1. Introduction
Diabetes is among the most prevalent chronic diseases worldwide. Economic growth, urban life development, lifestyle changes, weight loss, and weight gain affect diabetes development [1]. Approximately 90% of people with diabetes are affected by type 2 diabetes. It is estimated that the number of people affected by type 2 diabetes will increase to 246 million in 2021 and 592 million in 2035 globally [2]. Iran is also projected to have 9.2 million people with diabetes by 2030 [3]. Some causes of the disease include the patients’ characteristics, such as unawareness about diabetes, beliefs, disapproval, and adherence to a diet. Besides, the psychosocial aspects of patients, which gradually lead to biopsychosocial complications are may also contribute to this condition [4, 5]. Modern diabetes treatment is based on 5 principles; education, proper use of medicine, physical activity, proper dietary program, and daily blood glucose control [6].
Obesity is a major risk factor for type 2 diabetes. Furthermore, numerous epidemiological studies have suggested that the prevalence of this disease is progressively increasing among overweight individuals [7]. Obesity is defined as excessive body mass and fat according to a person’s height, which increases the risk of associated diseases. Obesity prevalence has been increasing in the world. Approximately 396 million adults, or 9.8% of this population, are overweight. This number is also estimated to reach 1120 million by 2030 [8]. The risk of death in people with diabetes and obesity together is 7 times higher than the healthy individuals. Therefore, diabetes and obesity are strongly correlated in epidemiological cognition, i.e. a serious threatening global health [9]. 
In a review of 17 prospective studies and 35 cross-sectional studies on 18-74-year-old adults investigated that body or waist mass index could independently predict type 2 diabetes [10]. Chronic diseases, such as diabetes could alter the family reactions and interactions. Diabetes should be considered as a family matter that affects all family members. These patients face more marital problems than healthy couples due to the generation of illness. Thus, the spouse has to alter their role and accept a new character. Such a relationship becomes a one-sided beneficial interaction with a double burden of responsibilities for the spouse due to the illness; therefore, it significantly impacts family life and relationship quality [11]. 
Unpleasant consequences of diabetes are mentioned as follows. 1. Physical exhaustion, including fatigue, boredom, weakness, chronic headaches, stomach ache, the loss of appetite, and overeating; 2. Emotional exhaustion, including resentment, fatigue, depression, loneliness, the lack of motivation, low self-esteem, and even suicidal thoughts; 3. Mental exhaustion, including low self-confidence, negative feelings about the spouse, frustration with the spouse, self-dissatisfaction, and prolonged lack of love, leading to marital burnout [11]. The Ekberg research studies data revealed that a chronic illness in one spouse could induce couple burnout in the other spouse due to the increasing burden of additional responsibilities associated with the disease, like day caring [12]. According to Kayser, marital burnout gradually declines the martial emotional attachments with a feeling of alienation, the lack of interest, indifference, and the replacement of negative emotions with positive ones [13]. 
The decrease in love and increase in hostile behaviors result from marital dissatisfaction that put the family structure at risk [14]. Pamuk and Durmus’s research indicated a significant gender difference in marital dissatisfaction feelings, and that women are more likely to be dissatisfied than men [15]. Among the new therapies [16, 17], one of the effective therapeutic approaches used to treat couple burnout in obese patients with type 2 diabetes is the Transactional Analysis (TA) approach. TA is an analytical approach, which incorporates structures, such as ego states, transactions, life scenario, life positions, and time structures [18]. 
TA is among the most influential approaches in the field of marriage counselling. Besides, it is a psychotherapy system, i.e. used to treat various mental disorders, from daily living problems to profound personality disorders i.e. important in personality growth and change. This method is most effective in understanding people, interpersonal relationships, and communication matters. Thus, this approach might improve the marital intimacy and sexual satisfaction, i.e. formed in an intimate relationship with another person. Furthermore, TA could be provided as individual, group, couple, and family therapy. TA involves an easy and complete interactive theory about personality that provides insight into how to encounter with oneself and others [19]. 
