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Ghahari S, Jamil L, Farrokhi N, Davoodi R. Comparing the Effects of Emotion-focused Couple Therapy and Acceptance and Commitment Therapy on Marital Conflict and Emotion Regulation. PCP 2021; 9 (2) :121-132
URL: http://jpcp.uswr.ac.ir/article-1-761-en.html
1- Department of Mental Health, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran.
2- Department of Clinical Psychology, AJA University of Medical Sciences, Tehran, Iran. , l.jamil@ajaums.ac.ir
3- Department of Clinical Psychology, School of Psychology, Roudehen Branch, Islamic Azad University, Roudehen, Iran.
4- Department of Clinical Psychology, School of Psychology, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran.
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1. Introduction
Communication, as a fundamental characteristic of all intimate relationships, makes the mismatch to be inevitable and extremely obvious. The issue of conflicts in married life is natural and profoundly prevalent in couples. Almost all couples who marry state a high level of marital satisfaction at the beginning; however, relationship satisfaction gradually diminishes (Kiecolt-Glaser, Bane, Glaser & Malarkey, 2003; Markman & Hahlweg, 1993; Markman, Rhoades, Stanley, Ragan & Whitton, 2010). Marital conflict and divorce are among the most stressful situations individuals encounter. Marital conflict can be described as the state of tension or stress between couples while they attempt to accomplish their marital roles (Tolorunleke, 2014). In other words, marital conflict is supposed as the interaction between spouses who have incompatible affairs, viewpoints, and opinions (Strong et al., 2011).
The impacts of marital conflict affect numerous familial aspects (Braithwaite, Delevi & Fincham, 2010). Moreover, research studies revealed that conflict and distress are critical risk factors for biopsychological problems. Partners in distressed relationships are more prone to experience anxiety, depression, suicidality, substance abuse, as well as acute and chronic medical conditions (Gurman, Lebow & Snyder, 2015; Hahlweg & Richter, 2010; Litzinger & Gordon, 2005; Miller, Hollist, Olsen & Law, 2013). Furthermore, studies on couples’ physical health indicated that marital conflict is usually accompanied by a more vulnerable immune system function in both spouses. Marital distress in couples presents direct adverse influences on cardiovascular, endocrine, nervous, sensory, and other physiological systems (Snyder, Castellani & Whisman, 2006). Additionally, marital destructive interaction results in decreased sexual satisfaction enhanced conflicts, and greater odds of divorce (Amato & Hohmann‐Marriott, 2007; Birditt, Brown, Orbuch & McIlvane, 2010; Birditt, Wan, Orbuch & Antonucci, 2017; Lindahl & Malik, 2011). 
Additionally, scholars determined that Emotion Regulation (ER) plays a critical role in interpersonal outcomes, such as couples’ relationship quality and conflict management (John & Gross, 2004; Qadar, 2016). Individuals employ various strategies to regulate their emotions. Accordingly, Cognitive Emotion Regulation Strategies (CERS) pertain to what individuals consciously consider to manage their emotions in response to evoking situations and adverse events (Balzarotti, Biassoni, Villani, Prunas & Velotti, 2016; Gross, 2001). CERS can be adaptive (e.g. positive reframing & reappraisal) or maladaptive (emotion suppression or rumination) (Aldao & Nolen-Hoeksema, 2012). For instance, reappraisal is associated with positive relationship consequences, like marital quality (Finkel, Slotter, Luchies, Walton & Gross, 2013); however, suppression is correlated with negative interpersonal behaviors (Vater & Schröder‐Abé, 2015). 
Generally, an effective ER can improve emotional harmony, foster interpersonal coherence, and result in higher marital satisfaction (Gottman, 2014; Levenson, Haase, Bloch, Holley & Seider, 2013). However, less effective ERSs are associated with aggravated harmful relationship conflicts (Curşeu, Boroş & Oerlemans,, 2012). Therefore, one vital developmental milestone is the capability to use strategies that regulate fractious emotions (McRae, 2016). Researchers proposed that partners’ ER problems were connected with hostile criticism (Klein, Renshaw & Curby, 2016), decreased relationship satisfaction (Bloch, Haase & Levenson, 2014), an elevated risk of relational violence (McNulty & Hellmuth, 2008), and high risks of cardiovascular conditions for both spouses through conflictual interactions (Ben-Naim, Hirschberger, Ein-Dor & Mikulincer, 2013). Couples who are unable to regulate negative emotions and focus on their anger and hatred subsequent stressful events experience fragile relationships (Herzberg, 2013). 
Consequently, there exist some general reasons why spouses seek or are referred for consulting. Such reasons usually include relational issues, such as emotional withdrawal and declined commitment, authority struggles, value and role conflicts, problem-solving and interactional challenges, extramarital relationships, sexual dissatisfaction, and violence (Geiss & Daniel O’Leary, 1981; Whisman, Dixon & Johnson, 1997). In general, spouses seek therapy due to perils to the safety and balance of their relationships with the most significant attachment figures of adult life (Gurman et al., 2015; Johnson & Denton, 2002). A helpful treatment approach is Emotion-Focused Couple Therapy (EFCT). EFCT is developed based on the attachment theory; it makes up an experiential focus on emotional experience with stress on how insecure emotional attachment can cause cyclical interactions (Johnson, Hunsley, Greenberg & Schindler, 1999). In this view, marital conflict is assumed as the negative loop of communication patterns. Such patterns arise from the pain and despair that emerge when the adult needs for attachment, being accepted and validated are failed to meet (Girard & Woolley, 2017; Greenberg & Goldman, 2007; Woldarsky Meneses, 2017)
