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Effectiveness of Group Therapy with Cognitive-Behavioral Approach on Negative Feelings of the Women Toward Their Husband’s Family and the Marital Conflicts

Background: Marital life is based on effective reciprocal relations such as quality of communications with the spouse’s family. Objectives: The present study aimed to investigate the effectiveness of cognitive-behavioral group therapy on negative feelings of the women toward their husband’s family and marital conflicts. Methods: This is a quasi-experimental study with a pretest-posttest design and follow-up with a control group. The statistical population included all women referring to Rahgosha Consultation Center in the town of Tiran (due to marital conflicts) in 2018. Thirty samples were selected using a convenient sampling technique. Then, the samples were randomly divided into two groups of experimental (15 women) and control (15 women). Women’s negative feelings toward the husband's family and marital conflicts questionnaires were used to collect data. The experimental group received eighth ninety-minute sessions of cognitive-behavioral group therapy. Finally, a posttest was performed for both groups. Moreover, the follow-up stage was administered a month after the posttest on both groups. Mean and standard deviation were used to analyze the data at descriptive statistics, and MANCOVA was used at the inferential statistics level through SPSS21 software. Results: Cognitive-behavioral group therapy could effectively decrease both the women’s negative feelings toward their husband’s family and marital conflicts (P < 0.05). Conclusions: This study demonstrated that cognitive-behavioral group therapy can be applied to decrease negative feelings toward the husband’s family and to address marital conflicts.


Background
Social life is based on communication with others. Lack of familiarity with correct communication methods may bring irrevocable consequences to the family and its members (1). Family members have simultaneous reciprocal effects on each other in the way that everyone's behavior causes unique cognitions, emotions, and behaviors in the other family members, and it, per se, leads to unique cognitions, emotions, and behaviors against that member (2).
In the same vein, the speech and behavior or specific expectations the person had had from the husband's family, while they have not been met, cause creating negative feelings in her, which in turn influences her feelings toward the husband and his family (1). Negative feelings manifest in different ways: they might appear through special behaviors such as shouting in anger or attempting to change the situation like commanding while clamoring or otherwise trying to suppress or deny feelings, which can bring about tension in the spirit and the body (3).
Increased negative feelings toward the husband's family can result in withdrawal and even breaking off with the husband's family. He, who is under the parent's and relative's pressure, transfers this pressure to his wife, which causes tension and conflict in the family. This breaking off may cause outcomes such as increased tension and conflict between the spouses as well as other negative emotions (4). Nowadays, many couples are faced with marital conflicts (5), and such events have harmful effects on both the person and the family's physical and mental health Copyright © 2020, Jundishapur Journal of Health Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. (6). Marital conflicts are the result of the couple's inconsistency in the type of the needs and the method of meeting them, egocentrism, the difference in the wills, behavioral plans, and irresponsible behaviors toward marital communication and marriage (7). Family conflicts can significantly decrease trust, friendliness, cooperation, and intimacy (8). One of the effective methods to address such problems might be cognitive-behavioral therapy. This approach is based on two fundamental principles: first, cognition schemata contain the controlling effect on the emotion and behavior; and second, the manner of behavior has a strong effect on the thought and emotion models; hence, cognition and behavior are equally taken into account (1). Cognitive-behavioral family therapists believe that negative thoughts lead to inefficient conflicts; In other words, according to this theory, family members can equally influence each other. That is, the behavior of a family member can arouse feelings and emotions in other members (1). According to this approach, issues that can disturb the communications between couples and the husband's family is their incorrect cognitions toward each other, which brings negative emotions in the individual. The more the couple's and family's mindset is negative toward each other, the stronger will be their negative feelings and as a result, the more unpleasant their attitude and the worse their communication will get toward each other (1). A meta-analysis study of effective factors on divorce from 2008 to 2018 by Niazi et al. (9), reported that numerous studies mentioned negative interactions with the husband's family as a factor of high importance in marital conflicts and the family breakdown. The study by Dattilio and Epstein (10) showed that cognitive-behavioral interventions have positive significant positive effects on preventing divorce and increasing communication quality.
Abbasi et al. (11) revealed that cognitive-behavioral therapy could effectively increase the marital satisfaction of the veteran's wives and their family integration. Furthermore, Azimifar et al. (12) reported that cognitivebehavioral therapy was effective in increasing dissatisfied couples' marital satisfaction. So taking the importance of negative feelings toward the husband and its undesirable outcomes, the present study aimed to investigate the following hypotheses: A) Cognitive-behavioral group therapy is effective in decreasing the women's negative feelings toward their husband's family. B) Cognitive-behavioral group therapy is effective in decreasing marital conflicts.

Objectives
The current study aimed to investigate the effectiveness of group therapy with cognitive-behavioral approach on the women's negative feelings toward their husband's family and marital conflicts.

