اثربخشی زوج درمانی تلفیقی به روش دایمند بر پیوستگی، انطباق پذیری و صمیمت زوجین بعد از تولد فرزند اول

The effectiveness of integrative couple therapy via Diamond method on continuity, adaptability and intimacy of couples after the birth of the first child

Sotoodeh Navroodi, S.O*[1]; Nicknam, M[2]; Fatahi Andabil, A[3]

Abstract

Introduction: The beginning of parenthood is a special stage in family life, because couples are looking for a new adaptation at this stage. The present study was conducted with the aim of investigating the effectiveness of integrative couple therapy via Diamond method on continuity, adaptability and emotional intimacy of the couples after the birth of the first child.

Methods: The present study was conducted as a quasi-experimental study with a pretest-posttest and a control group, which was randomly selected by availability sampling (convenience sampling) and divided into two experimental and control groups. The statistical population consisted of 32 parents with a child under 5 years of age who referred to the Rasht Rehabilitation Counseling Center from November 2018 to May 2019, who were assigned to two experimental (16 people) and control (16 people) groups. The experimental group underwent integrative couple therapy using Diamond method in eight 90-minute sessions. The data were evaluated using Schaefer & Olson's intimacy questionnaire and Olson et al.'s adaptability and cohesion questionnaire. The data were analyzed using covariance analysis and via SPSS Statistics 22v.

Results: Integrative couple therapy via Diamond method has had a significant effect on increasing continuity, adaptability and emotional intimacy of couples after the birth of their first child (P< 0/05).

Conclusion: As a result, it can be stated that the use of integrative couple therapy via Diamond is effective and efficient for couples who have problems in their marital relations after the birth of their first child.

Keywords: adaptability, continuity, integrative couple therapy, intimacy

Received: 5/September/ 2022                   Accepted: 18/October/2022

Introduction:

The birth of a child completes the dreams of parenthood, and on the other hand, it is the beginning of difficulty for parents. Although levels of anxiety are expected for this period, severe anxiety can have a negative effect on couple's relationships. In fact, changes in lifestyle and roles increase stress and decrease quality of life and dynamics of couples' relationship (1; 2). Family therapists have described the birth of the first child and the changes that accompany the couple's transition to parenthood, as a "crisis" (3). The birth of a child can have a positive effect on the marital relationship, as it can increase the love between couples and bring about a new parenting identity for the couples (4;5). However, some studies have shown that marital satisfaction declines after 15 years and after being a parent. Marital conflicts and couples' hostility toward each other increase and emotional intimacy decreases (6;7); also, passion, sex and emotion decline. To the extent that researches have shown, stressors resulting from parenthood are the strongest contributing factors to decreased marital satisfaction (3;8) and may appear as problems in sexual function, fatigue and exhaustion (9;10). Another study also showed that marital adjustment and parenting competence decreased significantly in couples after birth of a child (11;12). Although, the effects of child birth on parental subjective well-being depend on many factors such as demographic characteristics, life cycle stages as well as location and context of the couple's life, but the basis of family formation and growth is the quality of communication between couples (13;14).

Marriage is formed by developing intimate relationships, and having intimate relationships with others is one of the greatest human blessings, so that it seems nothing can contribute to the psychological well-being and quality of human functioning as it (15). However, reaching out to intimate relationships is not easy and a great bond like marriage does not guarantee reaching it. Since intimacy is a basic need and beyond human needs, so developing intimacy between spouses is the first step towards developing a desirable marriage (16;17). Many researchers have reported that the need for closeness and connection with others is inward and universal in humans and that intimate relationships are important sources of happiness, meaning, and satisfaction in life (4;18).

Cohesion and adaptability are also two aspects of marital and family behaviors that are the basis for understanding family and marital processes and the index of family health (19). There is considerable agreement among family therapists that family cohesion and adaptation are the most important concepts for understanding family functioning (12). In healthy family systems, members have good emotional relationships, roles are flexible and people are interconnected, but in unhealthy family systems roles are inflexible and rigid. Researches indicate that there is a significant relationship between family cohesion and adaptation with goal setting, dimensions of perfectionism, emotional intelligence, healthy eating behaviors, life satisfaction, and psychological problems (3). Cohesion, as one of the most influential structures of the family, is the feeling of solidarity, bond, and emotional commitment that members of a family have to one another (19). Families with strong backgrounds regularly schedule time and activities for group activities. Warm relationships and emotions, commitment and spending time for each other, as well as bonding and emotional commitment among family members are among the key characteristics of cohesive families (12; 20).