EFCT intends to modify problematic loops. This is achieved by aiding partners to explore and display their underlying fundamental emotions that may provide new and corrective emotional experiences (Greenberg & Johnson, 1988). Specifically, EFCT recognizes the emotions; subsequently, it interprets them into understandable and adaptive messages and behaviors. Thus, failure to transfer the affective conditions may lead to conflicts in interpersonal relationships (Girard & Woolley, 2017; Greenman & Johnson, 2013). The effectiveness of EFCT was evaluated in prior studies such as Solymani Ahmadi, Zarei & Fallahchai (2014), Soleimani et al. (2015), and Rostami and associates (2014). The results of these studies indicated that ECFT significantly decreased marital conflict, and significantly enhanced satisfaction, cohesion, and affectional expression. EFCT impacted physical and emotional-sexual satisfaction among infertile couples. Despite numerous research concerning the effects of EFCT on Cognitive Emotion Regulation Strategies (CERS) in various populations, research on the effects of EFCT on CERS in couples with marital conflict remains scarce.
Acceptance and Commitment Therapy (ACT) is the other approach with extensive literature respecting its effects on marital conflict (Ahmadzadeh, Vaezi, Sodagar & Golmohammad Nazhad, 2019; Amani, Isanejad & Alipour, 2018; Arabnejad et al., 2014; Peterson, Eifert, Feingold & Davidson, 2009). According to ACT, marital conflict develops through each spouse’s inflexible and unpractical experiential avoidance strategies in the context of couple relationships, such as avoiding expressing emotional or physical intimacy due to the fear of rejection. These experiential avoidance strategies may process temporary relief; occasionally, these approaches may prevent undergoing unpleasant thoughts and emotions. However, they ultimately cause more distress, pain, and relational disturbance (Peterson et al., 2009). Therefore, the objective of ACT is to make the spouses mindful of their own and their partner’s cognitive and emotional responses/actions. ACT also modifies psychological inflexibility in individuals. Such a goal is achieved by applying 6 central processes, namely acceptance, projection, one-self as the field, relationship with the present time, clarifying values, and committed action (Hayes & Strosahl, 2013; Peterson et al., 2009). 
On account of ACT investigations, these processes enhance psychological flexibility. In turn, it increases the satisfaction and quality of the marital life, also decreases marital conflicts with a constant impact (Arabnejad et al., 2014; Khanjani Veshki, Shafiabady, Farzad & Fatehizade, 2016). The effects of ACT were evaluated in studies, such as Khanjani Veshki et al. (2016), Kavousian, Haniffi & Karimi (2017), as well as Khanei, Jazayeri, Bahrami, Montazeri & Etemadi (2018). These studies revealed that ACT significantly decreased marital conflict and enhanced marital satisfaction. However, research respecting the effects of ACT on CERS in couples with marital conflict remains scarce.
Generally, no experimental evidence exists for evaluating the effects of EFCT and ACT on CERS in couples with marital conflict. Despite the relatively extensive research on the effects of couple therapies, scholars overlooked comparing the effects of EFCT and ACT on marital conflict and CERS in couples. Therefore, the main purpose of the present study was to compare the effects of EFCT and ACT on marital conflict and CERS. Studies highlighted that men and women played different roles in the relationship. Accordingly, women tend to attack more often than men; however, men tend to compromise more frequently. Furthermore, women are more prone to engage in conflicts and tend to evaluate relationships more critically than men. Besides, women may seek to modify marital interaction more actively and recurrently; as a result, they seek treatment for conflict resolution with a more probability than men (Delatorre & Wagner, 2018). Accordingly, this study aimed to only recruit women. Finally, the current study hypothesized that the effectiveness of EFCT is more than that of ACT on marital conflict and CERS.
2. Materials and Methods
This was a randomized controlled trial with two treatment groups (ACT & EFCT). In total, 30 married women participated in this study; however, only 28 subjects completed the treatment process (the samples dropped out in the first & second sessions). The necessary sample was selected among all married women with marital conflict referring to the Clinic of Tehran Psychiatric Institute for Couple Therapy. The study samples were selected by the convenience sampling method. Furthermore, the inclusion criteria of the study were the age range of 20-50 years, a minimum diploma certificate, as well as having marital conflict and problems. The exclusion criteria were participating in any concurrent psychological treatment, substance abuse problems, a diagnosis of personality disorders, and absence from >2 treatment sessions.
The relevant ethical approval was acquired from the Ethics Committee for Research at Mazandaran University of Medical Sciences (code: IR.MAZUMS.REC.1396.2695). After recruiting the study samples, an evaluation session was held to assess the inclusion and exclusion criteria, i.e., performed by the corresponding author. For this purpose, the absence of personality disorders was checked using the Second Edition of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM) (SCID-II) interview; the absence of substance abuse problems was assessed by probing drug use/abuse history. Eventually, the required explanations were provided to the study subjects about the process of treatment. Consequently, they voluntarily provided the informed consent form to participate in this research.
Next, the study participants were randomly assigned to the ACT and EFCT groups. All study participants completed the research questionnaires before the treatment (pretest). Additionally, at the end of the intervention phase, they were invited to re-complete the questionnaires (posttest). The EFCT was conducted based on the instructions of Johnson et al. (1999) and performed by the first author. Moreover, ACT was designed according to the instructions of Peterson et al. (2009) and performed by the third author. ACT and EFCT were performed in eight 90-min face-to-face individual sessions. 
The questionnaire battery included demographic characteristics form (age & academic level), the Marital Conflict Questionnaire, the Cognitive Emotion Regulation Questionnaire, and the SCID-II.

