Effectiveness of Cognitive Behavioral Couple Therapy on Reducing Depression and Anxiety Symptoms and Increasing Dyadic Adjustment and Marital Social Skills: An Exploratory Study

Abstract

Several kinds of marital conflict might be solved through constructive communication, development of interaction skills, and behavioral and thought modification. The aim of this study was to show results of the application of a protocol based on cognitive behavioral couple therapy (CBCT) on dyadic adjustment, marital social skills, depression, and anxiety symptoms. The sample consisted of 32 participants (16 couples) divided in two groups by length of marriage: Group 1 (1–7 years) and Group 2 (8–12 years). All subjects recruited were older than 18 and reported having communication problems in their relationship. The ages were M = 30.4, SD = 4.13. The measures were Dyadic Adjustment Scale (DAS), Beck Depression Inventory–II (BDI-II), Beck Anxiety Inventory (BAI), Marital Social Skills Inventory (Inventário de Habilidades Sociais Conjugais [IHSC]), and the Sociodemographic Questionnaire. Participants were assessed pre- and postintervention and had a 6-month follow-up. The intervention consisted of twelve 50-min sessions per couple. Based on three time analyses, both groups obtained the following results: DAS (p = .001), BDI-II (p = .000), BAI (p = .000), and IHSC (p = .001). We conclude that the CBCT protocol developed for this study, resulted in statistically significant improvements in the couple’s relationship for all variables studied in both groups.

Keywords

cognitive behavioral couple therapy communication skills dyadic adjustment depression anxiety

Indeed, the ability to communicate is shown to be one of the main skills for problem-solving. Several kinds of marital conflict may be solved through constructive communication, development of interaction skills, behavior modification, and negative thinking organization (D. H. Baucom et al., 2010; Shayan et al., 2018). Usually, each spouse brings different patterns of behavior and thoughts to their conjugal relationship, such as self-conflict, patterns of right and wrong, and rigid beliefs (K. J. W. Baucom et al., 2011; Dattilio, 2009; Epstein & Zheng, 2017). These rooted beliefs make couples increasingly resistant to change, and often incompatible with the reality of married life, thus generating further conflicts (A. T. Beck & Haigh, 2014; Butler et al., 2006; Padesky, 2004). Interventions that include positive interactions between partners such as assertion and communication skills diminish misunderstanding and conflicts in the relationship (Ammari et al., 2016; Dugal et al., 2018; Halford & Doss, 2016). The quality of the relationship may be indicated by the effectiveness of how couples solve their conflicts. Satisfying marital relationship might lead to happiness, social support and buffer several stressors (Karney & Bradbury, 1995; Robles, 2014).

Dyadic Adjustment, Marital Length, Gender, and Children

Protective factors in marital life might be intrapersonal or intra-dyadic (e.g., spirituality, commitment, personality, empathy, being supportive, self-acceptance, and other-acceptance) and interpersonal or extra-dyadic (e.g., communication, sexual relationship, intimacy, religious agreement, mutual respect, spending quality time, problem-solving, and conflict resolution). Besides aspects such as children, financial and gender issues may extend beyond these factors and might link to either stability or instability in long-term marriage (Karimi et al., 2019; Sorokowski et al., 2017). For example, in North American countries, the most prominent aspects in a couple’s relationship that is linked to marital stability consists of religion, sexual relationship, commitment, intimacy, and congruence in values and beliefs. On the other hand, in Asian countries, the most prominent factors include communication, religion, children, conflict resolution, and emotional issues. In European countries, sexual relationship, commitment, relationship satisfaction, and support from one’s mate are the most important factors for long-term marriage (Karimi et al, 2019; Sorokowski et al., 2017).

Jackson et al. (2014) showed results of meta-analysis of marriage duration and revealed small gender differences among participants married an average of 4 years or less and no gender differences among participants married an average of 5 years or more. It suggests that husbands are slightly less satisfied than wives in the first 4 years of marriage. In addition, on average, women report less marital satisfaction than men. In couples therapy, wives were substantially less satisfied with their marriages than their husbands.

Research has been shown that marital length correlates with marital satisfaction. Sorokowski et al. (2017) showed results of data from 7,767 individuals collected in 33 countries different effect of satisfaction in marital relationships (i.e., decreases with a length) or U-shaped (i.e., decreases in the beginning and increases after some time). However, it may differ across cultures as, for example, in arranged marriages relationship, satisfaction might be lower in the first year of the relationship (Lampis et al., 2018; Sorokowski et al., 2017).

Other important issues that have long been identified in literature as a predictor of marital satisfaction is gender. In general, men tend to report feeling more satisfied with their marriage compared to women. However, sex differences in marital satisfaction may differ across cultures due to traditional sex roles and other cultural variables (Jackson et al., 2014; Sorokowski et al., 2017). Different genders have different ways of portraying negative feelings, which may lead to depressive symptoms. For example, men may act distracted or avoid expressing negative emotions. On the other hand, women may confront or ruminate as response to their negative emotions (Meyer et al., 2019).