Although many studies have shown that there is a relationship between child birth and the dimensions of marital relationship, there are not enough therapeutic plans and models designed to intervene the marital relationships or have not achieved that much success in marital satisfaction of couples having children (2; 21). Researches have shown that educational interventions have no effect on postnatal marital communication and cannot prevent marital satisfaction (22; 23). On the other hand, the Family Foundations Prevention (FF) Intervention Program is a couple-centered program designed for couples in transition to parenthood. This program has had positive long-term effects on improving the performance of parents, couples, and children (24; 25). Dimand's Integrated Couple Therapy is a permanent program designed for couples who have been parents newly. This four-dimensional program is based on the four essential dimensions of commitment, consideration, connection and communication. This treatment is a combination of Gutman, Harvey Hendrix, Couple Cognitive Behavioral Therapy, Attachment Theory, Short Term Mixed Couple Therapy, and Structural Couple Therapy to increase the satisfaction of couples who have a child under 6 years old (1; 2; 6).

This treatment program has six stages: 1) Diagnostic evaluation of couples 2) Identification of desired behavioral change 3) Evaluation of available treatment modalities 4) Identification of aspects of couple’s therapy for work, 5) Application of combination therapy and 6) Re-evaluation of couples after treatment (2). In this regard, the results of the studies showed that Dimand's permanent couple therapy is effective on increasing marital satisfaction after the first child 's birth, and that the relationship training to couples helps them to maintain their satisfaction of relationship high and stable (2; 6). Therefore, identifying the vulnerable stages of marital relationship and designing educational and therapeutic interventions to maintain, continuity and enhance of this critical social unit is a necessity for family and couples’ therapists, and designing educational and preventive programs is of particular importance. Training programs also prevent couples from entering the progressive cycle of subsequent injuries, leading more therapists to use integrated approaches to address multifaceted family structure problems.

Research Method:

The present study is a quasi-experimental study with pretest, posttest, follow-up and control group. The statistical population consisted of all couples with one child under 5 years old who attended Ehya counseling centers of Guilan from November 2018 until the end of May 2019. The sample size of the study consisted of 32 individuals (16 parents of experimental group and 16 parents of control group) who were selected by available sampling method and according to inclusion criteria (minimum degree of diploma education, at least seven years of marital life experience, dissatisfaction with marital relations, having only one child under the age of 5 years, earning a score one standard deviation lower in the questionnaires, and committing to attend all treatment sessions in pairs), and exclusion criteria (being in psychotherapy or psychiatry courses other than this course, deciding to separate, having psychological disorders, and abusing drug) were selected and were randomly divided into two groups of control and experimental. Participants of the experimental group received 8 sessions of Dimand's integrated couple therapy and participants of the control group were placed in waited list. All subjects were evaluated in three stages (pre-test, post-test, one-month follow-up), using questionnaires of Family Adaptation and Cohesion Assessment Scale, Personal Intimacy Assessment Questionnaire and Communication Quality of Couples. The data collection tool of the study was a series of questionnaires including: Family Adaptation and cohesion assessment Scale and Personal Intimacy assessment questionnaire

Family Adaptation and Cohesion Assessment Scale (FACES-2): The Family Adaptation and Adaptation Scale (FACES-2) was developed by Olson, Bell, and Prentner. The scale has 30 items, 14 of which measure adaptation and 16 of them measure cohesion. The scores obtained in the dimensions of adaptability and cohesion are used to represent balanced and unbalanced families in the complex circular model. The scoring is Likert-type, with responses ranging from 1 to 5. High scores on this scale indicate that the family performs well. Olson obtained the reliability coefficient of the Family Adaptation and Cohesion Assessment Scale, using Cronbach's alpha for cohesion, adaptability, and for the whole Family Adaptation and Cohesion Assessment Scale, 0.87, 0.78, and 0.90, respectively (26).

