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Research Paper: The Effectiveness of a Unified Protocol for the Family Therapy on Emotional Divorce and Marital Boredom in Women with Marital Conflict

Article info: Received: 25 Jun 2020 Accepted: 10 Nov 2020 Available Online: 01 Jan 2021


Introduction
arital conflict results from a reaction to individual differences. It becomes abnormal and excessive when the feelings of anger, hostility, resentment, hatred, jealousy, and verbal and physical abuse prevail in the couple's relationship and take on a destructive state (Tam & Lim, 2008). About 61% of divorced people have reported excessive conflict as one of the reasons for their divorce (Troupe, 2008).
If the conflict is managed effectively, it prevents cold and stagnated relationships and creates positive and effective skills in line with stressful events in the couple. In contrast, if the conflict is poorly managed, it destroys marital life and has detrimental effects on the couple's physical and emotional health (Dunham, 2008).
One of the factors associated with marital conflict is emotional divorce. Divorce does not happen all at once; instead, it is formed gradually through a couple of stages. Emotional divorce is the first step in the divorce process and indicates a declining marital relationship replaced by feelings of alienation (Khodabakhshi-Koolaee, Falsafinejad, & Sabourei, 2019). Emotional divorce involves a lack of trust, respect, and love in the couple. Instead of supporting each other, spouses act to harass, frustrate, and lower each other's self-esteem, and each seeks to find a reason to prove the other's fault, inadequacies, and rejection (Laur & Laur, 2007). Some marriages that do not end in divorce turn into hollow marriages, lacking love, companionship, and intimacy and spouses move on with only the flow of family life and waste their time (Gottman, 2008). The frequency of emotions such as anxiety, discomfort, and anger can decline the couple's satisfaction resulting in marital conflict. Some people interpret emotions as disturbing feelings and respond to them in an aggressive or avoidant manner (Driver & Gottman, 2004;Gottman, 2008).
Another factor associated with marital conflict is marital boredom which refers to a set of emotional, physical, and psychological symptoms resulting in significant consequences for marital life (Kally, 2010). Marital boredom occurs when a couple finds that their relationship cannot meet their basic needs. Thus the two parties suffer from a series of painful states of fatigue, monotony, depression, and frustration in married life (Pines & Nunes, 2003). As a result, negative emotions dominate, leading to a loss of initial enthusiasm, emotional attachment, commitment, and ultimately marital boredom (Hockey, 2011). Boehler et al. defined boredom as a state of physical, emotional, and mental fatigue that results from prolonged conflict along with emotional demands. Levels of family emotional expression were defined as the main pattern of verbal and non-verbal expression of feelings within the family as a whole that affects marital relationships. In particular, the quality of marital relationships is consistently related to emotional expression in the family (Froyen, Skibbe, Bowles, Blow, & Gerde, 2013).
Studies have shown that emotions affect attention, decision-making, memory, physiological responses, and social interactions at all times. Even a wide range of interpersonal and intrapersonal processes are affected by emotions. One of the interpersonal factors influencing marital boredom is the way emotions are expressed. Emotional expression as one of the main components of emotion refers to the external display of emotions, re-gardless of their values (positive or negative) or manifestation (face, verbal, physical, or behavioral) (Khodabakhshi Koolaee & Adibrad, 2010).
McMaster model of family functioning utilizes a systemic approach to describe the structure, organization, and transactional patterns of the family unit. The basic principles of this model are the relationship between components of the family with each other, the comprehensibility of a component depending on other family components, the important role of family structure and transactional patterns in determining and shaping the behavior of family members, and the fact that family functioning is nothing more than the function of the sum of its components. The six fundamental dimensions of family functioning according to the McMaster model are problem-solving, communication, roles, affective responsiveness, affective involvement, and behavioral control (Epestein, Baldwin, & Bishop, 1983;Archambault, Mansfield, Evans, & Keitner, 2014). Teaching the family model (McMaster) has increased marital intimacy, and its effect is stable over time. A review of research evidence indicates that among the effective factors in the occurrence of marital boredom, the degree of marital intimacy in the relationship between the husband and wife and the general health of the individual play a decisive role (Epstein, Ryan, Bishop, Miller, & Keitner, 2003). Intimacy is the main motivation for forming a marital relationship and includes a degree of closeness and care that each couple feels and expresses towards each other (Friedman, 2000). Couples who experience a higher degree of intimacy, apart from their socioeconomic status, report significantly fewer boredom symptoms in their relationship (Olson, Larson, & Olson-Sigg, 2009).
