Volume 5, Issue 4 (November 2018)                   Avicenna J Neuro Psycho Physiology 2018, 5(4): 159-168 | Back to browse issues page

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Sepahvand T. The Effectiveness of Integrated Model of Self-regulation-attachment Couple Therapy on Dimensions of Marital Satisfaction of Insecure Couples. Avicenna J Neuro Psycho Physiology. 2018; 5 (4) :159-168
URL: http://ajnpp.umsha.ac.ir/article-1-140-en.html
Department of Psychology, Faculty of Humanities, Arak University, Arak, Iran. , T-sepahvand@araku.ac.ir
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1. Introduction
Today, exploring and understanding the different aspects of the romantic relationship is a worthy challenge for research [1]. In spite of abundant knowledge about preventing marital conflicts, understanding how to help couples have lasting and satisfying marriages, is still in the primary stages [2]. Researchers have assessed perceptions of benefits and costs of romantic relationships [3] and psychopathology involved in these relationships [4]. Almost all marriages and other couple relationships begin with high satisfaction [5]. However, marital satisfaction is not easily achieved [6]. Halford believed that, in many couples, these initial positive feelings decline over time, and couple relationship distress is a current problem [7]. Therefore, it would seem that planned interventions to improve marriages and couple relationships may have a positive effect on unhappy marriages [8]. Especially, integrative approaches to couple therapy have important implications for clinical practice about couples [9].
One of the essential approaches of couple therapy is self-regulation couple therapy. According to this perspective, the process of marital therapy usually includes moving and encouraging clients to recognize the changes that could be made to improve their relationship, until being dependent on changes in their partners [10]. Many findings explicitly show that couple intervention that enhances self-regulation relationship improves a couple’s satisfaction [11], and decrease emotional abuse and marital distress [12]. However, in recent years, researchers of self-regulation couple therapy state that some couples need more extensive therapy to attain self-change goals of their relationship, and using the techniques of other approaches can help the couples to change their relationships [13]. 
The attachment theory has advantages [14], and its application can especially enhance self-regulation in behavioral couple therapy [10, 13]. The critical point is that attachment theory is essentially a self-regulation theory [15], and attachment models have applications in the development of self-regulation capacities [16, 17]. Therefore, theoretical models that focus on self-regulation and mutual regulation suggest that individuals who have experienced trauma in their relationship tend to use insecure, avoidant, disorganized, or ambivalent strategies of stress regulation. These strategies create problematic interactive patterns in their couple relationships [18]. 
Thus, when there is an attachment breach, couples are taught how the state of interactive dysregulation can weaken and undermine their attachment bond if they do not attempt to stop it by more reparative approaches. Furthermore, each partner is encouraged to learn how to do self-regulation and become more sensitive to the partners’ affection regulation. This treatment builds mutual awareness and empathy within the dyadic relationship and interrupts the ongoing negative cycle [19]. Therefore, researchers propose the theory of attachment as an organizing framework or meta-perspective for couples’ therapy and marital intervention [20]. Byng-Hall believed that the internal working model might affect the cognitive-emotive process by which each partner implicitly regulate goals or ideals for relationship or criteria for satisfaction of couple relationship [20]. So if the behavioral interventions consider the potential motivations behind the behaviors, such as people’s preferred ways for controlling the attachment anxiety, relationship goals of couples, and emotional experiences, then acquired skills may be used better and therapists more effective in moving their couples toward behavior change [21]. 
With such a perspective, the researchers investigated the interactive effect of attachment anxiety and relationship threat on self-regulation by integrating research on attachment anxiety, rejection, self-regulation, and health behaviors in an exploratory examination. The results of this study indicated that the women (not men) develop excessive attachment anxiety, experience self-regulation failure when relationship threat is elicited [22]. Another research also shows the efficacy of the integrated model of self-regulation-attachment couple therapy on marital satisfaction and wellbeing of couples [23].
In general, secure clients appear to be better at making use of treatment than insecure clients [24], and essentially secure attachment style facilitates the ability of people to learn new experiences and, if necessary, accept change in themselves and others [14]. Understanding the different attachment styles of couples may provide essential clues and guidelines to establish a secure base of operation for the negotiation of change [20]. Thus, all therapists have to relate, in their particular ways, to attachments when they engage with family problems [25]. Also, they can use their chosen techniques when a secure base in therapy is established and enrich and facilitate their current practice [20, 21]. Thus, this research aimed to examine the efficacy of the integrated model of self-regulation-attachment couple therapy on dimensions of marital satisfaction of insecure couples.

2. Materials and Methods
This research was a quasi-experimental study with a pretest-posttest design and control group. The statistical population comprised the couples referring to the counseling centers of Khorramabad City, who attempted to receive professional aids because of communicational and marital problems. The research sample was selected by purposive sampling method among the couples that at least one of them had an insecure attachment style, based on the Adult Attachment Inventory. Given that these couples are few in these counseling centers, a sample with the least number but enough for experimental research were selected, and 11 couples (n=22) were randomly assigned to the experimental group and 11 couples (n=22) to the control group.
