Effects of integrative behavioral couple therapy on communication patterns and marital adjustment

Abstract

BACKGROUND:

Couples experience maladjustment and serious problems in establishing and maintaining intimate relationships. Therefore, therapists employ different methods for helping couples experience more intimate and compatible relationships. Nowadays, professionals are more interested in using integrative approaches than ever before. Integrative behavioral couple therapy (IBCT) is an exemplar of such methods. This study aimed to analyze the effects of IBCT on communication patterns and marital adjustment.

MATERIALS AND METHODS:

This study included pretest and posttest steps with a control group. The statistical population included couples aged 20–45 years old visiting the counseling and psychological service centers of Tehran for marital conflicts in 2022. After the initial evaluation, 76 couples were selected as the sample through convenience sampling. They were then randomly assigned to the test and control groups. All participants were asked to fill out the Spanier Dyadic Adjustment Scale (DAS) and the Communication Patterns Questionnaire (CPQ) one week before the first intervention session and one week after the last intervention session. Participants in the test group attended eleven 90-minute sessions of IBCT, whereas those in the control group received no interventions in this period. The one-way ANCOVA was used for data analysis in SPSS 26.

RESULTS:

The results indicated that IBCT managed to significantly improve marital adjustment and constructive communication patterns. It reduced two communication patterns called “mutual avoidance” and “demand/withdraw” in the test group (P = 0.001). However, since the effect size of “demand/withdraw” was 0.26, this result should be interpreted cautiously.

CONCLUSION:

According to the research findings, Iranian couple therapists can employ IBCT to improve constructive communication patterns and mitigate destructive ones in couples. Given the effect size, IBCT increased dyadic cohesion, affection, dyadic satisfaction, and dyadic consensus as well as improving the marital adjustment of participants.

Introduction

Marital adjustment refers to an adaptive behavior requiring spouses to respond to each other’s needs appropriately. In this process, spouses learn how to cooperate and compromise on various issues over time. Known as the basis of optimal family functioning, marital adjustment helps spouses play their parental roles and improve their satisfaction. Marital adjustment is also a psychological condition acquired through the efforts of couples. Nevertheless, insufficient or unproductive efforts to achieve marital adjustment can make couples suffer from adverse effects of marital maladjustment, among the most stressful situations that individuals may experience.[1]

Healthy communication patterns can lead to adjustment, mutual understanding, and empathy between spouses, whereas destructive communication patterns reduce mutual understanding, spousal support, and marital adjustment.[2] Studies have shown a correlation between the quality and manner of communication and marital adjustment.[1,3] Moreover, some aspects of conflicts can predict long-term changes in marital adjustment. For example, there is an inverse relationship between “mutual avoidance and withholding” and “marital satisfaction and adjustment.”[4]

Recent studies and clinical experiences indicate that couples experience maladjustment and major problems in establishing and maintaining intimate relationships.[5] Maladjustment and conflicts in relationships increase the risk of psychological problems such as depression, anxiety, low self-confidence, addiction, and physical conditions, for example, cardiovascular diseases and changes in the immune system.[6,7,8] Relationship dissatisfaction is also associated with certain outcomes such as poor parenting and psychological problems in children.[3,9] Furthermore, marital conflicts not only threaten the family entity but also affect the whole society.[10]

In addition to these destructive outcomes, half of marriages in Western societies end in divorce. According to Iran’s national statistics portal, one divorce is registered for every three to four marriages in Iran. These figures reflect only part of relationship disorders, for most people are always tackling conflicts and their outcomes without taking legal actions.[10]

Cultural changes and public awareness of these consequences in recent years have increased the willingness of couples to receive couples therapy services.[7] The significance of solving marital conflicts,[11] improving communication, and increasing spousal sense of satisfaction encouraged many researchers to focus on the factors affecting marital consolidation and adjustment.[5]

Although many useful and effective protocols and interventions have been developed for this purpose, experts show a greater tendency to use integrative approaches. In fact, experts argue that a single approach fails to comprehensively and deeply address marital problems.[7] In addition, couples therapy approaches influenced by common factors may lead to integration and eclecticism.[12]