Another model that can affect marital boredom and reduce marital conflict is the compassion-focused therapy model. Neff has defined self-compassion as a threecomponent construct that includes self-kindness vs selfjudgment, common humanity vs isolation, and mindfulness vs over-identification. Compassion-focused therapy is derived from the evolutionary approach, neuroscience, and social psychology and is related to neuropsychology and physiology, caring, and being cared for. Extensive studies have shown the effectiveness of compassionbased therapy techniques in increasing well-being and reducing patterns of self-criticism and shame (Gilbert, 2009;Khodabakhshi-Koolaee et al., 2019). Self-compassion involves promoting a relationship mixed with kindness, acceptance, and self-security, especially during challenging and difficult times (Gilbert, 2009;Neff & Dahm, 2015). In their study, Neff and Beretvas (2013) found that spouses' satisfaction was significantly related to self-compassion. Accordingly, people with high self-compassion show more positive behavior and high self-compassion is associated with increased well-being, including feeling worthy, being happy, and expressing oneself (Neff & Beretvas, 2013;Neff & Pommier, 2013). Self-compassionate people feel better about themselves and therefore experience greater satisfaction in their interpersonal relationships (Neff, 2011). Neff (2003) has stated that people with a low self-compassion focus on their negative emotions, leading to more aggressive behaviors toward their spouse. Self-compassion can be considered as an emotion regulation strategy that does not prevent the experience of unpleasant disturbing emotions. Instead, it seeks to accept feelings kindly. Thus, negative emotions change into positive ones, and the person finds new ways to deal with them (Neff, 2011). The third model is mindfulness-based therapy.
Mindfulness means being in the present and living in the here-and-now, and as a result, the mind is aware of what is going on (Hayes & Wilson, 2003). Mindfulness has five distinct aspects: acting with awareness, non-judging inner experience, non-reactivity to inner experience, describing experiences with words, and observing/noticing internal/ external experiences (Baer, Smith, & Allen, 2004).
Mindfulness is generally described as the deliberate focus of an individual's attention on the event experienced in the present moment in a non-judgmental manner (Kabat-Zinn & Kabat-Zinn,1997). Burpee and Langer (2005) reported a strong positive relationship between marital satisfaction and mindfulness. In their longitudinal study, Barnes, Brown, Krusemark, Campbell, and Rogge (2007) found that mindfulness was associated with high levels of relationship satisfaction, love, and commitment and low levels of emotional responses, interpersonal conflict, and hostility during dispute and anger. One of the beneficial effects of mindfulness is the reduction in automatic response (Smith, 2015). Mindfulness improves relationship satisfaction, intimacy, self-control, and acceptance, and reduces anxiety in couples' relationships, and has a positive effect on personal and spiritual optimism and peace of mind (Carson et al., 2004).
The interest in developing unified protocols has led to the expansion of a wide range of research into identifying transdiagnostic factors that target the common elements of multiple disorders (Barlow et al., 2017;McEvoy, Nathan, & Norton, 2009). Recent developments in unified protocols and therapies suggest that the transdiagnostic approach may be more effective than treating comorbid disorders in a separate and chain-like manner (Barlow et al., 2017). This mixed treatment plan takes into account several psychological factors to reduce marital conflicts and help to improve marital and communication relationships between couples.
Unresolved conflicts destroy marital life and lead to divorce. Besides using the integrative approaches in couple therapy and family issues are recommended by family therapists (Driver & Gottman, 2004). Given that previous research to reduce marital problems has had similar content programs, this therapeutic package integrating the three basic family therapy programs can be used in vastly different cultural contexts and family issues. Given that the effects of the unified transdiagnostic training program on marital conflict have not been explored, this study aims to explore the effectiveness of the unified protocol for the transdiagnostic treatment based on the McMaster model of family functioning, compassion-focused therapy, and mindfulness-based therapy on emotional divorce and marital boredom in women with marital conflict.