Concerning marital relationship and children, Sorokowski et al. (2017) and Ghahremani et al. (2017) have showed results from different cultures and revealed different results regarding the correlation between the number of children and marital satisfaction and suggest that it dependent of cultural factors. This studies also indicated that the mean score of marital satisfaction in participating women differed significantly depending on the number of their children. Thus, it was found that marital satisfaction tends to decrease with an increase in the number of the children, while increasing conflict in the relationship.

Cognitive Behavioral Couple Therapy (CBCT)

CBCT techniques aim to help couples with poor communication skills and problem-solving difficulties that affect the interaction process in the relationship. Training couples in communication skills, problem and conflict resolution, identification and expression of emotions, expression of affection and sexual problems, cognitive restructuring, and acceptance and tolerance are significant topics in couple therapy (Dugal et al., 2018; Epstein & Zheng, 2017; Sher, 2011). Furthermore, it is important to consider a partner’s vulnerabilities and the impact of the environment as a probable influence in the partner’s cognitions, emotional responses, behaviors, and the couple’s functioning (Halford & Doss, 2016). Marital adjustment is associated with better expectations about marriage and results in cost-benefit outcome (A. T. Beck, 1989; Dattilio & Padesky, 1990).

Thus, satisfaction with the conjugal relationship is more intrapersonal than an interpersonal concept. This is due to the various unrealistic expectations that a spouse has of their partner, the relationship, and the rewards received (Miller et al., 2013). In fact, unhappy couples tend to have more dysfunctional interactions and behaviors than those in a happy relationship. In addition, couples living in conflict tend to lack communication and problem-solving skills, have defensive attitudes, are emotionally detached, and are vulnerable to mental diseases and at risk of psychological disorders (D. H. Baucom et al., 2010; A. T. Beck, 1989). Several implications including physical, cognitive, behavioral aspects, and stress arise as a result of marital distress (Halford & Doss, 2016). Furthermore, relationship distress may predict the onset of an individual’s first episode of depression or anxiety.

Ongoing depression and anxiety symptoms might also predict weakening of the couple’s relationship satisfaction (Halford & Doss, 2016). Thus, CBCT may help increase the feelings of well-being and can lead to an increase in the couple’s physical and mental health or in reducing marital disappointment (Maleki et al., 2017). When depressive symptoms act as risk factors for maladjustment in the relationship, couple therapy for depression may be effective in reducing depressive symptoms and solve relationship problems (Dugal et al., 2018). Improvements in the perception of marital adjustment significantly reduce depression levels, especially in women (Miller et al., 2013). As a result, men also report greater marital satisfaction with this change in women’s perception.

Furthermore, women report that positive changes in their thoughts, attitudes, and behaviors are related to the perception of increased positivity and support from their husbands (Cohen et al., 2014). In order to alleviate spousal suffering, it is necessary to develop specific interventions that promote health and well-being, as well as offer resources that help to nurture loving relationships and develop communication and problem-solving skills, thereby improving dyadic adjustment and marital satisfaction (Fischer et al., 2016; Kavitha et al., 2014). Interventions that are based on psychoeducation and marital social skills are alternatives that are increasingly relevant for individual care and for couples.

These therapeutic interventions have helped couples with learning, reflection, awareness, and empathy that tend to improve levels of health and well-being (Fischer et al., 2016; Halford & Doss, 2016; Moazinezhad & Arefi, 2017; Sher, 2011). Cognitive behavioral therapeutic interventions have been effective in improving inappropriate communication (K. J. W. Baucom et al., 2011; Yalcin & Karahan, 2007) and solving marital problems (Dattilio, 2009; Wright et al., 2010). Its application for couples can help enable each spouse to understand how their behavior is associated with their way of thinking and their emotional reactions and how this can contribute to marital maladjustment (J. S. Beck, 2011; Dattilio, 2009; Schlesinger & Epstein, 2007).

In the process of cognitive restructuring, it is important to assist the person with the process of identifying the emotion, thought, and behavior related to significant suffering within a specific context and to reflect on the advantages and disadvantages in each specific situation (Charchat-Fichman et al., 2012; D. Dobson & Dobson, 2009; K. S. Dobson & Dezois, 2010; Hawton et al., 1992). In summary, CBCT treatments may improve relationship satisfaction and promote well-being and also reduce emotional and psychological violence (Hurless & Cottone, 2018). It is necessary to note that long-term intimate relationships in conflicts might lead to a range of harm psychosocial variables, aggressive behaviors, and greater risk and vulnerabilities for mental disease (Rajani et al., 2016). On the order hand, healthier people are more likely to remain in an intimate relationship and they tend to have more resources to solve problems. Moreover, cognitive behavioral therapy (CBT) training can act as protection to relationships (Halford & Doss, 2016). Cognitive phenomena, such as perception and expectations of the relationship, assumptions, partner assignments, and thought patterns, may influence behavior and affect one’s response to events in a loving relationship (D. H. Baucom & Epstein, 1990).