IBCT is a method of integrative couples therapy[13] based on clinical experiences and studies of Andrew Christensen and Neil Jacobson about traditional behavioral couple therapy and its limitations.[14] IBCT integrates different approaches from multiple sources within the context of a behavioral approach.[15]

IBCT employs a combination of acceptance-based and change-based strategies. Therapists usually begin the intervention with acceptance-based strategies such as empathic joining and unified detachment to allow spouses to convert their problems into opportunities to improve their intimacy and tolerance of problems and also mitigate the effects of problems on their relationship. Other techniques such as paying attention to the positive aspects of negative behaviors, performing negative behaviors in the intervention session, pretending to behave negatively outside the intervention sessions, and taking care of oneself, also aim to increase the tolerance of couples. Change-based techniques such as behavioral exchange and problem-solving training are employed to trigger specific behavioral changes.[12,15,16]

Many studies have corroborated the effectiveness of IBCT. A quasi-experimental clinical trial analyzed the effects of IBCT on emotional divorce in 20 couples. Participants in the test group attended eleven 120-minute sessions of IBCT once a week, whereas those in the control group received no intervention. The results showed a significant difference between the test and control groups in the pretest, posttest, and follow-up steps (P < 0.001), and IBCT reduced emotional divorce among the participants.[6] A study analyzed the effects of IBCT on cognitive emotion regulation and marital intimacy of 15 married women. According to the findings, the IBCT-based intervention was effective in improving cognitive emotion regulation (P < 0.001) and marital intimacy (P < 0.001) of married women.[5] Another research addressed the effects of IBCT on marital harmony and parenting competency of couples after the birth of a child. For this purpose, three couples who had only one child aged below three years old were selected through purposive sampling to participate in the IBCT-based intervention. The results showed that IBCT significantly improved marital harmony (by 48.26%) and parenting competency (by 30.02%).[17]

Materials and Methods

Study design and setting

This study included pretest and posttest steps with a control group. A follow-up step was not included because this study was part of a larger qualitative analysis, and follow-up measurements could expose the rest of the research to bias. The statistical population included couples aged 20–45 years old visiting the counseling and psychological service centers of Tehran, Iran, for marital conflicts in 2022.

Study participants and sampling

Assuming α =0.05, a test power of 0.08, and a hypothesized effect size medium to high (0.08), the sample size was calculated as 27 in each group in G*Power. Considering an attrition rate of 37%, the final sample size was decided to be 38 in each group.

The participants were purposively selected from individuals who met the inclusion criteria. The inclusion and exclusion criteria were based on previous studies such as the ones conducted by Eldridge et al. (2021) and Heidari et al. (2021).[2,12]

The inclusion criteria were as follows:

• - Diagnosis of marital adjustment problems based on interviews with participants and scores below 110 on Spanier DAS (excluding severe maladjustment leading to an application for legal divorce)

• - Educational attainment (a high school diploma or higher)

• - Age: 20–45 years

• - Duration of marriage: 1–7 years

• - Enough free time for participation in the intervention sessions.

The exclusion criteria were also as follows:

• - Absence in more than three sessions (the data obtained from such participants were excluded from analysis)

• - Distorted evaluation results (questionnaires and interviews)

• - Affliction with severe psychiatric disorders (according to the initial interview)

• - Being under no psychological or psychiatric treatments (to prevent possible interferences with the intervention)

• - Addiction to drugs, alcohol, and gambling over the past three months

• - Engagement in other romantic relationships (betrayal)

• - Experiencing severe domestic violence.

The participants were selected with respect to the initial interview and evaluation, demographic information, inclusion and exclusion criteria, and informed consent forms. They were then randomly assigned to the IBCT group and the control group. Afterward, the Mann–Whitney U test was conducted to compare the two groups in terms of educational attainment and gender. According to the results, the two groups had no significant differences in educational attainment (0.882) and gender (P = 1.000).

The independent t-test also indicated no significant differences between the two groups in age (0.773), duration of marriage (0.962), and number of children (0.822) because the significance levels of all variables were greater than 0.05. Therefore, the hypothesis of the equality of mean values between the two groups was established, and the two groups were matched in these variables.