Methods
The present study used a quasi-experimental method with a pre-test, post-test design and a control group. The research population included all women with marital conflict referred to four selected private counseling centers in the District 2 of Tehran Municipality (Dana Counseling Center, Elixir Counseling Center, Mehr Counseling Center, Iran Zamin), Iran, in 2019 for marital conflict. The reason choice of women in this study was due to the fact that two and a third women are more than men seeking psychological help (Liddon, Kingerlee, & Barry, 2018).Therefore, in this study, our participants were women. The participants were a total of 30 women who were selected via simple random sampling and randomly assigned to two groups (transdiagnostic intervention group and the control group), each with 15 participants. The sample size was calculated for each group equal to 15 based on the effect size of 0.25, alpha of 0.05, and test power of 0.80.
The inclusion criteria were at least 18 years old, having at least a high school diploma, being married, and lacking a severe physical and mental illness approved by a psychiatric and clinical psychologist by a structural interview in the clinic. The exclusion criteria were getting divorced or separated from spouse and absence of more than three sessions of treatment sessions. Then, they filled out the Emotional Divorce Scale (1997) and the Marital Disaffection Scale (MDS) (1996).
The instruments used to collect the data are described as follows:

The Emotional Divorce Scale (EDS)
The scale was developed by Katz and Gottman (1997). This scale contains 24 items. Each item is scored using a 2-point scale: Yes (1) or No (0). The scale comprises statements about different aspects of married life that one may agree or disagree with it. The minimum and maximum scores obtained by a respondent are 0 and 24, respectively. A score of 8 and higher indicated that the person's married life is subject to separation, and there are signs of emotional divorce (Gottman, 2002). Khodabakhshi-Koolaee et al. reported the reliability of this scale equal to 0.91 using the Cronbach alpha. The formal validity of the scale was confirmed by experts (Khodabakhshi-Koolaee et al., 2019). In this study, the reliability index of the scale was calculated as 0.78 using the Cronbach alpha.

The Marital Disaffection Scale (MDS)
This scale was developed by Kayser (1996). It is a self-report tool to measure the rate of marital boredom between couples. The scale consists of 21 items that indicate boredom syndrome and has three subscales; physical weakness (e.g. feeling tired, lethargic, and having trouble sleeping), emotional weakness (feeling depressed, frustrated, trapped), and mental weakness (e.g. feelings of worthlessness, frustration, and anger at the spouse). Each item is scored on a 7-point scale ranging from 1 (no experience) to 7 (high experience) (Kayser, 1996). Scores range from 21 to 84, and Kayser (1996) assigned the following classifications to the following score ranges: 21-26= low disaffection; 27-34= belowaverage disaffection; 35-42= average disaffection; 43-54= above-average disaffection; and 55-84= high disaffection (Durham-Fowler, 2010). The MDS validation showed that the internal consistency between the items in the scale is in the range of 0.84 and 0.90. The validity of MDS has been confirmed by negative correlations with positive communication characteristics (Kayser, 1996). In Iran, Khodabakhshi-Koolaee and Adibrad (2010) translated this scale into Persian and measured the test-retest reliability of the scale with 1-month, 2-month, and 4-month intervals, and the corresponding values were 0.89, 0.76, and 0.66, respectively. Besides, the internal consistency was measured for most participants with an alpha coefficient which ranged from 0.91 to 0.93 (Khodabakhshi Koolaee & Adibrad, 2010).