The primary task of a TA therapist is to make clients skilled and guide them on analyzing their relationships and monitor the results. In Berne’s view, stages of behavioral change include removing inappropriate behaviors, psychiatric discharging, describing, and clarifying new communication and orientation practices. TA also emphasizes on social positive recognition (caring) and unconditional positive attention (I am good, you are good); these are considered as essential needs in human psychological transformation, changing through personal responsibility, decision-making, and intentional action. Moreover, these factors emerge in contract-based therapies with focus on liberty and empirical challenges [18]. 
The effectiveness of TA on improving psychiatric symptoms has been examined and supported by various studies; e.g. the relationship between social psychosocial functioning and life quality in patients with personality disorder [20], recovering depression and anxiety [21], reducing adolescent verbal aggression [22], and reducing the symptoms of generalized anxiety disorder [23]. Alkasir et al. investigated the effect of group TA training on reducing spouse centered-control behaviors in marital conflicts. The relevant results revealed a significant decrease in the experimental group, compared to the controls [24]. Mostafavi et al. also argued that TA has improved family disputes [25].
 Additionally, Nayeri et al. reported that TA training could develop family intimacy [26]. Many type 2 diabetics face serious biopsychological problems. This is because it is a chronic disease and has a devastating effect on the physique and emotion of people. Therefore, it is necessary to more seriously consider the psychological consequences of this condition. As a result, we could use effective non-pharmacological therapies along with medications to prevent the progression of this disease to the patients’ mental health dimension. Problems associated with diabetes are essential in marital life. However, few studies explored the effects of psychological therapies in this regard, especially TA, with its effects supported by many international and domestic studies. Accordingly, it is necessary to examine the effectiveness of this treatment of married obese women with diabetes. Therefore, this study aimed to investigate the effect of TA on couple burnout in obese married women with type 2 diabetes.
2. Materials and methods
This was a quasi-experimental study with a pre-test/ post-test, follow-up, and a control group design. The study population comprised all married obese women with type 2 diabetes who were members of the Gonbad Kavous Diabetes Association, in 2018. Of them, 40 individuals were selected and randomly assigned to the experimental and control groups (20 patients per group). The study inclusion criteria included being diagnosed by type 2 diabetes for at least one year, Body Mass Index (BMI) of kg/m2, the age range of 35-60 years, educational level of at least primary school, the lack of physical limitations impeding individual care, and providing a consent form for study participation. The exclusion criteria included not consenting to take part in the study, a history of hospitalization in psychiatric hospitals, consuming psychiatric, psychedelic, or any sedatives medicine, alcohol and substance use, participation in similar training programs, participation in individual counseling sessions, and >3 sessions of absenteeism. 

The study initiated after the necessary coordination with the management of the Diabetes Society of Gonbad-e Kavous. The researcher provided the call for registration and participation in the therapeutic sessions to the center. After registering the applicants within the designated timeframe, the researcher had an initial interview with each of them. Based on the study inclusion and exclusion criteria, 40 women were selected and randomly assigned to two experimental and control groups (20 per group). It should be noted that 3 subjects (2 subjects in the control group and 1 subject in the experimental group) were excluded from the study for various reasons, and statistical studies were performed on 37 women. Then, the experimental group received TA intervention in 10 two-hour sessions, one session per week (Table 1). 
The control group received no intervention during the research period. The research instrument was the Pines Couple Burnout Measure (CBM), which was completed by the study participants in the Pre-test, Post-test, and follow-up stages. After the completion of the study, therapeutic sessions were provided to the control group participants to observe the ethical and professional research issues and to thank them for their cooperation in the research. The obtained data were analyzed by repeated-measures Analysis of Variance (ANOVA) and Bonferroni posthoc test in SPSS.

