven sessions, participants were re-evaluated by emotional divorce questionnaire and the follow-up phase began after 45 days. Participants in the follow-up phase were also evaluated by the above questionnaire. Table 1 provides a brief description of the IBCT sessions. The instrument in this phase was also the emotional divorce questionnaire; it consists of 24 items in a two-point scale including “Yes or No” choices developed by Guttman (19). Positive answers are given a score of one and negative answers are given a score of zero, and then the scores are added up. If the person’s score is eight or higher, it means that the person’s married life is subject to separation and there are signs of psychological divorce. The reliability coefficient of this scale has been reported above 0.70 in the original version. The reliability of this questionnaire in Iran was 0.93 using Cronbach’s alpha. The face validity of this questionnaire was confirmed by Mousavi et al (20). Mami and Asgari in 2013 reported the reliability of the questionnaire with Cronbach’s alpha value of 0.83 (21). Also, the value of 0.77 for Cronbach’s alpha was reported in 2015 by Demirchi sadri E, et al (22).

Statistical analysis
The collected data were analyzed using descriptive statistics and repeated measures ANOVA, Mauchly’s sphericity test, Box test, and Bonferroni post hoc test using SPSS software V18 and p-value of 0.05.

Results
In this study, the mean age of the participants was 37.5±6.48 years. Also, 56.7% of the participants had bachelor degree or higher, 11.7% had associate degree and 31.7% had diploma. As can be seen in table 2, the mean score of emotional divorce during pre-test was almost the same in the experimental group (14.65) and the control group (14.35). Next, repeated measures ANOVA was used for analysis. The scores were normally distributed as the skewness coefficient (0.244) turned out to be between -3, 3 and the elongation coefficient (-1.05) was between -5 and 5. Moreover, Mauchly’s test and statistics were used to check the sphericity of the control and experimental groups. The results of this test show that the value of the Mauchly’s sphericity test was not significant at the probability level less than 0.05. So, the sphericity of the variance-covariance matrix of the dependent variable was accepted. To examine the equality of variance-covariance matrix of emotional divorce, Box’s test was used in both control and experimental groups. According to the result of the test (p-value=0.17), the p value was greater than 0.05. Therefore, the pre-test, post-test and follow-up covariance matrix was equal in other groups. Results of repeated-measures ANOVA in control and experimental groups in the pre-test, post-test, and follow-up are shown in table 3. The significance or non-significance of the whole model, as well as the independent effects of the variables of time, intervention and, interaction of the two groups can be seen on the components of emotional divorce. As can be seen in table 3, the effect of the intragroup variable of time on the total score of the emotional divorce variable is significant (p≤0.05), i.e. the score of this component in post-test and follow-up is significantly different from the pre-test. Also, the effect of the intergroup variable of the intervention was significant in reducing the score of the emotional divorce component (p≤0.05), i.e. the integrated couple therapy intervention was able to reduce the score of the emotional divorce component compared to the control group. The interaction between time and intervention and the simultaneous effect of these two variables on the score of the emotional divorce component is also statistically significant (p≤0.05); in other words, the score of the emotional divorce component involved in the intervention varies from time to time. Bonferroni post hoc test was used to compare the two intervals of intervention regarding emotional divorce component in the control and experimental groups. According to the data in table 4, emotional divorce component showed significantly different results between pre-test and post-test and between pre-test and follow-up, but there was no significant difference between post-test and follow-up. Based on the results of this test, integrated couple therapy intervention shows a statistically significant, lasting effect on emotional divorce in the subjects.

Sessions

Brief description

First

Therapist making the couples acquaintance-Defining treatment goals, expectations and working methods-Assessing the suitability of couples for treatment-Introducing current problems-Obtaining a developmental history-Explaining the strengths of the relationship through behavioral examples

Second

Assessing the specific problems of each couple-Discussing about initial orientation-Understanding the conflict pattern - Understanding the conflict pattern of the source family-Assessing physical violence- Assessing each party’s commitment to treatment-Assessing extramarital relationships

Third

Reviewing previous sessions-Summarizing-Reviewing the written assignment prepared by the therapist-Sharing questionnaire information and interviewing the clients-Expressing expectations from the treatment-Engaging clients in the formulation-Identifying problem areas - Expressing topics

Fourth

Maintaining affinity with the couples-Delineating marital disorder as Charge + Pain-Delineating acceptance as Pain-Charge-Assigning homework based on cooperative alliance in couples-Explaining about how to make right judgment-Creating a safe space to express annoyances

Fifth

Advising couples to talk about their problems without blaming - Understanding the interactive sequence that led to the couple’s failure-Engaging spouses to think about their state of constant conflict

Sixth

Reviewing  past sessions-Summarizing-Encouraging the couples to accept spouses as they are-Explaining that each negative behavior may bring positive outcomes so desensitizing couples to the behavior-Educating the aggressive spouses on the consequences of their negative behavior

Seventh

Assessing the homework done-Pretending to perform negative behavior-Advising couples about doing homework-Identifying negative behaviors that can be done at home-Planning to perform negative behaviors at home-Analyzing spouse’s feedback

Eighth

Reviewing past sessions-Summarizing-Identifying couples’ needs-Motivating couples to select activities tailored to the needs-Encouraging respecting both parties independence

ninth

Increasing positive behaviors and interactions through behavior exchange-Identifying the behaviors that each spouse can do for the other to increase relationship satisfaction-Looking back and detecting positive behaviors

Tenth and eleventh

Training couples to discuss without destructive methods-Teaching speaking and listening skills-Teaching constructive discussion to solve the problem-Teaching and practicing problem detection skills-Teaching and practicing problem solving skills-Performing follow-up and specifying the date of the follow-up session