Methods
This is a quasi-experimental study with a pretestposttest design and follow-up with a control group.

Participants
The statistical population included all women referring to Rahgosha Consultation Center in the city of Tiran during 2018. Thirty people were selected using a convenient sampling technique and then were randomly divided into two groups of experimental and control (each with 15 subjects). The inclusion criteria were history of mental health problems, contact with the husband's parents, being aged from 28 to 40 years old, and not participating in other psychiatric and psychological programs. The exclusion criteria were not participating in more than 3 sessions, not filling the tasks, and unwillingness to continue the study.

Data Collection
In the present study, data were collected using two questionnaires. The questionnaire of negative feelings (Simin Ghasemi et al. (13)), which intends to assess the degree of negative feelings and emotion toward the husband, contains 25 items scored on a Likert scale. Its reliability is evaluated using the Cronbach alpha (0.96), which implies a high internal consistency. Also, its content validity was evaluated by obtaining the opinions of five professors in the field of family consultation.
The questionnaire of marital conflicts is designed to assess marital conflicts according to the clinical experiences by Sanaie (14). This questionnaire includes 54 items scored on a five-point Likert. Higher scores indicate more severe conflicts, and lower scores indicate better communications. In order to determine its validity on the parents of mentally retarded children, the questionnaire was confirmed by the experts. Its reliability is assessed using the Cronbach alpha coefficient (0.81), which shows desirable reliability.

Intervention
After evaluating the potential participants against inclusion criteria through face-to-face interviews, 30 subjects were selected. Then, they were randomly divided into two groups of experimental (15 individuals) and control groups (15 individuals). Afterward, the pretest was administered. The intervention group received eighth 90minute sessions of group therapy in a way that half of the time in each session was spent on training skills and the rest for practical exercises. At the end of therapy sessions, the posttest was implemented. Then, after one month, the follow-up stage was administered for both groups. The content of group therapy sessions was specified after reviewing different resources in the field of cognitivebehavioral therapy (e.g. Hawton et al. (15)). The description of cognitive-behavioral therapy sessions is provided in Table 1.

Results
The data were analyzed using mean and standard deviation at descriptive statistics level and using MANCOVA method at inferential statistics level via SPSS21 software. The summary of descriptive findings, separated by the group, is provided in Table 2.
As shown in Table 2, the mean score of negative feelings toward the spouse's family and marital conflicts has decreased in the experimental group in the posttest and follow-up investigations, while such reduction did not happen for other variables. MANCOVA method was used at the inferential statistics level to analyze the data and to control the effect of the pretest. The following assumptions should be observed in this type of analysis to get ensured about the results: investigating the consistency of variance-covariance using the Box's test (Box's M = 13.29, F = 1.44, and P = 0.09 were calculated for the posttest scores). The significant degree of Box's test was more than 0.05, so it can be concluded that the variance-covariance matrix is equal. The Shapiro-Wilk test for Multivariate Normality was applied to test for a normal distribution (Mvw = 12.39, P = 0.52), which indicated the normality of data. Leven's test was used to investigate the equality of variances of both groups at the posttest stage. The test statistic was insignificant for the variable of negative feelings (F = 2.15, P = 0.18) and marital conflicts (F = 4.21, P = 0.08), which confirms the above assumption. Bartlett's test was used to evaluate the assumption regarding the association between research variables. The results showed a significant correlation between dependent variables (P = 0.001, chi-square = 56.87). Considering the presence of the MANCOVA assumption, the statistical test could be used.
The related multivariate statistic, i.e., Wilk's lambda, was significant (Wilk's lambda = 0.24, F = 87.72, P = 0.001) at the confidence level of 95% (α = 0.05). So, after adjusting the differences of two covariate variables, the linear combination of the two variables of negative feelings and marital conflicts was influenced by the independent variable. Therefore, it can be concluded that the MANCOVA is generally significant; in other words, according to the results, the training method could effectively influence the linear combination of dependent variables.
Considering the fact that the above-mentioned multivariate test was significant and the linear combination of the dependent variable was influenced by the independent variable, the study was followed by investigating the following question: "Has each of the dependent variables been influenced by the independent variable or not?". Univariate analysis of covariance was used to compare the posttest mean scores of the variables of negative feelings and marital conflicts after controlling the effect of pretest in two groups. The results are provided in Table 3. Table 3, there is a significant difference between posttest mean scores of negative feelings after removing the effect of pretest (η 2 = 0.66, P = 0.001, F = 141.88); in other words, there is a significant difference between two experimental and control groups concerning the variable of negative feelings at the posttest stage. Hence, the first hypothesis of the study was confirmed; That is, cognitive-behavioral group therapy could decrease women's negative feelings toward the husband's family.