Pines Couple Burnout Measure (CBM)
In this study, we used the Pines CBM 21-item Questionnaire to measure the couple burnout. The questionnaire has three subscales; physical exhaustion (feeling tired, fatigued, & having sleep disorders), emotional exhaustion (feeling depressed, hopeless, trapped), and mental exhaustion (feeling worthless, frustrated, and angry with the spouse). Scoring was based on a 7-point Likert-type scale (ranging from 1=never to 7=always) [27]. On this scale, the highest band score is 147, and the lowest is 21, with higher scores indicating greater burnout. The questionnaires with scores ranged from 0.84 to 0.90 are considered as valid variables [27]. In the Adibrad study, the test-retest reliability coefficient of this scale was calculated as 0.89 for a month, 0.76 for two months, and 0.66 for three months. Its alpha coefficient was reported to be between 0.91 and 0.93 [28]. Furthermore, Ebadatpour et al. reported the reliability of the questionnaire equal to 0.81 using Cronbach’s alpha coefficient [29].

3. Results 
According to Table 2, the mean age of the experimental and control groups was 39.95 and 38.60 years, respectively. The mean marriage duration in the experimental and control groups was 10 and 9.45 years, respectively. The mean duration of the disease of the participants in the experimental and control groups was 3.05 and 3.45 years, respectively. Table 2 demonstrates data on marital and illness characteristics. 
Table 3 summarizes the mean±SD values of couple burnout and its components at Pre-test, Post-test, and follow-up stages in the experimental and control groups. According to this table, the mean scores of couple burnout for the experimental group (TA recipients) in the Pre-test was 78.25, in the Post-test was 46.20, and in the follow-up was 45.95. The mean ​​value of this variable for the control group are also presented in Table 3. The scores of control group subjects in the couple burnout variable and its components did not significantly change at different testing stages. To determine whether the changes in the experimental group at the Post-test and follow-up stages were statistically significant, the repeated-measures ANOVA was used, considering if its assumptions were met, i.e. the normal distribution of data and homogeneity of variances. The Kolmogorov-Smirnov test data suggested no significant difference between the two study groups in couple burnout and its components; accordingly, the data were normally distributed (P<0.05). Levene’s test results revealed no significant difference between the two groups’ variances (P<0.05).
Table 4 presents the results of repeated-measures ANOVA for examining inter- and intra-group effects. It presents the F value was significant for the couple burnout and its components over time (P<0.01). Therefore, there were significant differences among the scores of three stages of the Pre-test, Post-test, and follow-up in this variable and its components (Table 5). Moreover, the difference between the two groups was significant (P<0.01). The mean score of couple burnout and its components in the experimental group were lower than those of the control group at the Post-test and follow-up stages. The effect size of the treatment was 73% on couple fatigue, 67% on physical exhaustion, 74% on emotional exhaustion, and 60% on mental exhaustion.
Table 5 indicates a significant difference between couple burnout and all its components in Pre-test and Post-test, as well as between Pre-test and follow-up stages (P<0.01). Considering the mean scores of this variable and its components in these three stages, the mean value of couple burnout and its components in the experimental group decreased in the Post-test and follow-up stages.

4. Discussion 
The present study revealed that TA significantly reduced the total score of couple burnout and its components, physical exhaustion, emotional exhaustion, and mental exhaustion in the experimental group, compared to the controls. The present study findings were in line with those of Tizdast and Jafari Senejani [30], Van Rijn et al., [31], Alkasir et al., [24], Mostafavi et al., [25], and Nayeri and associates [26]. Ostovar et al. studied the impact of attending counter-behavior analysis consultation group meetings on couple burnout, adjustment, and intimacy. Their results indicated that the counter-behavior analysis approach increased marital intimacy and adjustment and reduced couple burnout [32]. Amini et al. documented that communication skills training across the counter behavioral analysis approaches significantly reduced marital conflict and its components [33]. Sodani et al. examined the effects of cross-behavior analysis training on enhancing the performance of maladaptive marital. The related findings revealed that counter-behavioral analysis training increased overall family function and its domains in the experimental group, compared to controls [34].
According to the obtained data, providing TA training to ill women could modify their relationship with their spouses. The training positively modifies the aggravating variables of couple burnout, such as conflicting demands, the excessive burdens of responsibilities, family commitments, as well as the lack of diversity and appreciation. Thus, in TA, individuals become more aware of their psychological states and patterns. Besides, after achieving self-knowledge, they could develop new patterns for themselves. It seems a sense of confidence increased in them for improvement. Contradictory demands are among the variables that exacerbate couple burnout. In TA, when people recognize the adult dimension of their personality, they probably can change their contradictory demands to sensible demands. Besides, when they recognize the parent dimension of their personality as their negative controller, they can be free of the pressures of family commitments to signify “musts” in meeting expectations. 