Study procedure
To conduct the study, we administered a pre-test to the participants in the Two groups before the intervention. The participants completed the questionnaires. Then, 12 weekly transdiagnostic sessions, each lasting two hours, were held for the intervention group at Mher Counseling Clinic Center in Tehran. An expert with PhD in family counseling held the therapy sessions. Table 1 presents the content of the sessions.
However, the participants in the control group received no intervention during this period. In this study, no participant left the study, and all of them completed the training sessions and attended the post-test. The questionnaires were re-administered to the participants in the two groups after finishing the interventions, and the data were collected. Upon completing the intervention, the participants in both groups completed the questionnaires immediately after the intervention and then three months later.
To comply with the ethical standards in this study, we took the following measures: 1. Written informed consent was obtained from all participants in the study; 2.
The participants were assured of the confidentiality of their information; 3. All questionnaires were completed questionnaires indecently; and 4. Five intervention sessions were held for the members of the control group to observe the ethical considerations, after the completion of the intervention.
To implement the intervention, we prepared a researcher-made unified protocol based on the McMaster model of the family (Epstein et al., 1983;Epstein et al., 2003), compassion-focused therapy (Neff, 2003;Neff, 2011), and mindfulness-based therapy (Burpee & Langer, 2005;Crane, 2017). The therapies' content was implemented in the group by the researchers, as detailed in Table 1. The meetings took place on Monday for three months (one session per week) in Mehr Counseling Center. Therapeutic interventions were not provided to the control group during the study. The drop-out samples did not report. Figure 1 shows the chart of the study process.
Finally, the collected data were analyzed using descriptive statistics (Mean and Standard Deviation) and inferential statistics, including Multivariate Analysis of Covariance (MANCOVA) in SPSS V. 24 software.  Teaching the family therapy diagram based on the McMaster model, compassion-focused therapy, exploring systems of self-affirming thoughts, their effects on the comfort system (providing self-compassion worksheet, self-compassion prayer, and self-confirmative self-talk), introducing the mindfulness tree by focusing on the root of description rather than judgment (providing a worksheet to focus an object)

Results
The analysis of the participants' demographic data indicated that 15 participants (50%) in the intervention group were between 25 and 34 years old and the remaining 15 (50%) between 38 and 45 years old. Besides, 18 participants (60%) in the control group were 25 to 34 years old, and 12 (40%) were 38 to 45 years old. Table 2 compares emotional divorce and marital boredom between the two groups. As can be seen, there is a difference between the control and intervention groups in terms of emotional divorce and marital boredom in the pre-test, post-test, and follow-up stages. The mean scores of marital boredom on the pre-test and post-test for the participants in the intervention group were 80.10 and 73.60. The corresponding values for the participants in the control group were 80 and 82.90, respectively. Moreover, the mean scores of emotional divorce on the pre-test and post-test for the participants in the intervention group were 13.50 and 11.5. The corresponding values for the participants in the control group were 11.70 and 12, respectively. The intergroup differences in terms of both marital boredom and emotional divorce were significant and in favor of the intervention group, as shown by the Multivariate Analysis of Covariance (MANCOVA) in Table 2.
To run the analysis of covariance, it is necessary to examine the assumptions of this test. Accordingly, to check the normality of the data, the Shapiro-Wilk test was used. Besides, to check the homogeneity of the variancecovariance matrix, Box's M test was used. The equality of variances was also checked using Levene's test. Given the result of Levene's test (P>0.05), the equality of variances was established for emotional divorce and marital boredom, and it was possible to run the Multivariate Analysis of Covariance (MANCOVA). Table 3 are greater than 0.14, implying the effectiveness of the transdiagnostic treatment program. The eta-squared value for the new compound variable (group) is 0.224, which indicates that the treatment program was highly effective. Also, the results of the Wilks' lambda test for the compound variable are significant. The MANCOVA results for emotional divorce and marital boredom are presented in Table 4. The significance level for the new compound variable shows significant differences between participants in the two groups, and their mean scores were significant under the influence of the independent variable.

The eta-squared values shown in
The MANCOVA results on the post-test and follow-up phase indicate that the F value is statistically significant (P<0.05), indicating a significant difference between the participants in the intervention and control groups in terms of at least one of the variables (emotional di-Excluded (n=8) • Not meeting the inclusion criteria Randomized (n=30) Allocated to the intervention group (n=15)

Received treatment
Allocated to the control group (n=15)

Analysis
Analyzed (n=15) Analyzed (n=15) Assessed for eligibility (n=38) Figure 1. The CONSORT flow diagram of the data process vorce and marital boredom). Table 5 presents the results of one-way Analysis of Covariance (ANCOVA) for the research variables on the post-test: The one-way ANCOVA for the participants' scores in both post-test and follow-up stages was performed with Bonferroni correction at the significance level of 0.005. Generally, as shown in Table 6, there were significant differences between the two groups in terms of the emotional divorce and marital boredom, showing the effectiveness of the treatment for the women with mari-tal conflict (P<0.05, α<0.01, F=9.537). Accordingly, the participants in the intervention group had significantly lower scores for emotional divorce and marital boredom compared to the participants in the control group.