The aim of this article is to show the results of the application of the protocol based on CBCT on dyadic adjustment, marital social skills, depression, and anxiety symptoms.

Method

Participants

The sample consisted of 32 participants (16 heterosexual couples) divided into two groups by length of marriage: Group 1 (1–7 years) and Group 2 (8–12 years). The couples recruited were all Brazilians from Brown skin color, fluent and literate in Portuguese, and older than 18 and 37.5% had completed high school. The mean ages were 30.4 years (SD = 4.13). All the couples were included for having communication problems in their relationship.

Sample Selection

Participants of this study was recruited for in high schools, universities, and churches by posters, announcement, and oral presentation. Couples contacted us through email, WhatsApp, and cellphone and were recruited to the first step of enrollment and screening (inclusion's criteria: No drug addictions, between 1 and 15 length of marriage, and communication problem in the relationship). Couples selected were invited to sign the informed consent form and filled out the Sociodemographic Questionnaire. One week after, an appointment was scheduled with each couple in order to complete the measures instruments (see Measures section) and then sorted in two groups for marriage length (Group 1[G1], 1 to 7 and Group 2[G2], 8 to 13). Of the 20 couples selected, 16 completed the therapy in 12 sessions. Four couples dropped out of the study – three of them not started in the therapy and one of them gave up on sixth session (see Flow Diagram in the Figure 1).

Figure 1.
Flow diagram of recruitment and inclusion.

Measures

Dyadic Adjustment Scale (DAS)

The DAS is a valid and reliable version (Hernandez, 2008; Spanier, 1976). The self-reported measure contains 32-item scale with four subscales: consensus, satisfaction, cohesion, and affectional expression. The total score ranges from 0 to 151 with higher scores indicating a better adjustment to one’s relationship. The internal consistency coefficients obtained in this study was α = .92.

Beck Depression Inventory–II (BDI-II)

This inventory is a valid and reliable version (A. T. Beck et al., 1996). This inventory consists of 21 items on a 4-point scale ranging from 0 (symptom absent) to 3 (severe symptoms). The total score is the sum of the highest ratings for all 21 items. The minimum score is 0 and maximum score is 63. A total score of 0–13 is considered the minimal range, 14–19 is mild, 20–28 is moderate, and 29–63 is severe. The internal consistency coefficients obtained in this study was α = .92.

Beck Anxiety Inventory (BAI)

This inventory (Beck et al., 1988; Cunha, 2001) consists of 21 items with a Likert-type scale ranging from 0 to 3 and raw scores ranging from 0 to 63. It was developed in 1988 and a revised manual was published in 1993 with some changes in the scoring process. The BAI scores are classified as minimal (0–7), mild (8–15), moderate (16–25), and severe anxiety (30–63). The internal consistency coefficients obtained in this study was α = .90.

Marital Social Skills Inventory (Inventário de Habilidades Sociais Conjugais [IHSC])

This inventory is a valid and reliable version (Villa & Del Prette, 2012). This inventory consists of 32 items across five factors (assertive communication, expression of positive feeling/pleasure, expression of disagreement/dislike, disinhibition/spontaneity, and control of aggression). The total score ranges from 32 to 160. The internal consistency coefficients obtained in this study was α = .83.

Dysfunctional thoughts record (DTR)

These records are cognitive restructuring techniques which encourage balanced thinking (Burns, 1999). This tool is a style of thought record which encourages identification of any cognitive biases/cognitive distortions. It is composed of questions such as: What is the evidence that the automatic thought is true? Is there an alternative explanation? What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic outcome? What’s the effect of my believing the automatic thought? What could be the effect of changing my thinking? What should I do about it? If (e.g., friend) was in the situation and had this thought, what would I tell him/her?

Sociodemographic Questionnaire

This questionnaire contained the following items: sex, children, age, educational level, income, religion service, and divorced parents.

Procedures

All participants were assessed pre- and postintervention and had a 6-month follow-up using the measures described above. The intervention consisted of 12 sessions (once a week) per couple, each lasting 50 min. Each session followed steps and time (see Table 1).

Table 1.
Structure of One Session (50′).

Steps Contents Time

First Greeting; brief update on the week and homework review. 10′

Second Mood checking. Noting whether humor has changed in comparison to previous sessions. We used a scale from 0 to 10/100. 2′

Third Setting the agenda, in collaboration—therapist couple. 5′

Fourth Use of agenda items and therapeutic tools. 25’

Fifth Setting new homework. 3′

Sixth Feedback and summary request for the current session. 5′

Each couple discusses the issues raised in the current session, drawing their final conclusions. They can also comment on whether they got the help they needed that day, and whether they felt fully understood. Between the 11th and last session, there was a gap of 15 days. We divided the couples into two groups (years of marriage) in order to verify the efficacy of therapy to couples in recent and older relationships. Table 2 shows the structure of the 12 Sessions.

Table 2.
Structure of the Therapy (12 Sessions).