Accordingly, understanding the “adult dimension of personality” and its application could prevent another cause of couple burnout, i.e. an inconsistency between the expectations and reality. This is because the “adult dimension of personality” acts as a computer to analyze data and conform them to the realities. According to Pines, another reason for couple burnout is a lack of diversity in life. Furthermore, TA introduces the concept of rejection, that one follows a constant routine process due to expelling one or more of their mental states. Recognizing this condition brings the lost dimensions of personality back to the mental structure of individuals. Thus, using all mental states, the diversity returns to marital relationships and saves the relationships from fatigue and monotony. The theoretical foundations of couple burnout suggested that disillusioned individuals have no hope to improve their relationships and have a negative attitude toward relationships, especially a spouse. moreover, TA theory refers to foreground notions that affect relationships and thoughts since childhood, which carry messages, such as “you cannot,” “do not think,” and “do not be important.” However, altering these messages could reduce frustration, negativity, and lead to improving the relationships [35]. 
Therapists consider that one way to resolve conflicts and disagreements between spouses is setting time to be alone together, as the schedule is among the most practical issues in transactional analysis. Therefore, the trained individuals could organize their time with their spouses more efficiently and contribute to resolving their conflicts. Creating complementary relationships is among the most essential functions of proper communication. Upset people may feel that although they try hard, they can never achieve their intended result, they get angry earlier than usual, and they have lost the ability to have fun and lack a sense of humor. In complementary relationships, due to using “ego” on time and the parallel lines of the relationship, the mentioned feelings could be appropriately used in communication. Educating such ability to individuals could reduce their couple burnout [36]. 
A study limitation should be considered in generalizing the results to other populations, as it was performed only on obese women with type 2 diabetes in two towns of Gonbad Kavous. The applied research instruments were another study limitation that must be concerned. In most behavioral science investigations, many interfered variables simultaneously intervene in the study and the intervention effectiveness concerning specific independent variables. Such variables are often difficult to identify, and their effects are tough to remove. Therefore, overlooking the impacts of these factors may lead to the reduced repeatability of achieved results. Conducting follow-up tests is necessary to evaluate the long-term effects of the interfered variables. Thus, the follow-up was performed to investigate the intervention’s stability.
The obtained data supported that the TA intervention significantly reduced couple burnout and its components, i.e. physical exhaustion, emotional exhaustion, and psychological exhaustion. Therefore, TA is an appropriate intervention to reduce marital problems in obese female diabetics. Consequently, it is recommended that psychologists and family counselors use the therapeutic components of the TA approach to reduce couple burnout in obese diabetic patients.

Ethical Considerations
Compliance with ethical guidelines
In this study, necessary ethical considerations were noticed, such as explaining the research purposes, participation consent form provided by the study subjects, participation was voluntarily in the study, the study subjects had the right to discontinue study participation; harmless intervention, answering all questions, and the results were provided to the study participants if desired. 
Funding
This article was extracted from the first author’s PhD. thesise in Health Psychology at Islamic Azad University, Tonekabon Branch, and approved by the Faculty of Research Council under the code 11539.
Authors' contributions
All authors contributed in preparing this article.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
We are grateful to the respected management of the Gonbad-e Kavous Diabetes Association and to all dear patients who work with the researchers closely. 