Marital Conflict Questionnaire (MCQ)
MCQ is a 42-item scale assessing marital conflict in couples, designed by Barati and Sanai, in 1996. This tool has 7 subscales, including reduced cooperation; reduced sexual intercourse; increased emotional reactions; child support; personal relationships with relatives; reduced family relationships with the spouse’s relatives, and separating finances. Each item is rated on a scale of 1 to 5. This questionnaire categorizes couples’ conflict at 4 levels, as follows: non-conflict (ranged from 42 to 74), normal conflict (ranged from 75 to 114), conflict higher than normal (ranged from 115 to134) and escalated conflict (ranged from135 to 210). The designers of the questionnaire reported good reliability of MCQ using Cronbach’s alpha coefficient (0.73).

Cognitive Emotion Regulation Questionnaire- Short
The CERQ-S was developed in 1999 to assess the particular CERS that individuals apply in response to threatening or stressful life events. It has 18 items and 9 subscales, consisting of self-blame; other-blame; rumination; catastrophizing; putting into perspective; positive refocusing; positive reappraisal; acceptance, and planning. Each item is rated on a scale of 1(never) to 5(always). A higher score indicates greater use of CER. The psychometric properties of the CERQ have been signified to be good, with Cronbach’s alpha coefficients over 0.70 in most studies (Garnefski, Baan & Kraaij, 2005; Garnefski & Kraaij, 2006). The reliability of the Persian version of the CERQ-S was found as 0.76-0.92 using Cronbach’s alpha coefficient approach (Hasani, 2011).