According to
Moreover, there was a significant difference between the posttest scores of marital conflicts after removing the effect of the pretest (η 2 = 0.54, P = 0.001, F = 127.25); in other words, it can be argued that there is a significant difference between experimental and control groups concerning marital conflicts at the posttest stage. So, the second hypothesis was also confirmed; that is, the cognitivebehavioral group therapy could decrease marital conflicts.
The study is followed by describing the scores of the follow-up stage to investigate the stability of the effect of the independent variable on the experimental group. Besides, the repeated measurement test was used to compare three measurement stages. Before using the repeated measurement test, observing the assumption of equality between all combinations related to the groups is a prerequisite. In this line, Mauchly's sphericity test was used to investigate this issue. The results showed that the assumption of covariance similarity among observations is significant Table 1

First session
Familiarization with the leader and other members of the group, describing the general structure of the sessions, and investigating the members' expectations from group therapy plan

Second session
Familiarization with the field of consciousness and increasing the members' ability in the field of consciousness to find more knowledge about the characteristics, needs, wills, purposes, merits and demerits, feelings, values, and identity of the self.

Third session
Familiarization with the ration of creating negative mood, cognitive mistakes and distortions, automatic thoughts and their nature, and empowering the members in coping with negative mood

Forth session
Familiarization of the members with the concepts of attribution and investigating the reasons of many misunderstandings and training how to change attribution.

Fifth session
Familiarization with the stepwise problem-solving with other members

Sixth session
Describing various communicative models and familiarity with effective communication skill, and training effective methods of settling the disputes

Seventh session
Familiarization with courageous behavior and roleplaying role in training courageous behaviors

Eighth session
Stating theoretical bases of rage and familiarization with the skill of coping with rage, session sum up (W = 0.68, P = 0.001, chi-square = 20.42), so this assumption is violated. Therefore, the Epsilon Green House Gazer index was used to modify the identified problem in testing the significance of within-subject effects. The results of the repeated measurement test showed a significant difference between different measurement stages (F = 212.96, P = 0.001, η 2 = 0.52) at the error level of 0.05. Since the results of the repeated measurement analysis test were significant, the couples' difference was investigated between the stages using the Bonferroni follow-up test. The results of couples' comparison between stages are provided in Ta-ble 4.
As can be observed in Table 4, there is a significant difference between the mean score of negative feelings at pretest and posttest stages and the difference between the posttest and follow-up scores at the error level of 0.05 was not significant. Furthermore, concerning marital conflicts, there was a significant difference between pretest and posttest stages. However, there was no significant difference between the posttest and follow-up stages. As a result, we can argue that the independent variable had a stable effect on both negative feelings and marital conflicts.

Discussion
The present study investigated the effect of behavioralcognitive group therapy on the women's negative feelings toward their husband's family and marital conflicts. According to the findings, cognitive-behavioral group therapy could effectively decrease negative feelings. Therefore, the first hypothesis of the study was confirmed. The findings of the present study are consistent with the results reported by Ghasemi,et al. (13), Cappeliez (16), Kush and Fleming (17), Lesure-Lester (18), Stith et al. (19), and Ranjbar et al. (20). Moreover, the results of the present study confirmed the second hypothesis of the study, i.e., cognitivebehavioral group therapy can effectively decrease marital conflicts. The results of this study are in line with studies conducted by Mirzania et al.  (24), and Hogberg and Hallstrom (25). Besides, the follow-up stage was administered to investigate the stability of the effect of cognitive-behavioral group therapy. Since the scores were measured in three stages, we did not use the repeated mea- surement method. After confirming the presence of a general difference between the three stages, the difference between scores of couples was investigated using the Bonferroni follow-up test. The results showed a significant difference between pretest and posttest stages concerning both dependent variables, but there was no significant difference between the scores of the posttest and follow-up stages. Therefore, it can be concluded that the effect was stable.
Cognitive-behavioral family therapy using cognitivebehavioral therapy techniques aims to train cognitive skills, problem-solving skills, solving the conflict, and methods of making effective communication, which finally leads to decreased levels of the women's negative feelings toward the husband's family as well as marital conflicts. Cognitive training can modify preconceptions and incorrect attributions of husbands and wives from each other's behavior and cause removing misapprehension, decreasing irritation and rage, and attending to positive aspects of each other's behavior.

Conclusions
Based on the findings and considering that disturbed interaction with the husband's family is a major contributor to marital conflicts, which roots in incorrect cogni-tions, negative feelings toward the husband's family can be modified by the cognitive-behavioral approach to help those couples who face such problems. Hence, couples can enjoy many advantages of appropriate communication with the husband, such as: maintaining and promoting mental hygiene and physical health, peace of mind, employing the elder's experience, using the relatives' intellectual support, social growth, and power. The current study had limitations, including only available investigating cases and its small sample size. The authors recommend performing more extensive research to investigate the couple's negative interactions with their husband's family and factors that contribute to the couple's life quality, as well as underlying reasons, and factors, and the techniques to cope with them.