 

Table 2. Descriptive statistics of emotional divorce score in pre-test, post-test and follow-up in experimental and control groups

Variable

Time

Experimental group

Control group

Mean

SD

Mean

SD

Emotional divorce

Pre-test

14.65

4.63

14.35

4.24

Post-test

4.85

2.23

18.35

2.7

Follow-up

4.2

2.94

19.9

2.59

 

Table 3. Analysis of emotional divorce component in control and experimental groups in pre-test, post-test and follow-up

Variable

Source

 

Sum of squares

Df

Mean square

F

p value

Partial eta squared

 

Within subject

Time

194.86

2

97.43

16.59

<0.001

0.304

Emotional divorce

 

Error

446.2

76

5.87

 

 

 

 

Between subject

Intervention

2784.03

1

2784.03

127.3

<0.001

0.77

 

 

Error

831

38

21.86

 

 

 

 

Interaction

Time * Intervention

1504.26

2

0.13

0.11

<0.001

0.77

 

* Time means changes between pre-test, post-test and follow-up

** Intervention means changes between the experimental and control groups

Table 4. Results of binary comparison of intervention times in emotional divorce component in control and experimental groups

Variable

Time 1

Time 2

Mean differences

Std division

p value

Emotional divorce

Pre-test

Post-test

2.9

0.593

< 0.001

Follow-up

2.45

0.652

< 0.001

Post-test

Pre-test

-2.9

0.593

< 0.001

Follow-up

-0.45

0.322

0.5

Follow-up

Pre-test

-2.45

0.652

< 0.001

Post-test

0.45

0.322

0.5

 

 


Discussion
The aim of this study was to determine the effectiveness of IBCT in reducing emotional divorce and treatment durability in the follow-up phase. The results showed that the mentioned intervention had a positive effect on reducing the score of the emotional divorce. Therefore, there was a significant difference in emotional divorce component between couples who were under couple therapy and couples who did not receive treatment. The findings of Christensen A et al showed that IBCT is an effective treatment in reducing divorce rate in the long time and treatment duration (15). Furthermore, Christensen A et al in their study showed that after two years, the relations of %67 of couples improved with IBCT at the level of clinical significance (23). Peleg O showed that marital satisfaction has inverse relation with emotional divorce which was in agreement with our findings (24). Moreover, the results of Baucom KJ et al’s research confirmed the effectiveness of IBCT which was similar to our findings (25). Regarding the effectiveness of IBCT on disturbed couples, Montesi JL et al showed that this treatment model increases safe behaviors by reconstruction of relationship between couples and also, reduces conflicts of marital relationships and the tendency to divorce (26). Differences in characteristics between spouses hinder the development of appropriate relationships between spouses. This fact leads to misunderstandings among spouses or initiates conflict over trivial problems. Finally, it has a destructive effect on the basic components of the relationship such as harmony, respect, love, cooperation, emotional support, etc. The research has shown that IBCT was effective on various types of marital disorders because it is based on acceptance techniques and has been able to manage different behaviors of spouses (27). The IBCT can be helpful by providing communication training and problem solving strategies among couples with difficulty which leads to establishment of an empathetic relationship and improvement of conflict management skills (12). In addition, in intimate relationships, the need for attention, value and desirability between couples is mutually satisfied (28). For example, learning to express emotions, using “I “ pronoun, actively listening to, identifying communication barriers, and removing them will lead to less blame, disrespect and humiliation between couples (29). The second strategy of IBCT is to solve the problems. Instead of blaming, spouses focus on how to improve each other’s skill to interact during a conflict by avoiding discussions on bothersome issues and preventing destructive conversations. Finally, couples are encouraged to increase their tolerance for situations which are out of their control. In addition to emotional acceptance, IBCT changes behavior by helping couples to identify, hold, and enjoy discussions about desirable activities that each person can do for the other. Additionally, communication skills including speaking-listening skills and problem-solving strategies are taught to couples (30). In this intervention, it is expected that the improved acceptance skills lead to increased relationship satisfaction. It is assumed that incompatibility occurs between couples who are unaware of the fact that insisting on changing each other leads to resistance and emotional reactions as problematic behaviors (31). The use of acceptance technique along with traditional methods of change such as communication training, problem solving and behavioral exchange empowers couples to solve external problems and conflicts which ultimately culminates in continuation of change (32).
The current study which was conducted in Zanjan city has been associated with several limitations. So, it is necessary to be careful in extending the results to other places and cities. In fact, the findings cannot be generalized to larger population due to limited number of samples as a result of prevalence of Covid-19, and the unwillingness of some couples to participate in the study.

Conclusion
In response to the main question of the study, it was concluded that IBCT has an effect on reducing emotional divorce and showed a statistically significant lasting effect on emotional divorce in the subjects. Based on the findings of this research at the theoretical level, the results of previous research can be confirmed and at the practical level, the findings of this research can be used in the development of educational programs. Considering the increasing prevalence of divorce in Iran and subsequent stressful conditions and problems for couples, IBCT is an important step in preventing emotional or legal divorce which successfully revives a relationship and stops deadly harm to the family. Moreover, it is suggested that future research be conducted in other communities and the follow-up phase extends to one year.

Acknowledgements
The present research was approved by Ethics Committee (IR.ZUMS.REC.1399.039) of Zanjan University of Medical Sciences and also Iranian Registry of Clinical Trials (IRCT20201011048990N1). This study was extracted from a doctoral dissertation on counselling. The authors thank the staff of Abhar branch of Islamic Azad University and Zanjan University of Medical Sciences for their supports and also the couples who sincerely cooperated in conducting this research despite many difficulties.

Conflict of Interest
The authors declare there are no conflicts of interest.

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