References
Cho N, Shaw J, Karuranga S, Huang Y, Da Rocha Fernandes J, Ohlrogge A, et al. IDF diabetes atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Research and Clinical Practice. 2018; 138:271-81. [DOI:10.1016/j.diabres.2018.02.023] [PMID]
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Research and Clinical Practice. 2014; 103(2):137-49. [DOI:10.1016/j.diabres.2013.11.002] [PMID]
Javanbakht M, Mashayekhi A, Baradaran HR, Haghdoost A, Afshin A. Projection of diabetes population size and associated economic burden through 2030 in Iran: Evidence from micro-simulation Markov model and Bayesian meta-analysis. PloS One. 2015; 10(7):e0132505. [DOI:10.1371/journal.pone.0132505] [PMID] [PMCID]
Yazdi-Ravandi S, Taslimi Z, Ahmadpanah M, Ghaleiha A. Adjustment to diabetes among diabetic patients: The roles of social support and self-efficacy. Avicenna Journal of Neuro Psych Physiology. 2016; 3(1):1-5. [DOI:10.17795/ajnpp-37470]
Feghhi H, Saadatjoo S, Dastjerdi R, Kalantari S, Alidousti M. [The effect of a training program based on roy’s adaptation model on psychosocial adaptation in patients with type II diabetes in Birjand, Iran (Persian)]. Journal of Diabetes Nursing. 2016; 4(2):8-24.
Afshari M, Tol A, Taghdisi M, Azam K. [The effect of BASNEF-based blended educational program on on diabetes control among type 2 diabetic patients referred to diabetes clinic of Samirom city (Persian)]. Razi Journal of Medical Sciences. 2015; 22(132):56-62.
Boffetta P, McLerran D, Chen Y, Inoue M, Sinha R, He J, et al. Body mass index and diabetes in Asia: A cross-sectional pooled analysis of 900,000 individuals in the Asia cohort consortium. PloS One. 2011; 6(6):e19930. [DOI:10.1371/journal.pone.0019930] [PMID] [PMCID]
Kelly T, Yang W, Chen C-S, Reynolds K, He J. Global burden of obesity in 2005 and projections to 2030. International Journal of Obesity. 2008; 32(9):1431-7. [DOI:10.1038/ijo.2008.102] [PMID]
Cummings DE, Rubino F. Metabolic surgery for the treatment of type 2 diabetes in obese individuals. Diabetologia. 2018; 61(2):257-64. [DOI:10.1007/s00125-017-4513-y] [PMID] [PMCID]
Qiao Q, Nyamdorj R. Is the association of type II diabetes with waist circumference or waist-to-hip ratio stronger than that with body mass index? European Journal of Clinical Nutrition. 2010; 64(1):30-4. [DOI:10.1038/ejcn.2009.93] [PMID]
Pines AM, Neal MB, Hammer LB, Icekson T. Job burnout and couple burnout in dual-earner couples in the sandwiched generation. Social Psychology Quarterly. 2011; 74(4):361-86. [DOI:10.1177/0190272511422452]
Ekberg JY, Griffith N, Foxall MJ. Spouse burnout syndrome. Journal of Advanced Nursing. 1986; 11(2):161-5. [DOI:10.1111/j.1365-2648.1986.tb01234.x] [PMID]
Kayser K. The marital disaffection scale: An inventory for assessing emotional estrangement in marriage. American Journal of Family Therapy. 1996; 24(1):83-8. [DOI:10.1080/01926189508251019]
Huston TL. What’s love got to do with it? Why some marriages succeed and others fail. Personal Relationships. 2009; 16(3):301-27. [DOI:10.1111/j.1475-6811.2009.01225.x]
Pamuk M, Durmuş E. Investigation of burnout in marriage. Journal of Human Sciences. 2015; 12(1):162-77. [DOI:10.14687/ijhs.v12i1.3002]
Hajsadeghi Z, Yazdi-Ravandi S, Pirnia B. Compassion-focused therapy on levels of anxiety and depression among women with breast cancer: A randomized pilot trial. International Journal of Cancer Management. 2018; 11(11):e67019. [DOI:10.5812/ijcm.67019]
Azami E, Hajsadeghi Z, Yazdi-Ravandi S. [The comparative study of effectiveness of training communication andemotional skills on parenting stress of mothers with autism children (Persian)]. Zanko Journal of Medical Sciences. 2017; 18(56):1-11.
Berne E. Transactional analysis in psychotherapy: A systematic individual and social psychiatry. Pickle Partners Publishing; 2016.