The independent t-test was also performed to measure the pretest status of the two groups in terms of marital adjustment and communication patterns. Since the significance levels of all variables were greater than 0.05 (0.804 for marital adjustment, 0.868 for constrictive communication, 0.983 for mutual avoidance, and 0.947 for demand/withdraw), there were no significant differences between the two groups in marital adjustment and communication patterns before the intervention.

After the two groups were matched in terms of demographics and research variables, participants in the test group were invited to attend eleven 90-minute sessions of an IBCT-based intervention. For several reasons such as the COVID-19 pandemic, death of family members, and absence in more than three sessions, the final research sample included 30 couples (15 men and 15 women) in the test group and 28 couples (14 men and 14 women) in the control group.

IBCT sessions

The Table 1 presents an overview of the IBCT-based intervention extracted from Integrative Behavioral Couple Therapy (A Therapist’s Guide to Creating Acceptance and Change) by Christensen et al. (2020).[15]

Table 1.

An overview of the IBCT-based intervention

Session	Description
1	Greeting (the therapist and couples identified themselves); the principles of the intervention sessions were explained; the eligibility of couples for entering the intervention was reassessed; the current problems and development history of couples were reviewed; the relationship strengths were explained through behavioral examples; the intervention goals were set; the perspectives of couples therapy were outlined.
2	Couples participated in individual sessions; couples were briefed on the principles of confidentiality; couples were asked to go beyond the current problems based on the initial assessment and interviews; violence-related issues were addressed; couples were asked to express their commitment to the intervention; extramarital affairs were discussed; the history of their relationship was reviewed; the family conflict pattern and its origin were explained; emotional sensitivities and external tension were discussed.
3	Previous sessions were reviewed; previous content was summarized; the therapist provided feedback to couples; couples were encouraged to engage in the formulation of their problems; problematic areas were identified; the strengths of the spousal relationships were identified; the therapist provided his/her formulation and compared it with that of couples.
4	Previous sessions were reviewed, communication patterns were discussed; couples were asked to create a safe environment for each other to express their discomforts and frustrations; couples were trained in interventions to stop, limit, or redirect problematic patterns of communication; spouses were assigned tasks based on a mutual alliance.
5	Previous sessions were reviewed; couples were trained in talking about problems without blaming; couples were trained in emotion-based interventions (empathic connection and united neutrality); communication patterns leading to marriage failure were discussed; spouses were asked to engage in a situation of persistent conflict; problems of couples were reformulated case by case based on the main themes identified in the feedback session.
6	Previous sessions were reviewed; previous content was summarized; couples were encouraged to use acceptance-based techniques to somewhat distance themselves from their problems emotionally; couples were asked to reduce their sensitivity to negative behaviors because some negative behaviors might produce positive results.
7	Couples’ completed assignments were reviewed; couples were trained in interventions for increasing tolerance such as identifying negative behaviors and pretending to negative behaviors at home, and then the spouses’ feedback was analyzed; couples were asked to increase their tolerance through self-monitoring and listing self-care practices.
8	Previous sessions were reviewed; previous content was summarized; spousal needs were identified; couples were motivated to choose activities that would suit their needs; spouses were encouraged to respect each other’s independence and autonomy.
9	Previous sessions were reviewed, and couples were trained in change-based interventions such as practicing communication patterns and skills in the intervention sessions, identifying the behaviors that spouses could show to each other to improve relationship satisfaction, behavioral exchange, and recognition of positive behaviors in a retrospective manner.
10	Couples were trained in holding conversations without destructive methods, speaking and listening skills, constructive conversation for solving problems, problem diagnosis skills, and problem-solving skills.
11	Previous content was summarized and concluded; couples were provided with necessary support and assistance to cope with stressors; the intervention achievements and couples' decisions about the future were discussed; the follow-up session was planned and scheduled.