The criteria for choosing the couples were as follows: being married for at least 1 year and at most 15 years, lacking serious problems such as severe physical or mental illnesses and substance abuse, not willing to divorce, and having a desire to participate in the study program. An expert psychologist assessed these criteria. Before performing the couple therapy program, the ENRICH questionnaire was administered to all couples as the pretest. Then, the couples of the experimental group participated in a couple therapy program for 8 weekly sessions, but the control group remained on the waiting list. After the completion of the therapeutic sessions, the couples of the two groups completed the questionnaires again as the posttest. For decreasing the conflicting factors in the process of therapy, the agreement of the couples was obtained, and the problematic conflicts were resolved during the therapeutic sessions. Finally, the collected data of the two groups were analyzed by multivariate analysis of variance (MANOVA).
Adult Attachment Inventory (AAI)
The Adult Attachment Inventory (AAI) is a questionnaire derived from the attachment style questionnaire [26], the relationship questionnaire [27], and the attachment history questionnaire [28] and validated to measure attachment styles in the Iranian population [29, 30]. The AAI is a 15-item questionnaire with three subscales of secure attachment style, avoidant attachment style, and ambivalent attachment style, each of which has 5 items. Each item is rated on a 5-point Likert-type scale ranging from 1 (very little) to 5 (very much). The Cronbach coefficient alpha values for the subscales of secure, avoidant, and ambivalent styles were calculated in a sample of 1480 participants (860 females, 620 males). The Cronbach alpha values were 0.85, 0.84, and 0.85 for secure, avoidant, and ambivalent attachment styles, respectively, for all participants. The test-retest reliability of the AAI was calculated twice in a sample of 300 participants at a 4-week interval. The coefficients of secure, avoidant, and ambivalent attachment styles for all participants were 0.87, 0.83, and 0.84, respectively. All correlation coefficients were significant at P<0.001. These scores indicate adequate test-retest reliability of the AAI. Factor analysis identified that secure, avoidant, and ambivalent attachment styles were confirmed by the AAI [29]. In another study, the internal reliability coefficients were 0.90, 0.87, and 0.85 for secure, avoidant, and ambivalent attachment styles, respectively [30]. The Cronbach's alpha value of this questionnaire in this research was calculated as 0.79.
Enriching and Nurturing Relationship Issues, Communication, and Happiness 
Enriching and nurturing relationship issues, communication, and happiness or simply ENRICH marital satisfaction questionnaire is a 115-item instrument, and another form of it has 125 items. This questionnaire consists of 12 subscales [31]. ENRICH questionnaire has good psychometric characteristics. Its internal consistency is estimated from 0.73 to 0.90 [32]. All subscales of this questionnaire distinguish satisfied from unsatisfied couples, indicating the high criterion validity of this questionnaire [31]. Fowers and Olson [33] found that ENRICH can differentiate between happy and unhappy married couples with 85% to 90% accuracy. In this research, the Iranian 47-item ENRICH was used, and its internal consistency was reported to be about 0.95 [34]. Nine subscales of this version of ENRICH are personality issues, marital communication, conflict resolution, financial management, leisure activities, sexual relationship, marriage and children, family and friends, and spiritual beliefs. In this research, the Cronbach alpha of this questionnaire was found 0.87. 
Integrated Model of Self-Regulation-Attachment Couple Therapy 
According to theories about self-regulation [10, 13] and attachment [14, 20, 25], the integrated model of self-regulation-attachment couple therapy is the change of behaviors, cognitions, and emotions of couples by themselves that facilitates reconstruction and expansion of attachment styles by helping the therapist and creating a secure interactional atmosphere among them. This therapeutic model has been made by the integration of theoretical concepts and therapeutic principles of self-regulation and attachment theories performed during 8 sessions. Table 1 presents The titles and content of sessions in this therapeutic program.
3. Results
The collected data from the experimental group (11 couples, Mean±SD age, 31.2 [5.4] years), and the control group (11 couples, Mean±SD age, 34 [5.8] years) were analyzed. These couples had 0 to 2 children, and their age differences were between 2 and 12 years. Table 2 presents the pretest and posttest scores of the participants in marital satisfaction and its subscales.
Since the present research had a pretest-posttest quasi-experimental design with a control group, the data were analyzed by the analysis of covariance (ANCOVA) and multivariate analysis of covariance (MANOVA). The pre-assumptions of these analyses were examined. The tests of homogeneity for regression line for two experimental conditions were not significant in all variables (P< 0.01), the covariance matrices of two groups were equal and had no significant differences (Box’s M= 53.818, P=0.672) and Bartlett’s test of sphericity showed significant differences between dependent variables (Approx. Chi-Square= 73.768, P=0.004), that included subscales of marital satisfaction. With confirming these pre-assumptions, ANCOVA and MANCOVA were performed. Table 3 presents the results of ANCOVA for comparisons between the experimental and control groups in marital satisfaction.