 Personal Intimacy Assessment Questionnaire: The Personal Intimacy Assessment Questionnaire was developed by Schafer and Olson. Using this questionnaire, people describe their communication intimacy according to what they are currently experiencing in their relationship as well as what they expect from the relationship. The questionnaire is a 36-item self-report tool used to rate items from a 5-point Likert-style scale of 1 to 5. In this questionnaire, higher scores indicate greater intimacy. Schafer and Olson estimated the reliability of the questionnaire subscales using Cronbach's alpha between 0.70 to 0.77 (27; 28). 

In the present study, to apply the independent variable, an integrative couple therapy protocol via Diamond method was used (2). Diamond integrative couple therapy program was implemented for eight weeks, one session per week for 90 minutes as follows:

Table 1: Summary of integrative couple therapy sessions using the Diamond method

Results:

In this research, data was analyzed using SPSS-22 software. To examine the effectiveness of the intervention, univariate analysis of covariance (ANCOVA) was used. The maximum level of alpha error to test the hypotheses, was considered 0.05 (P < 0.05). In Table 2, the level of education of the respondents was examined. Chi-square test was used to examine the homogeneity of respondents' education.

Table 2: Describing the level of education of the respondents along with the Chi-square Homogeneity test

The results of chi-square test showed that there is no significant difference in terms of education between the two groups (P>0.05). The results showed that most of the respondents in the two groups had bachelor's and master's degrees. Also, the mean and standard deviation of the age of the participants of the control group was 36.18 ± 2.04 years and the experimental group was 35.62 ± 2.77 years, and the mean and standard deviation of the history of the marriage in the control group was 7.64 ± 0.96 and in the experimental group was 1.20 ± 7.87 years.  The result of the independent t-test showed that the two groups were homogeneous in terms of age and marriage history (P>0.05). 

Table 3 describes the main variables (continuity, adaptability and emotional intimacy). The variables are described using mean and standard deviation statistics.

Table 3: Mean and standard deviation of continuity, adaptability and intimacy based on Group and test time

Multivariate covariance analysis was used to investigate the effect of integrative couple therapy via Diamond method on continuity, adaptability and intimacy of couples after the birth of the first child. The results of the pre-test and post-test regression slope homogeneity test of adaptability and continuity components in the experimental and control groups showed that the regression slope was the same in both groups (P < 0.089, F2.27=1.606). The results of Levine's test to examine the homogeneity of the variance of the dependent variables in the groups showed that the variance of the components of adaptability (P < 0.036, F = 1.30 =4.803) and continuity (P < 0.007, F1.30=8.381) is not equal in groups. The results of the Box test to examine the equality of the covariance matrix of the dependent variables between the experimental and control groups also showed that the covariance matrix of the dependent variables was equal in the two groups (P<0.947, F=0.122, BOX M=0.396).The results of Bartlett's chi-square test to examine the sphericity or significance of the relationship between the components of adaptability and continuity showed that the relationship between these components is significant (p<0.036, d.f=5, X2= 6.631). After examining the assumptions of multivariate covariance analysis, the test results showed that there is a significant difference between the two groups in the components of adaptability and continuity (P < 0.001, F = 27.2= 548.530, Wilk’s Lambda=0.024). In order to examine which of the components of adaptability and continuity between the experimental and control groups differ from each other, the results of multivariate covariance analysis are reported in Table 4.

Table 4: results of multivariate analysis of covariance the difference between the experimental and control groups in the components of adaptability and continuity

According to Table 4, the F statistic for the components of adaptability (231.225) is significant at the 0.001 level and continuity (653.998) at the 0.001 level. These findings indicate that there is a significant difference between the groups in these components. The results of examining the corrected averages show that the average of the experimental group in adaptability (39.78) and continuity (44.48) is higher than the average of the control group in these components with an average of 30.33 and 35/63, respectively. According to these findings, it can be said that integrative couple therapy with Dimond approach increases the adaptability and continuity of parents after the birth of the first child. Also, the effect size in Table 3 shows that group membership explains 89% of the changes in adaptability and 95% of the variance of continuity.