Data collection tool and technique

The measurement tools employed in this study were the Spanier Dyadic Adjustment Scale (DAS) and the Communication Patterns Questionnaire (CPQ). The DAS is a 32-item questionnaire developed by Spanier (1976) to measure the adjustment of couples or romantic partners. This scale consists of four subscales: dyadic cohesion, affection, dyadic satisfaction, and dyadic consensus. The overall score on this scale indicates the general satisfaction of spouses with a relationship. Higher scores denote higher marital adjustment. The overall score on this scale ranges between 0 and 151, and items 16, 17, 18, 19, 20, 21, 22, 23, 31, and 32 measure dyadic satisfaction, whereas items 24, 25, 26, 27, and 28 measure dyadic cohesion. In addition, items 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 13, 14, and 15 measure dyadic consensus, and items 4, 6, 29, and 30 measure affection. Based on Cronbach’s alpha, the internal consistency of the overall score on this scale was good, and the internal consistency rates of dyadic satisfaction (94%), dyadic cohesion (81%), dyadic consensus (90%), and affection (73%) were evaluated good to excellent. Molazadeh et al. (2002)[18] reported an internal consistency of 0.95 for this scale. Moreover, this scale has shown acceptable concurrent validity and is also correlated to the Lock–Wallace Marital Adjustment Scale (LWMAT). The reliability coefficient of this scale in Iran was reported to be 95%.[18]

The CPQ was developed by Christensen and Solari in 1984 to evaluate the spousal perception of communication patterns related to the problematic areas of relationships. This 35-item questionnaire measures the behavior of couples during the three stages of marital conflicts: 1. When a couple faces a communication problem; 2. When a couple discusses the communication problem; and 3. After discussing the communication problem. Spouses express their opinions about each behavior based on a 9-point Likert scale ranging from 1: Not possible at all – very unlikely to 9: very possible – very likely. The CPQ consists of three subscales: demand-withdraw, constructive communication, and mutual avoidance. Cronbach’s alpha for “constructive communication” is 0.78 in women and 0.80 in men, and the total score on this subscale is obtained from the sum of items 2, 6, and 8 subtracted by the sum of items 5, 7, 19, and 20. Cronbach’s alpha for “demand-withdraw” is 0.55 in women and 0.69 in men, and the total score on this subscale is obtained from the sum of items 3, 4, 9, 10, 11, and 12. Cronbach’s alpha for “mutual avoidance” is 0.66 in both women and men, and the total score on this subscale is obtained from the sum of items 1, 24, and 26. Ebadatpour (2000) measured the correlation between the subscales of the CPQ and the ENRICH Marital Satisfaction to estimate the CPQ validity in Iran. The correlation coefficient was reported as 0.58 for constructive communication”, -0.58 for “mutual avoidance”, and 0.35 for “demand-withdraw,” all of which were statistically significant at an alpha level of 0.01. The analysis of data from the Iranian sample demonstrated that CPQ was acceptably reliable (with a Cronbach’s alpha of 0.67). In addition, the convergent validity of this scale and its subscales was reported to range between 0.03 and 0.59.[4]

Participants in both groups filled out the abovementioned questionnaires one week before the first intervention session and one week after the last intervention session. However, those in the control group received no interventions until the end of the study. Finally, the one-way ANCOVA was employed for data analysis in SPSS 26.

Ethical considerations

The research was approved by the Committee of Ethics in Research in Royan Institute with the code (IR.ACECR.ROYAN.REC.1401.062) and registered with the Iranian Registry of Clinical Trials. The participants were informed that the intervention sought only research purposes and that their allocation to the test and control groups would be performed randomly. The written consent forms were obtained from participants before the study began, and they were assured that their personal information would be kept confidential. In addition, all participants were briefed on the research purposes and procedures before the consent forms were obtained from them for entering the study. Moreover, there was no compulsion to participate in this research. All participants were asked to provide the author with an informed consent form and were assured that the results would be published anonymously. Furthermore, after the positive effects of IBCT on the test group were proven. This intervention was also implemented in the control group to improve their communication patterns and marital adjustment.

Results

According to Table 2, the pretest and posttest mean marital adjustment scores were 91.2 and 37.105 in the test group, respectively. They were 90.36 and 86.89 in the control group, respectively. The marital adjustment consists of four subscales: dyadic cohesion, affection, dyadic satisfaction, and dyadic consensus, all showing an increase in the posttest. The mean score of the healthy communication pattern, i.e., constructive communication, increased in the test group, whereas the mean score of destructive communication patterns, i.e., mutual avoidance and demand-withdraw, reduced in this group. Such significant changes were not observed in the control group.