Structured Clinical Interview for DSM-IV Disorders-2 (SCID-II)
SCID-II is a semi-structured interview, used to diagnose common axis II disorders according to the DSM-IV criteria. SCID-II contains 10 personality disorder criteria. The inter-rater reliability coefficients of this tool ranged from 0.48 to 0.98 for categorical diagnosis, as well as from 0.90 to 0.98 for the intraclass correlation coefficient. The internal consistency coefficients of SCID-II were adequate, from 0.71 to 0.94 (Maffei et al., 1997). The content validity of the Persian version of SCID-II was confirmed. Besides, the reliability coefficient of this test was obtained using the test-retest method within one week, i.e., 0.87.
All analyses were conducted using SPSS. First, descriptive statistics were used for the subjects’ demographic data. For evaluating the normal distribution of the data, Kolmogorov Smirnov was performed. The Independent Samples t-test was conducted to compare the differences between the study groups. Furthermore, the Paired Samples t-test was calculated for assessing the difference between the pretest and posttest data. Moreover, the effect size of each sample was estimated. The significance level was set at P<0.05 for all statistics.

3. Results
The collected demographic characteristics demonstrated that most of the subjects in the EFCT group aged 26-30 years, i.e., approximately 28.6%. Moreover, most of the ACT group’s sample aged 31-35 years, i.e., about 17.9%. Most of the ACT and EFCT groups subjects’ educational level was BA and diploma and BA, respectively (Table 1).

As per Table 2, the obtained data were normally distributed in all study variables; thus, the Independent Samples t-test was performed. 

The Independent Samples t-test data indicated no difference in the pretest scores of the study subjects. Besides, significant differences were detected between the study groups in the posttest scores (Table 3).

According to Table 4, significant differences were found between pretest and posttest data of the intervention groups.

In other words, the relevant results demonstrated that both provided couple therapies were effective in improving marital conflict and CERS among the research sample. Regarding Cohen’s d, the effects of both interventions were clinically significant on marital conflict and CERS in the study participants. Moreover, based on Cohen’s d and r rates, EFCT was clinically more effective than ACT on marital conflict and CERS in the study subjects. 