Session Content Homework (Action Plan)

1st (Conjoint) Rapport, psychoeducation of CBCT approach. Reading

2nd (Individual) Identifying cognitive, emotional, and environmental factors that affect a couple’s functioning. Reading

3rd (Conjoint) Showing case conceptualization and treatment plan. Self-monitoring tasks

4th (Conjoint) Identifying and naming of emotions and thoughts. Identifying the interrelations between the couple’s cognitions, emotions, and behaviors. Self-monitoring tasks

5th (Conjoint) Cognitive distortions and communication. Monitoring of cognitions + DTR

6th (Conjoint) Communication training and role-playing. Reading + DTR

7th (Conjoint) Communication training and role-playing. Considering difficulties in communication + DTR

8th (Conjoint) Marital social skills training and role-playing. Reading + DTR

9th (Conjoint) Marital social skills training and role-playing. Considering difficulties in social skills

10th (Conjoint) Problem-solving skills and action plan. Planning tasks

11th (Conjoint) Relapse prevention. Action plan (i.e., What, when, where, how often, and how long)

12th (Conjoint) Relapse prevention, feedback and summary of the treatment.

Note. After 12 sessions, in the next week, couple was invited for fill in Dyadic Adjustment Scale, Beck Depression Inventory–II, Beck Anxiety Inventory, and Marital Social Skills Inventory for the postassessment and 3 months after they filled in again for the follow-up appraisal. DTR = dysfunctional thoughts record; CBCT = cognitive behavioral couple therapy.

Characteristics and Training of the Therapists

The therapists have over 10 years of experience providing cognitive therapy to couples. In addition, we have received cognitive behavioral training and supervision. The supervisor has a PhD in clinical psychology and has over 30 years of experience. The main characteristics showed by therapists were interpersonal skills, such as verbal fluency and clarity in the instructions, interpersonal perception, empathy, and acceptance. The therapists also demonstrated beliefs in the client’s capability to form a collaborative working alliance and were aware of the context and characteristics of the patient and the importance of the tasks and goals of therapy. Thus, we presented the explanation and the treatment plan for the patients and the scales were managed in discussion with the client.

Data Analysis

Statistical tests were performed using software R to analyze the data. We used the mixed model for repeated measures to statistically verify the effect of the group on time (intragroup), to compare G1 and G2 between them (intergroup), interaction between the groups on time (pre, post, and follow-up), and the effect of the sociodemographic variables, sex and children, in the general scales (DAS, BDI-II, BAI, and IHSC) results. We assessed the efficacy of results by the increase in marital adjustment, reduction of depression and anxiety symptoms, and social skills in couples. For all analysis p ≤ .05 was considered statistically significant.

Results

The sociodemographic data of this study sample is presented in Table 3. It shows a low level of education and household income, high-level parental divorce, with the majority having either one or two children. Almost two thirds of the total sample reported to practice in religious services.

Table 3.
Sociodemographic Characteristics of the Sample.

Variables Man (n = 16) Woman (n = 16) Total (N = 32)

Age (years)—M (SD) 31.7 (SD = 3.11) 29.1 (SD = 4.69) 30.4 (SD = 4.13)

% (n) % (n) % (n)

Children 0 (none) 12.5 (2) 12.5 (2) 12.5 (4)

1 or 2 68.8 (11) 62.5 (10) 65.6 (21)

3 or 4 18.8 (3) 18,8 (3) 18.7 (6)

5 or beyond 0 6.3 (1) 3.1 (1)

Educational level CHS 25.0 (4) 50.0 (8) 37.5 (12)

IES 25.0 (4) 6.3 (1) 15.6 (5)

IHS 18.8 (3) 12.5 (2) 15.6 (5)

CES 12.5 (2) 12.5 (2) 12.5 (4)

IHE 6.3 (1) 12.5 (2) 9.4 (3)

CHE 6.3 (1) 6.3 (1) 6.3 (2)

PGS 6.3 (1) 0 3.1 (1)

Income R$500–2,000 81.3 (26)

R$2,100–4,000 18.8 (6)

Religious service Weekly 62.5 (10) 62.5 (10) 62.5 (20)

Divorced parents 75.0 (12) 68.8 (11) 71.9 (23)

Note. N = 32 participants. CHS = complete high school; IES = incomplete elementary school; CES = complete elementary school; IHE = incomplete higher education; IHS = incomplete high school; CHE = complete higher education; PGS = postgraduate student; SD = standard deviation.

Figure 2 presents the results of the analysis for intragroup (f = 11.129, p = .001), intergroup (f = 17.211), in the dyadic adjustment variable analyses. There was a statistically significant difference between the two groups over time for DAS. The group with more married time presented more maladjustment in the relationship compared to the group with less length of marriage, in the preintervention evaluation. However, CBCT intervention had a positive impact for both groups (p = .000). For the sex variables (f = 2,823, p = .104), there was no statistical relevance, that is, they had no influence on the results over time. However, number of children (f =* 5.048, p = .032) influenced the overall DAS result.