Univariate covariance analysis was used to investigate the effectiveness of integrative couple therapy via Diamond method on parents' emotional intimacy after the birth of their first child. The results of the homogeneity test of regression slope of pre-test and post-test of emotional intimacy in experimental and control group showed that the regression slope is equal in both groups (P < 0.08, F1.28= 3.33). The results of Levin's test to investigate the homogeneity of the variance of the dependent variable in the groups showed that the variance of emotional intimacy in the groups is equal (P < 0.691, F1.30 = 0.162). Table 5 shows the results of univariate covariance analysis to investigate the difference between the experimental and control groups in the pre-test and post-test of the emotional intimacy variable.

Table 5: Results of univariate analysis of covariance the difference between the experimental and control groups in the intimacy

According to Table 5, the F statistic of emotional intimacy in the post-test is 370.156, which is significant at the 0.001 level, and this shows that there is a significant difference between the two groups in terms of emotional intimacy. The effect size of 0.92 also shows that this difference is large in statistical population. The results of covariance analysis showed that the corrected average of the experimental group in emotional intimacy is 16.40 and the average of the control group is 11.02, which is significant at the level of 0.001 according to the F statistic. According to this finding, it can be said that integrative couple therapy via Diamond method increases the emotional intimacy of parents after the birth of the first child.

Conclusion and Discussion:

The results of this study showed that Dimand's integrated couple’s therapy method led to increased cohesion and adaptability and intimacy of the studied couples. These results are consistent with the findings of previous studies by Abbaspour, Salehi & Choobdari (29) based on the effectiveness of Dimand's integrated couple therapy on marital coordination and parental competency, and a study by Bash (2) on the effectiveness of this method on increasing marital satisfaction after birth of the first child. In explaining these results, it can be said that one of the indicators indicating the health or unhealthiness of marital relationships is considering dimensions such as cohesion, adaptability, intimacy between couples that are associated with individuals' mental and physical health. In fact, birth of the first child and couples facing new challenges in life and changing roles can leave couples in a sea of turmoil that require healthy coping skills to maintain basic family frameworks such as cohesion, adaptability and intimacy. Although couples may seek treatment for a variety of reasons, they often seek to restore the intimacy and appropriate relationship that they once had with each other and changed with the presence of children and changes in the normal course of life (1; 7). People who experience a higher degree of intimacy in relationships can present themselves in a more desirable way in relationships and express their needs more effectively to their partner and spouse (4). Healthy intimate relationships and having appropriate quality of communication and existence of cohesion in family can contribute to the psychological well-being of each couple by providing a space where both couples can meet their important needs. Satisfaction of intimacy needs, which is a common need between two couples, is positively correlated with marital satisfaction and self-esteem and negatively associated with symptoms of depression and anxiety, psychological distress and loneliness (7; 18).

The inefficiency of families in the area of cohesion and adaptation resulting from the dysfunction of individual’s actions is the interaction process between family members. Communication skills enables families in expressing basic needs and their prioritizing in connection with cohesion and adaptability and lack of these skills, minimizes the ability of family members to express feelings, thus limits their moving in dimensions of cohesion and adaptability. So, with the birth of a new child and the weakness of parents to cope with this important role, it leads to a reduction in warm relations, commitment, spending time and energy for family members and repression of feelings, inflexibility, lack of awareness, emotional separation and overuse of defensive mechanisms, all of these are rooted in lack of self-esteem and weak relationships, can disturb the family interactions (20).