Discussion
The results of this study showed that the transdiagnostic treatment program (based on the McMaster model, compassion-focused therapy, and mindfulness-focused therapy with the here-and-now component, mindfulness skills training, emotion cognition and expression (focusing on emotions), and accepting and paying attention and understanding instead of judging and teaching interpersonal communication and relationships can reduce emotional divorce and marital boredom of women with marital conflict. Also, Khodabakhshi-Koolaee et al. (2019) showed a significant relationship between emotional divorce and six dimensions of women's quality of life (personal feeling, family relationships, social relationships, health quality, satisfaction with environmental conditions, and satisfaction with economic conditions). They also reported a low level of quality of life for women with low emotional divorce and higher quality of life for normal women. It can be suggested that marital conflicts will increase with a decline in life quality, especially in terms of individual and family dimensions and life satisfaction.
Marital boredom is a gradual decrease in emotional attachment to the spouse, accompanied by feelings of alienation, apathy, and indifference between couples and replacing negative emotions with positive ones (Kayser, 1996). However, as marital intimacy increases, marital boredom will decrease. Couples' participation in compassion-focused therapy sessions increases marital intimacy and regulates couples' excitement, reducing marital boredom. Zahedi (2019) suggested that compassion-focused training significantly affects marital intimacy, emotional intimacy, intellectual intimacy, physical intimacy, socio-recreational intimacy, communication intimacy, psychological intimacy, sexual intimacy, and general intimacy. Furthermore, Najjari et al. showed that acceptance and commitment therapy, because of its focus on emotionalpsychological components, can reduce women's loneliness and increase their post-divorce adjustment (Najjari, Khodabakhshi Koolaee, & Falsafinejad, 2017). The results of this study showed that the transdiagnostic treatment program reduces emotional divorce and marital boredom of women with marital conflict.
The available evidence about compassion-focused therapy indicates that of the effective factors in the occurrence of marital boredom, marital intimacy in the relationship between the couple and the general health of the individual play a decisive role (Henderson, 2011). Intimacy is the main motivation for forming a marital relationship and includes a degree of closeness and care that each couple feels and expresses towards each other (Friedman, 2000). Couples who experience a higher degree of intimacy, apart from socioeconomic status, report significantly fewer boredom symptoms in their relationships (Olson, DeFrain, & Skogrand, 2009). Mohammadi and Mohammadi (2018) stated an association between marital fatigue and mindfulness. Therefore, mindfulness can predict couples' marital boredom.
This study was conducted with some limitations. The participants were selected from several counseling centers in the west of Tehran, and thus caution must be ex- ercised when generalizing the findings of the study to other populations. Besides, some events could not be controlled in this study. For instance, conflicts among the couples between the pre-test and post-test could have affected the study results. Because of the communication problems of couples that lead to their dissatisfaction, this protocol can be used to increase the communication skills of couples with each other. Also, applying mindfulness and compassion to oneself helps couples to know themselves and their spouses. This protocol is also recommended to family counselors for premarital counseling.

Conclusion
This study showed that combining family therapies with mindfulness and self-compassion therapies can provide a unified model for women who suffer from coldness, emotional divorces, ongoing marital conflicts, emotional divorce, and marital boredom in their lives. Besides, simultaneous attention to emotion, cognition, behavior, and family relationships allowed the women participating in the therapy sessions to think about their relationship with their husbands in addition to their feelings, needs, behaviors, and thoughts. They also gained a clearer understanding of the causes of marital conflicts that can lead to emotional divorce and disgust in couples.

Funding
This article is an excerpt from the PhD. dissertation of the first author in the Islamic Azad University, Tehran North Branch.