Widdowson M. The importance of research in transactional analysis for transactional analysts. Transactional Analysis Journal. 2018; 48(1):33-42. [DOI:10.1080/03621537.2018.1397965]
Horn EK, Verheul R, Thunnissen M, Delimon J, Soons M, Meerman AM, et al. Effectiveness of short-term inpatient psychotherapy based on transactional analysis with patients with personality disorders: A matched control study using propensity score. Journal of Personality Disorders. 2015; 29(5):663-83. [DOI:10.1521/pedi_2014_28_166] [PMID]
Widdowson M. Transactional analysis psychotherapy for a case of mixed anxiety & depression: A pragmatic adjudicated case study-’Alastair’. International Journal of Transactional Analysis Research. 2014; 5(2):66-76. [DOI:10.29044/v5i2p66]
Furqon N, Yusuf S, Rusmana N. Solving adolescent verbal aggressions through transactional analysis counseling approach. Journal of Education and Practice. 2016; 7(18):169-77.
Sepehrian-Azar F. [Effectiveness of psychotherapy transaction analysis in decreasing symptoms of generalized anxiety disorder (Persian)]. The Journal of Urmia University of Medical Sciences. 2015; 26(4):311-9.
Alkasir E, Jafarian Dehkordi F, Mohammadkhani P, Soleimani-Sefat E, Atadokht A. Effectiveness of transactional analysis group training in reducing control-oriented behaviors of spouse in marital conflicts. Iranian Rehabilitation Journal. 2017; 15(1):57-64. [DOI:10.18869/nrip.irj.15.1.57]
Mostafavi S, Ghojavand K, Mosavi S. [The effect of group counseling with transactional analysis method on self-acceptance of couples with family dispute in counseling centers in Esfahan city (Persian)]. MAGNT Research Report. 2014; 2:27-31.
Nayeri A, Lotfi M, Noorani M. The effectiveness of group training of transactional analysis on intimacy in couples. Procedia-Social and Behavioral Sciences. 2014; 152:1167-70. [DOI:10.1016/j.sbspro.2014.09.294]
Pines A. Couple burnout: Causes and cures. New York: Routledge; 1996.
Adibrad N, Adibrad M. [The Relationship between communication beliefs and couple burnout and comparison in women seeking divorce and women seeking to live together (Persian)]. Journal of Counseling Research. 2005; 4(13):99-110.
Ebadatpour B, Navabinejad S, Shafiabadi A, Falsafinejad M. [Formulation of a pattern for marital burn out based on family function, individual resilience and spiritual beliefs (Persian)]. Journal of Psychological Methods and Models. 2014; 3(13):29-45.
Tizdast T, Jafari Senejani M. The effect of Eric Berne’s transactional analysis on parent-child conflict. International Journal of Philosophy and Social-Psychological Sciences. 2016; 2(2):40-5.
Van Rijn B, Wild C, Fowlie H, Sills C, Van Beekum S. Impact of transactional analysis psychotherapy training on self awareness and ability for contact. International Journal of Transactional Analysis Research & Practice. 2011; 2(1):16-24. [DOI:10.29044/v2i1p16]
Reza Ostovar J, Ghorban Shiroodi S, Karimi B. The effect of participation in group counseling sessions of transactional analysis on the marital burnout, adjustment and intimacy. Family Pathology, Counseling and Enrichment Journal. 2018; 3(2):21-44.
Amini M, Amini Y, Hosseinian S. Efficacy of couples communication skills group training using interaction analysis approach (TA) on reducing marital conflicts. Journal of Family Counseling and Psychotherapy. 2013; 3(3):377-401.
Sodani M, Mehrabizadeh Honarmand M, Soltani Z. The effectiveness of transactional analysis training on family function of maladjusted couples. Family Counseling and Psychotherapy. 2012; 2(3):268-87.
Pines A. Couple burnout: Causes and cures. New York: Routledge; 2013. [DOI:10.4324/9781315022291]
Tangolo AE, Massi A. A contemporary perspective on transactional analysis group therapy. Transactional Analysis Journal. 2018; 48(3):209-23. [DOI:10.1080/03621537.2018.1471288]