Figure 2.
Linear mixed models with repeated measures in three times for Dyadic Adjustment Scale (DAS) in two groups (G1: n = 14 participants; G2: n = 18 participants).

The results in Figure 3 present analysis for BDI-II in intragroup (f = 30.270, p = .000), intergroup (f = 2.787, p = .105). We also verified sex (f = 5.302, p = .029), children (f = 1.131, p = .310). Length of marriage had no influence on the depressive symptoms’ findings, however, for the group that had less length of marriage the reduction of symptoms levels was higher and remained at follow-up. Yet, the follow-up of the group married for longer demonstrated a tendency to continue to reduce depressive symptoms over time. Sex had a positive effect on the overall response of the BDI-II results. Women had more depressive symptoms in preintervention and reductions in post and follow-up were higher among men.

Figure 3.
Linear mixed models with repeated measures in three times for Beck Depression Inventory–II (BDI-II) in two groups (G1: n = 14 participants; G2: n = 18 participants).

Figure 4 present the results of the BAI. The findings were for intragroup (f = 25.930, p = .000), intergroup (f = 0.517, p = .478). The results of anxiety symptoms were similar to those of depression (see Figure 3) with regard to trends over time, that is, depressive symptoms tend to decrease over time for the group with longer married and a slight increase in anxious symptoms over time for the group married for less time. Regarding influence on the overall results to BAI, it was negative for sex variable (f = 0.035, p = .853). Number of children had influence (f = 7.891, p = .009) on the general result of the anxiety symptoms variable.

Figure 4.
Linear mixed models with repeated measures in three times for Beck Anxiety Inventory (BAI) in two groups (G1: n = 14 participants; G2: n = 18 participants).

Regarding marital social skills, Figure 5 presents that the results were significant for the intragroup analysis (f = 12.496, p = .001). In the analysis for intergroup (f = 1.201, p = .282), there were no differences. Likewise, the variables sex (f = 0.537, p = .470) and children (f = 1.321, p = .260) had no influence on the general findings as well. Both groups maintained the development of social skills over time (pre, post, and follow-up). In this graphic (Figure 5), lower levels mean higher marital social skills in the relationship.

Figure 5.
Linear mixed models with repeated measures in three times for Marital Social Skills Inventory (IHSC) in two groups (G1: n = 14 participants; G2: n = 18 participants).

Table 4 shows all the variables used (marital adjustment, depressive and anxiety symptoms, and marital social skills) to assess the effect of therapy were statistically significant (p ≤ .001) in both groups (N = 32) over time (pre, post, and follow-up).

Table 4.
Results of the Measures in the Three Times for Both Groups (G1 and G2).

Measures Preintervention Postintervention Six-Month Follow-Up p Value

M (SD) M (SD) M (SD)

DAS 38.1 (14.5) 33.5 (16.7) 32.4 (13.9) .001

BDI-II 14.3 (5.9) 10.4 (5.9) 9.97 (3.8) .000

BAI 14.34 (7.18) 9.19 (7.93) 8.69 (4.81) .000

IHSC 111.9 (15.0) 109.5 (17.9) 106.5 (16.8) .001

Note. N = 32 participants. DAS = Dyadic Adjustment Scale; BDI-II = Beck Depression Inventory–II; BAI = Beck Anxiety Inventory; IHSC = Marital Social Skills Inventory; M = mean; SD = standard deviation.

Discussion

The aim of this study was to describe the effect of application of a protocol based on of CBCT on dyadic adjustment, marital social skills, depression, and anxiety symptoms. In this exploratory study, we sought to gather preliminary information that might help define the protocol of intervention for couples, adding suggestions and hypothesis.

In the assessment preintervention of this study, findings confirm the previous research in the literature. The complaints in a marital relationship are related to each spouse’s perception of their partner and of their relationship. This cognitive activity of underlying and core thoughts affects emotion and behavior, however, in this study were monitored and changed (A. T. Beck, & Haigh, 2014; Dozois, et al., 2009; Hofmann et al., 2013; Hofmann et al., 2012; Knapp, & Beck, 2008; Overall & McNulty, 2017; Sardinha et al., 2009).

This research showed higher levels of depressive symptoms and feeling of marital maladjustment among women, both before the intervention, compared to men. This backs up the literature, which states that women tend to have higher depression levels than their husbands in cases of marital dissatisfaction (Cohen et al., 2010; Miller et al., 2013; Rehman et al., 2010; Scorsolini-Comin & Santos, 2012; Sher & Baucom, 2003; Whisman & Kaiser, 2008). Other important point is that men tend to behavior themselves such as distraction or avoidance of negative emotions. On the other hand, women may confront or ruminate as response to their negative emotions (Meyer et al., 2019).

According to report of the couples in this study, dysfunctional communication was the most common factor for stress and conflicts in the relationship. These results corroborate data from the literature which shows communication to be one of the main problems between spouses. These conflicts usually consist of expression of disagreement or anger, contempt, mockery, insults, sarcasm, humiliation, silence, judgment, and irrational attributions (Ahmady et al., 2009; K. J. W. Baucom et al., 2011; Kavitha et al., 2014; Moazinezhad & Arefi, 2017; Sher & Baucom, 2003; Yalcin & Karahan, 2007).