Table 2.

The pretest and posttest descriptive statistics of the research variables (n=30 in the test group and n=28 in the control group)

Groups	Variables	Median		Std. Deviation		Minimum		Maximum
		Pretest	Posttest	Pretest	Posttest	Pretest	Posttest	Pretest	Posttest
Test	DAS (Total)	91.20	105.37	12.46	17.30	60	71	109	130
	Dyadic Satisfaction	31	35.20	4.16	5.13	23	26	40	46
	Dyadic Cohesion	13.63	16.37	2.20	2.64	8	10	18	21
	Dyadic Consensus	39.73	45.13	8.53	10.05	21	25	51	61
	Affection	6.83	8.67	1.59	2.07	2	6	11	12
	Constructive Communication	-8.30	3.50	5.94	5.94	-19	-9	1	18
	Mutual Avoidance	17.87	13.53	4.74	4.27	8	6	27	24
	Demand-Withdraw	32.07	27.93	4.75	6.78	25	16	43	40
Control	DAS (Total)	90.36	86.89	12.98	13.72	62	55	109	102
	Dyadic Satisfaction	30.68	29.43	3.81	4.11	23	23	39	38
	Dyadic Cohesion	13.82	13.46	2.09	2.30	9	8	17	17
	Dyadic Consensus	39.21	37.89	9.14	8.90	21	20	50	50
	Affection	6.64	6.11	1.63	1.66	2	2	10	8
	Constructive Communication	-7.61	-8.04	5.87	5.18	-18	-18	2	2
	Mutual Avoidance	18.04	18.61	4.69	4.33	9	11	27	27
	Demand-Withdraw	32.86	33.86	5.52	4.75	26	28	42	43

After the assumptions of one-way ANCOVA were established, the research hypotheses were analyzed. The optimal goal of the first hypothesis was to improve the marital adjustment of couples in the test group. Considering the pretest statistical control, IBCT managed to significantly improve the marital adjustment of couples in the test group compared with those in the control group (P < 0.001). Since the effect size of this intervention was 0.398, it can be stated that IBCT was responsible for 0.398% of the variance in marital adjustment scores, [Table 3].

Table 3.

An overview of the one-way ANCOVA with the pretest statistical control (marital adjustment)

Source	SS	df	Ms	F	P	η2	OP
DAS (Total)	6883.652	1	6883.652	54.997	0.001	0.500	1.000
Grope	4552.200	1	4552.200	36.370	0.001	0.398	1.000
Error	6883.993	55	125.164

The subscales of marital adjustment were also interpreted to add to the accuracy of the results. “Dyadic satisfaction” significantly improved marital adjustment in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.394, this intervention was responsible for 0.394% of the variance in dyadic satisfaction scores. According to the results, the IBCT significantly improved dyadic cohesion in the test group compared with the control group (P < 0.001). Since the effect size of the IBCT was 0.47, this intervention was responsible for 0.47% of the variance in dyadic cohesion scores.

The IBCT significantly improved dyadic consensus in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.224, this intervention was responsible for 0.224% of the variance in dyadic consensus scores. However, this figure is smaller than 0.3; hence, this finding should be interpreted cautiously. Considering the pretest statistical control, the results indicated that the IBCT significantly improved “affection” in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.339, this intervention was responsible for 0.339% of the variance in “affection” scores. Considering the size of the effect of IBCT on each of the subscales of marital adjustment, the greatest effect of IBCT was observed on dyadic cohesion (0.470), affection (0.399), overall marital adjustment (0.398), dyadic satisfaction (0.394), and dyadic consensus (0.224), respectively, [Table 4].

Table 4.