Therefore, the use of Dimand's integrated couple therapy approach is a designed program for couples who have a child recently. This four-dimensional program is based on the four essential dimensions of commitment, consideration, connection and communication. This treatment is a combination of Gutman, Harvey Hendrix, Couple Cognitive Behavioral Therapy, Attachment Theory, Short Term integrated Couple Therapy, and Structural Couple Therapy to increase the satisfaction of couples who have a child under 6 years old (2). This method helps couples spend time together as a homework assignment and talk about their personal issues. These designated times, in addition to the perception of the marital relationship along with the feeling of shared parenting, with associating the time before the baby is born, had a sense of reassurance that the two have a stronger relationship. Couples' agreements on parental responsibilities can also minimize marital conflicts. Couples who can manage conflicts of their relationships by using positive methods and using fewer negative interactions, create an environment where there is more opportunity for self-disclosure and agreement on family problems and this is one of the important methods in creating intimacy, cohesion and quality of communication in the family. In explaining these results, it can be stated that in this integrative therapy, couples can minimize their differences by talking about the nature of responsibilities and shared attitude. Also, by strengthening the social support of couples, this program helped them to perceive themselves together and reduce the feeling of loneliness and responsibility of couples. This feeling leads to an increase in more positive interactions, trust and marital harmony in sensitive times, and probably dimensions of social support, including emotional support (the availability of one of the spouses when the other is under pressure and needs care, such as expressing feelings, worries, fears, approval, love and acceptance), instrumental support (practical help that one gives to another, such as cooperation in household affairs and child care), informational support (providing knowledge, guidance and giving advice to each other), social support (accompanying and spending time with each other, including going on vacations, participating in friendly gatherings, eating together, going to the movies) and validating (recognizing each other's behaviors and feelings as normal and helping each other in problems), have expanded. When couples do these joint activities, respect, appreciation and connection between them increases and more harmony is formed between couples in a way that they can act like a team. All these joint activities, in addition to understanding the marital relationship, along with the feeling of joint parenthood, with the association of the time before the birth of the child, have resulted in a feeling of confidence that the relationship between two individuals will become stronger. Couples' agreements on parenting responsibilities can also minimize marital conflicts. Couples who can manage the conflicts in the relationship by using positive methods and using fewer negative interactions, create an atmosphere in which there is more opportunity for self-disclosure and agreement about family problems, and this is one of the important ways to create intimacy, connection and quality of communication in the family.

Recommendations: 

It is suggested to increase the generalizability of the results, at the level of the research proposal, to conduct this study in other provinces and regions and societies with different cultures, and also by controlling other influential factors such as the employment status of both couples, financial status, having the support of the couple's family, and so on. Considering the effectiveness of the integrative couple therapy via Diamond approach on the dimensions of continuity, adaptability and emotional intimacy at the practical level, it is suggested that this treatment approach be introduced to family therapists and counselors at the level of universities, municipal cultural centers and judicial counseling centers, so that they can take a scientific step by using this therapeutic approach to improve the quality of life of couples and prevent bigger problems in couples' relationships.

Research limitations

The scope of the research is limited to parents referring to the counseling centers of Rasht city, who have been living together for at least 7 years. The lack of control of some variables affecting the level of marital satisfaction and the investigated dimensions, such as the employment status of both couples and the socio-economic conditions and the interaction with the families of both individuals was one of the limitations of the present study.

Applied research results

The results of this research can be used to help new parents to adapt to the new role of parenthood and solve their communication problems and finally increase family cohesion and intimacy between couples.

Ethical considerations

This research is based on the doctoral thesis of Seyed Omid Sotoudeh with the supervision of Dr. Mozhgan Niknam and the consultation of Dr. Azam Fatahi in the field of counseling at the Islamic Azad University of Roudhan, with the thesis number 11321602971021. Also, the permission to implement it on sample people has been issued from the Welfare Organization of Gilan province with the letter number 934/98/49237 dated 2/7/2018 and the code of ethics 254. 2019.IR.GUMS.REC.

Conflict of Interests

The authors declared no Conflicts of interest.

Acknowledgement

We hereby express our gratitude and appreciation to all the dear ones who helped us in carrying out this research, especially the welfare organization of Gilan province, the kindergarten center of the province and the management of the rehabilitation counseling center where the parent training sessions were held.

References:

[1] . PhD Student, Department of Counseling, Roodehen Branch, Islamic Azad University, Tehran, Iran

Orkid cod:240266529   Email: omid.sotodeh@yahoo.com

[2] . Assistant Professor, Department of Counseling, Roodehen Branch, Islamic Azad University, Tehran, Iran, Nicknam.mojgan@gmail.com, ORCID: 000000315523288

[3] . Assistant Professor, Department of Counseling, Roodehen Branch, Islamic Azad University, Tehran, Iran, Orkid cod:306359404