Communication reflects a way of thinking and when spouses can talk to each other about these patterns, it is possible for them to clarify the meaning of their thoughts and how they may affect their partner as well as how their partner responds (K. J. W. Baucom et al., 2011; Moazinezhad & Arefi, 2017; Overall & McNulty, 2017; Sher & Baucom, 2003; Yalcin & Karahan, 2007). Thus, couples might cognitively incorporate this knowledge into their own cognitive systems and change dysfunctional patterns of interaction and communication (Ammari et al., 2016). Further, cognitive distortions are also linked to emotions, feelings, and dysfunctional behaviors. It may reinforce dysfunctional communication and increase dissatisfaction in a marital relationship (K. J. W. Baucom et al., 2011; A. T. Beck & Haigh, 2014; Fischer et al., 2016; Kavitha et al., 2014; Knapp & Beck, 2008; Sher & Baucom, 2003; Yalcin & Karahan, 2007). These factors were applied to the participants in the study through cognitive and behavioral techniques such as role-playing, DTR. The process of intervention developed in this study might enhance communication between couples and improve marital adjustment.

Thus, we used role-playing as technique and it has been used for a wide range of purposes, such as to evoke automatic thoughts; to identify schemas; and to develop skills, communication styles, empathic postures, adaptive responses, and assertive practices in relationships. Furthermore, role-playing may assist in the modification of perception, underlying and core beliefs (Cohen et al., 2014; Corsini, 2010; Dozois et al., 2009; Epstein & Zheng, 2017; Knapp & Beck, 2008; Moazinezhad & Arefi, 2017; Sholomskas et al., 2005).

We noted that these factors were present in the feedback given by participants, and one of the great differentials of this study was the role-playing. Throughout the sessions, couples reported improvements in problem-solving, interaction and social skills, as they began to reflect on alternative behavioral responses and question their own feelings in specific situations. In addition to the role-playing technique, there was an improvement in assertive communication as a result of the training sessions in communication and problem-solving. In order to do so, firstly, the therapists helped the couple identify a topic of conversation that is problematic in the relationship. Then, partners were successively assigned the rules of speaker and listener. The speaker was guided in expressing his or her subjective experiences and feelings within the relationship (Dugal et al., 2018).

Our findings suggest that couple’s conflicts and difficulties in solving their problems were sustained by a lack of social skills, rigid and irrational thought patterns, unrealistic expectations about marriage, and/or dysfunctional attributions. Moreover, these marital maladjustment and dissatisfaction issues are risk factors for mental disorders, especially depression (Cohen et al., 2014; Dozois et al., 2009; Fischer et al., 2016; Miller et al., 2013; Mosmann & Falcke, 2011; Parker et al., 2013; Shayan et al., 2018). It is worth noting that our study focused on important issues to couples intervention such as perception and expectations of the relationship, assumptions, partner assignments, marital social skills, and dyadic adjustment (Butler et al., 2006; Halford & Doss, 2016; Hofmann et al., 2012; Kavitha et al., 2014; Moazinezhad & Arefi, 2017; Peçanha & Rangé, 2008; South et al., 2009).

Furthermore, couples were trained to investigate the origin of their distorted beliefs and articulate their advantages and disadvantages, identifying when these thoughts were triggered and how to modify them. Another important aspect of this study was the use of DTR as a tool of identification of thought (e.g., cognitive biases/cognitive distortions). We observed positive results in the couples’ reports in the postexercise. The DTR is useful in this activity because, in addition to helping the individual to identify their dysfunctional thoughts, it also helps him or her to develop skills that reduce the frequency and intensity of these thoughts (D. H. Baucom & Epstein, 1990; Dezois & Beck, 2008; Leahy, 2003).

At the end of the therapy, the couples reported that the treatment developed more rational perception and help themselves in identifying and naming automatic thoughts, feelings, and expectations. Furthermore, they were encouraged to consider more realistic alternative solutions, thereby reducing conflicts. This is an important process in behavior change (cf. Cohen et al., 2014; Dozois, 2010; Fischer et al., 2016; Halford, & Doss, 2016; Hofmann et al., 2013; Knapp & Beck, 2008). Maladjusted relationships may lead to marital dissatisfaction and a lower quality of life due to unrealistic expectations and perceptions (D. H. Baucom & Epstein, 1990; Kavitha et al., 2014; Sher & Baucom, 2003; Yalcin & Karahan, 2007).

Thus, this study was also positive because according spouses’ reports, they improved their perception of cognitive distortions and of their partners, and consequently, they also reported improvements in communication, dyadic adjustment, and depressive and anxiety symptoms. In this article, we have emphasized that CBCT intervention modified this panorama significantly; both spouses within a couple showed reduced depression levels, improved marital adjustment, and social skills in the post therapy, thereby corroborating the literature data (Cohen et al., 2014; Del Prette et al., 2008; Epstein & Zheng, 2017; Fischer et al., 2016; Moazinezhad & Arefi, 2017; Rajani et al., 2016; Sardinha et al., 2009; Shayan et al., 2018; Sher, 2011).