An overview of one-way ANOVA with pretest statistical control (subscales of marital adjustment)

Source	SS	df	Ms	F	P	η2	OP
Dyadic Satisfaction	440.737	1	440.737	35.743	0.001	0.394	1.000
Dyadic Cohesion	135.745	1	135.745	48.679	0.001	0.470	1.000
Dyadic Consensus	675.149	1	675.149	15.833	0.001	0.224	0.974
Affection	84.966	1	84.966	36.563	0.001	0.399	1.000

Another objective of this study was to improve healthy communication patterns, e.g., constructive communication, and mitigate destructive communication patterns, i.e., mutual avoidance and demand-withdraw. Considering the pretest statistical control, the IBCT significantly increased “constructive communication” in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.525, this intervention was responsible for 0.525% of the variance in “constructive communication” scores. The results also showed that IBCT significantly reduced “mutual avoidance” in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.421, this intervention was responsible for 0.421% of the variance in “mutual avoidance” scores. In addition, the IBCT significantly reduced “demand-withdraw” in the test group compared with the control group (P < 0.001). Since the effect size of IBCT was 0.260, this intervention was responsible for 0.260% of the variance in “demand-withdraw” scores. However, this figure is smaller than 0.3; hence, this finding should be interpreted cautiously. Considering the size of the effect of IBCT on each of the communication patterns, IBCT increased “constructive communication” (0.525) and reduced “mutual avoidance” (0.421) and “demand-withdraw” (0.260), [Table 5].

Table 5.

An overview of one-way ANCOVA with pretest statistical control (communication patterns)

Source	SS	df	Ms	F	P	η2	OP
Constructive Communication	2053.144	1	2053.144	18.510	0.001	0.525	1.000
Mutual Avoidance	356.466	1	356.466	39.953	0.001	0.421	1.000
Demand-Withdraw	400.594	1	400.594	19.826	0.001	0.260	0.991

Discussion

Based on the study hypotheses, it can be concluded that the IBCT was effective in increasing marital adjustment, improving healthy communication patterns, and reducing destructive communication patterns. Although a few studies have analyzed the effects of IBCT on these variables, many studies have proven the general effectiveness of this intervention. In a semi-experimental study based on a pretest-posttest design with a control group, the communication beliefs of 30 maladjusted couples were analyzed. The results showed that the IBCT was effective in reducing the posttest scores of beliefs in terms of destructiveness, mind-reading expectation, belief in the immutability of a spouse, and sexual perfectionism. The findings generally suggested that this approach was beneficial in increasing the marital adjustment of couples.[19] Another study compared the effects of IBCT and re-decision therapy on early maladaptive schemas, marital commitment, and marital turmoil of conflicting couples. The results showed that the IBCT outperformed re-decision therapy in solving marital conflicts and improving marital commitment. In fact, the IBCT caused more lasting changes.[20] The results of another study demonstrated that IBCT helped couples modify their behavior by increasing a sense of security, support, and accessibility, responding to their spouse’s needs appropriately, committing safe behaviors, increasing intimacy, and learning correct and effective communication skills.[21]

A study compared the effects of narrative couple therapy and IBCT on the conflict solving tactics of 45 victims of violence. The results of the multivariate analysis of variance showed a significant difference between couples in the test and control groups in terms of conflict solving tactics. The results also confirmed the research hypotheses indicating the effectiveness of narrative couple therapy and IBCT in improving conflict solving tactics.[21] The findings of this study are theoretically consistent with the results of similar existing studies. Since the IBCT is a new approach that has not yet been widely applied by Iranian couple therapists, the study findings can be practically used for treating Iranian clients. Considering the growing prevalence of marital problems and the greater attention paid to integrative approaches by researchers, the IBCT can be adopted to solve a wider range of marital problems.

Limitations and suggestions for further studies

A major limitation of this study was related to the age range of participants. There was not enough time and opportunity to increase the sample size with older ages. In addition, the maximum duration of marriage was set to seven years. The problems of couples whose marriages lasted more than seven years required longer treatments, which could not be performed in this study due to time constraints. This study did not include a follow-up step to eliminate the effects of biased responses provided by participants. Therefore, it was not possible to measure the long-term effects of IBCT. Considering the limited size of the research sample, the findings should be cautiously generalized to other couples. The results can be freely generalized to couples who meet the inclusion criteria.

According to Christensen, the IBCT can also be applied to informal romantic partners and homosexual partners. Future studies are also recommended to analyze the effects of IBCT on such partners. Future studies are also recommended to perform this intervention on larger samples with a follow-up step after 2–6 months. Moreover, similar studies can be conducted on older couples with a longer duration of marriage. The effects of IBCT on other relevant variables are also recommended to be addressed in future studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.