4. Discussion
The present study compared the effects of EFCT and ACT on CERS and marital conflict in females. The obtained results supported the effectiveness of EFCT and ACT on the marital conflict in the study subjects. The collected findings were consistent with those of Shamsipour, Norouzi Kouhdasht, Mohammadi, Azari & Norouzi (2018), Havaasi, Zahra Kaar & Mohsen Zadeh (2018), Naghdi Hatami, Kayamanesh & Navobinejad (2017), Beasley & Ager (2019), Najafi, Soleimani, Ahmadi, Javidi & Hoseini Kamkar (2015), Solymani Ahmadi et al. (2014), Priest (2013), Khanjani Veshki et al. (2016), Amani et al. (2018), as well as Farahanifar, Heidari, Davodi & Aleyasin (2019).
Furthermore, the present research results revealed that EFCT was more effective than ACT on marital conflict; these data may be explained based on some assumptions of EFCT regarding the origins of couples’ conflicts. Marital conflict and relationship distress are viewed as emerging from spouses being unable to fulfill each other’s needs. Besides, EFCT helps spouses to become informed of their needs, express them, and become sensitive and responsive to their spouses’ needs (Vanhee, Lemmens, Moors, Hinnekens & Verhofstadt, 2018). Furthermore, the need for attachment is central in the understanding of couple distress; insecure attachment to the spouse has been generally correlated with relationship dysfunctioning, including decreased relationship satisfaction, commitment, and intimacy, as well as aggravated conflicts and less stable relationships (Kirkpatrick & Davis, 1994; Mikulincer & Shaver, 2010; Treboux, Crowell & Waters, 2004). Consequently, EFCT assists couples to develop a secure attachment bond by expressing the vulnerabilities, i.e., soothed in an emotionally harmonized manner and forming mutual emotional approachability and responsiveness (Wiebe & Johnson, 2016). However, from ACT’s perspective, distress and conflicts in couples originate from each partner’s inflexible and impracticable experiential avoidance strategies. Additionally, there exists fusion with thoughts and feelings about the actions or lack of actions in the relationship. Furthermore, accepting such thoughts as real and acting on them preserves spouses’ negative relationship loops. Therefore, ACT attempts to minimize such thinking processes; thus, it decreases pain in couples induced by each partner’s experiential avoidances. ACT helps spouses become mindful of their cognitive and emotional responses within the relationship. Moreover, it facilitates purifying the values of couples in their relationship and supports harmoniously acting with these values (Peterson et al., 2009). Substantially, EFCT helps couples to recognize, experience, and communicate clear and poignant emotional necessities. These profound emotional experiences commonly unfold vulnerable rather than aggressive emotions that lead to a need for connection with the spouse. In this case, when couples are emotionally involved with each other, conflict can mitigate; consequently, new patterns of interaction can develop, which may explain the effectiveness of EFCT, compared to ACT (Fauchier & Margolin, 2004). This result is in line with Akhavan Bitaghsir et al.’s study which indicates EFCT is more effective than ACT on marital adjustment and marital satisfaction (Akhavan Bitaghsir, Sanaee Zaker, Navabinejad & Farzad, 2017).
The obtained results corroborated the effectiveness of EFCT and ACT on CERSs; however, there no study examined the effect of ACT and EFCT on CERSs in couples. However, few studies generally measured the effectiveness of ACT and EFCT on CERSs; the present study findings were consistent with those of previous research, such as Karaminezhad, Sodani & Mehrabizadeh Honarmand (2017), Binandeh, Seraj Khorami, Asgari, Feizi & Tahani (2020), Sheibani, Aerab Sheibani, Nezhad Amreei & Javedani Masrour (2019), as well as Hamid, Boolaghi & Kiani Moghadam (2018)
Additionally, the obtained results presented that EFCT was more effective than ACT on CERS in the explored subjects. Accordingly, the purpose of CERS is to change one’s attention to or one’s appraisals of a condition to alter an emotion’s duration, severity, or both (Ochsner & Gross, 2005). Moreover, in EFCT, couples’ emotional processing was conducted to raise 3 main processes, as follows: retrieving and improving underdeveloped emotional responses, i.e., arrested in an earlier period and did not grow or mature; the application of the inborn adaptive potential in emotion by relating it to cognition; and the regulation of emotions when they suppress meaning creation and can no longer be linked to cognition. In other words, 3 processes were focused on the EFCT approach, including emotion development, emotion utilization, and emotion regulation (Greenberg & Goldman, 2019). In EFCT, earlier denied emotions, when aroused in therapy, can be applied to retrieve undesired self-experience that supplies the individual information about needs satisfied or not satisfied and gives information about one’s response to conditions as well as action tendencies to cope with them. Activating new emotions in therapy may support reform archaic emotional responses and change previously denied feelings from the past. Activating such denied feelings in the session makes them responsive to development. This is achieved by fusing new experiences to the past situation, produced in the present. This novel experience aids in modifying couples’ memory-based problematic emotional states applying a process of memory reconsolidation (Lane, Ryan, Nadel & Greenberg, 2015). Consequently, this helps subjects adjust their interactions with their surroundings and may be a reason for the effectiveness of EFCT, compared to ACT (Greenberg & Goldman, 2019). 

5. Conclusion
Based on the present study findings, EFCT and ACT reduced marital conflict and enhanced CERS in the explored married women. Moreover, the obtained results signified that EFCT was more effective than ACT in improving marital conflict and CERS in the study subjects. Applying EFCT, as the main and first-choice treatment, can help improve marital conflict and CERS in this population.
This study had some limitations. First, the sample was inadequately diverse; thus, it may hamper the generalizability of the findings. Furthermore, the study subjects were restricted to women referring to Tehran’s clinics. Future research in this domain may wish to replicate in the other clinics of Tehran or even other cities with more diverse populations and considering both couples. Another study limitation was the inadequacy of control on intruding variables, such as socioeconomic status and income level of the study sample. Future studies are suggested to consider these intruding variables.

Ethical Considerations
Compliance with ethical guidelines

The relevant ethical approval was acquired from the Ethics Committee for Research at Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1396.2695).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization and Supervision: Shahrbanoo Ghahari and Leili Jamil; Methodology: Shahrbanoo Ghahari; Investigation, Writing – original draft, and Writing – review & editing: All authors; Data collection: Shahrbanoo Ghahari, Leili Jamil, and Nazanin Farrokhi; Data analysis: Shahrbanoo Ghahari and Reza Davoodi.

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors would like to thank the management and staff of Tehran Psychiatric Institute for their contribution to this research. This work would not have been possible without their support.


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Type of Study: Research | Subject: Family and group therapy
Received: 2020/10/12 | Accepted: 2021/01/25 | Published: 2021/04/1

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