The research also revealed an influence of dyadic maladjustment in the depressive symptoms (Kavitha et al., 2014; Parker et al., 2013; Sher, & Baucom, 2003; South et al., 2009), marital functioning and depression risk factors (Miller et al., 2013; Whisman & Kaiser, 2008), and effects of depression on marital satisfaction and communication skills (Rehman et al., 2010). A differential aspect of this study lies in the evaluation of dyadic adjustment, marital social skills, and depression and anxiety symptoms in pre- and post-CBCT intervention and follow-up; it showed that the therapy had a significant impact on improving the couple’s relationship.

The group with the greater length of marriage (8–12 years) presented more maladjustment in the relationship compared to the group with a shorter length of marriage (1–7 years) in the preintervention evaluation. Some literature suggest that marital length may have a negative relationship with marital satisfaction, however, in general this effect tends to improve after some time, although it may vary due to cultural influence (Lampis et al, 2018; Sorokowski et al., 2017). It is not clear after how long marriage tend to increase. In studies of longitudinal data, Karney and Bradbury (1995) showed that half of all marriages that eventually end in divorce do so within the first 7 years of relationship. Nevertheless, in this study, CBCT intervention had a positive impact for both groups. For the sex variables, there was no statistical relevance, that is, they had no influence on the results over time in this study. However, meta-analyses (Karimi et al, 2019) suggest that, especially among women, communication is crucial to marital stability. In one meta-analysis (Jackson et al., 2014), results suggested that wives in marital therapy were less likely to be satisfied with their marital relationship than husbands. The number of children had a positive relationship with the overall dyadic adjustment findings. In the other words, number of children impacted marital adjustment. In this study, the number of children influenced the general result of the anxiety symptoms variable. Raising children might create a sense of responsibility, teamwork, togetherness, and effectiveness between partners, which might promote a stable marriage (Jackson et al., 2014; Karimi et al., 2019). On the other hand, increasing the number of children might have negative effects on marital satisfaction, such as increasing levels of pressure and demands, parental stress and anxiety, and sexual dissatisfaction which may then impact marital adjustment (Ghahremani et al., 2017; Lawrence et al., 2008).

Concerning length of marriage, it had no influence on depressive and anxiety symptoms’ findings on the general results in this study. However, it is important to note that for the group with shorter marriage length, the reduction of symptom levels was greater and was maintained at follow-up. In the follow-up of the group with greater marriage lengths, there was also a tendency to decrease depressive symptoms over time. Couples tend to decrease marital satisfaction over time, and it might lead to depressive symptoms (Halford & Doss, 2016), however, Sorokowski et al. (2017) suggest that marital adjustment might have U-shaped effect (i.e., decreases in the beginning and increases after some time), resulting in a reduction of depressive and anxiety symptoms (Dugal et al., 2018; Halford & Doss, 2016).

Although the study was not aimed at understanding how to decrease Intimate Partner Violence (IPV), we identified reductions of emotional and psychological violence based on reports of couples, especially in the follow-up assessment. We noted couple reports such as “He or she has not been angry or upset if I want to be with someone else and not her or him anymore,” “He or she did not ignore me anymore when I started talking,” “He or she has no longer told me that I am crazy or stupid,” “He or she did not let me down anymore when I criticized or asked for emotional support,” “He or she has not ignored me anymore when I need help when I’m sick or tired,” “He or she has not ridiculed anymore the things I value in me,” “He or she has not made critical comments about my work indoors or out anymore,” “He or she has no longer made the TV, magazine, newspaper, or other people seem more important than me,” and “He or she has no longer discouraged my plans or minimized my successes”. We described and reformulated the couple reports based on a profile of psychological/emotional abuse (e.g., jealous controlling, ignoring, ridiculing traits, and criticizing behavior; Patra et al., 2018; Sackett & Saunders, 1999; Thompson et al., 2006).

Intimate partner violence may result in the development of psychological and somatic symptoms of trauma, including anxiety, depression, and other mental health issues. CBT is not only effective in treating IPV survivors (Arroyo et al., 2015), but also, once directed at couples, may identify and reduce emotional and psychological violence and help avoid revictimization. This particular effect is more descriptive than conclusive, however, several debates around the world have been raised in the couples therapy field regarding interventions, such as CBCT, directed to reduce or avoid IPV, promote safety within the relationships, responsible actions, and management of conflict and problem-solving skills (Halford & Doss, 2016).