 The results of ANCOVA indicate the pretest effect for two groups. Nevertheless, after controlling the pretest effect, it was found that the effect of integrated self-regulation-attachment couple therapy on the posttest scores of the two groups was significant, and the two groups were different in the posttest. Accordingly, the hypothesis, asserting that the integrated model of self-regulation-attachment couple therapy increases marital satisfaction was confirmed (F1,41= 10.55, P= 0.002), which indicates the effect of the mentioned program on marital satisfaction.
This research also examined the effect of the therapeutic program on the subscales of marital satisfaction with the ENRICH questionnaire. Accordingly, MANOVA was used to analyze the differences between the two groups in these variables. Table 4 presents the results of MANCOVA for subscales of marital satisfaction.
Based on Table 4, the effect of group membership (therapeutic program) on a linear compound of dependent variables (subscales of marital satisfaction) was significant after the control of the pretest effect. Accordingly, Table 5 presents the results of univariate analysis for examination of the inter-group effects of these subscales.
The results of Table 5 indicate that the observed F scores for the subscales of sexual relationship, marriage and children, and spiritual beliefs were significant. Therefore, the means of these variables in the two groups had significant differences, but there were no such differences for other variables. Finally, Table 6 presents the results of pairwise comparisons between these subscales.
The results of Table 6 also indicate the significant differences between the experimental and the control groups in these variables. Accordingly, the integrated model of self-regulation-attachment couple therapy is efficient in increasing marital satisfaction based on the subscales of sexual relationship, marriage and children, and spiritual beliefs.
4. Discussion 
The results indicate that the integrated model of self-regulation-attachment couple therapy is useful for marital satisfaction. All couple therapies are necessary to facilitate changes in the couple relationship toward higher effectiveness of the relationship and satisfaction of the partners [20]. The findings of this research are consistent with this goal and with the research that supports the effectiveness of self-regulation couple therapy on couple relationship satisfaction [11]. These findings also confirm the results based on the approaches that consider the process of attachment in couple therapy [14], and the results of the studies that examine the treatment of couple problems and distresses based on emotionally focused therapy.
The same results have been obtained in the interventions investigated the application of emotional regulation and integration of attachment and self-regulation [22, 23]. These results are expected considering Daniel’s notion [24] about the better function of secure clients in making use of treatment, and that secure style (and expansion of secure attachment) facilitate people’s ability to accept change in themselves and others [14]. On the other hand, the results of this research support the other studies that an integrated model of self-regulation-attachment couple therapy is effective in increasing marital satisfaction.
To explain how the integrated model of self-regulation-attachment couple therapy is effective on marital status, it is said that the strong relationship between marital distress and problems is related to the health and well-being of couples [7], and marital satisfaction and well-being of couples mutually affect each other [1]. So the effect of integrated couple therapy on one of them can affect the other one. 
This therapeutic program was also effective on the subscales of marital satisfaction, including sexual relationship, marriage and children, and spiritual beliefs. Some research studies have shown the effectiveness of integrated couple therapy on sexually unsatisfied couples. In the present research, the sexual relationship was considered as an important problem in the couple’s relationship in some therapeutic sessions, and the expansion of secure attachment and self-regulation of negative cognitions, affect the behaviors related to the sexual relationship with useful results. 
About the effectiveness of this program on the subscale of marriage and children, it can be said that the filled security and self-change that integrated couple therapy can produce in couples are efficient to some extent, which easily expands to the domains of marriage and children. Finally, about the effectiveness of this program on the subscale of spiritual beliefs, it can also be said that, in spite of lack of an evident program for considering spiritual beliefs, many couples during the sessions of assessment and self-change, consider their spiritual problems and conflicts as self-change goals. Thus, the effects of this program were evident on these subscales of marital satisfaction. 
The main limitation of this research was the difficulty in accessing more couples for perfect matching of the groups and better control over the intervening variables. Although the primary problems of the couples were measured in the pretest and the effect of the pretest was controlled, more confident causal results would be attained if it were possible to recruit more couples and randomly select or match them. Accordingly, future research studies should take this into account. Considering the effective use of this therapeutic program based on the principles of two important theories of couple therapy (attachment and self-regulation) and its positive effects on marital satisfaction, we suggest that its application can be useful and effective in decreasing problems of couples, especially those who have unhappy relationships.
5. Conclusion
The integrated model of self-regulation-attachment couple therapy could be an effective treatment for promoting marital satisfaction and its components in couples with insecure attachment. However, more research with different samples of couples must be done to confirm this effectiveness further. 
Ethical Considerations
Compliance with ethical guidelines
This research had not received a moral code by an Ethics Committee. However, all ethical principles were considered in this article. The participants were informed about the purpose of the research and its therapeutic stages. They were also assured about the confidentiality of their information. Furthermore, they were allowed to leave the study whenever they wanted.
This research did not receive any specific grant from funding agencies.
Conflict of interest
The authors declared no conflict of interest.
The author would like to thank the couples that participated in this research.

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Article Type: Research Article | Subject: Clinical Psychology
Received: 2018/04/10 | Accepted: 2018/08/13 | Published: 2018/11/1

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