Clinical Implication

Couples treatment might relieve psychological distress, decrease symptoms of mental illness such as depression and anxiety, and also prevent IPV (this last particular effect is more descriptive than conclusive). It may significantly improve the health of both the spouses and other family members including children. In summary, CBCT has displayed an effective role in improvement in marital conflict as well as in the learning processes, reflection, awareness, empathy, health, and well-being among the couples in the study. Expectations of the relationship, and assumptions regarding each partner’s role in the relationship, were identified and then modified using more realistic perceptions and interpretations. This is an opportunity for the clinician to work with the couple to identify the couple’s emotional responses, including lack of marital social skills, and their impact within the relationship in an attempt to improve the dyadic adjustment and couple satisfaction. This may additionally reduce risk of depressive symptoms and anxiety. Regarding IPV, marital disharmony has been underrecognized as a risk factor of emotional, psychological, and physical harm. This study suggests that it is important issue to investigate in couples therapy. We conclude that the CBCT protocol developed in this study has resulted in statistically significant improvements in relation to the variables related to marital adjustment and marital social skills. Furthermore, we also suggest that CBCT might be effective for the reduction of symptoms of anxiety and depression.

Limitations and Future Research

Some limitations of this study are stated as follows. Firstly, the small sample size limits the generalizability of findings. It is possible that a more robust “N” could have provided different results. Once this study contains a small sample size, it might be considered inconclusive. Secondly, it is important clarify the specific impact of number of children in CBCT treatment, that is, with more children more dyadic maladjustment may occur; however, it is not clear the effect of this in couple therapy. Finally, the present study design did not include a control group to provide a robust comparison of results. It is important to assess the specific variables that lead a marriage to maladjustment before and after 7 years. Future research could extend to more time of marriage (e.g., 13–20 years). It is probable that different variables may lead a marriage to either distress or end in each different time of the relationship.

Steps	Contents	Time
First	Greeting; brief update on the week and homework review.	10′
Second	Mood checking. Noting whether humor has changed in comparison to previous sessions. We used a scale from 0 to 10/100.	2′
Third	Setting the agenda, in collaboration—therapist couple.	5′
Fourth	Use of agenda items and therapeutic tools.	25’
Fifth	Setting new homework.	3′
Sixth	Feedback and summary request for the current session.	5′

Session	Content	Homework (Action Plan)
1st (Conjoint)	Rapport, psychoeducation of CBCT approach.	Reading
2nd (Individual)	Identifying cognitive, emotional, and environmental factors that affect a couple’s functioning.	Reading
3rd (Conjoint)	Showing case conceptualization and treatment plan.	Self-monitoring tasks
4th (Conjoint)	Identifying and naming of emotions and thoughts. Identifying the interrelations between the couple’s cognitions, emotions, and behaviors.	Self-monitoring tasks
5th (Conjoint)	Cognitive distortions and communication.	Monitoring of cognitions + DTR
6th (Conjoint)	Communication training and role-playing.	Reading + DTR
7th (Conjoint)	Communication training and role-playing.	Considering difficulties in communication + DTR
8th (Conjoint)	Marital social skills training and role-playing.	Reading + DTR
9th (Conjoint)	Marital social skills training and role-playing.	Considering difficulties in social skills
10th (Conjoint)	Problem-solving skills and action plan.	Planning tasks
11th (Conjoint)	Relapse prevention.	Action plan (i.e., What, when, where, how often, and how long)
12th (Conjoint)	Relapse prevention, feedback and summary of the treatment.

Variables	Man (n = 16)	Woman (n = 16)	Total (N = 32)
Age (years)—M (SD)		31.7 (SD = 3.11)	29.1 (SD = 4.69)	30.4 (SD = 4.13)
% (n)	% (n)	% (n)
Children	0 (none)	12.5 (2)	12.5 (2)	12.5 (4)
1 or 2	68.8 (11)	62.5 (10)	65.6 (21)
3 or 4	18.8 (3)	18,8 (3)	18.7 (6)
5 or beyond	0	6.3 (1)	3.1 (1)
Educational level	CHS	25.0 (4)	50.0 (8)	37.5 (12)
IES	25.0 (4)	6.3 (1)	15.6 (5)
IHS	18.8 (3)	12.5 (2)	15.6 (5)
CES	12.5 (2)	12.5 (2)	12.5 (4)
IHE	6.3 (1)	12.5 (2)	9.4 (3)
CHE	6.3 (1)	6.3 (1)	6.3 (2)
PGS	6.3 (1)	0	3.1 (1)
Income	R$500–2,000			81.3 (26)
R$2,100–4,000			18.8 (6)
Religious service	Weekly	62.5 (10)	62.5 (10)	62.5 (20)
Divorced parents		75.0 (12)	68.8 (11)	71.9 (23)

Measures	Preintervention	Postintervention	Six-Month Follow-Up	p Value
DAS	38.1 (14.5)	33.5 (16.7)	32.4 (13.9)	.001
BDI-II	14.3 (5.9)	10.4 (5.9)	9.97 (3.8)	.000
BAI	14.34 (7.18)	9.19 (7.93)	8.69 (4.81)	.000
IHSC	111.9 (15.0)	109.5 (17.9)	106.5 (16.8)	.001

Footnotes

Acknowledgments

We thank Arachel Abella and Lauren Nicole Greenwood for their assistance in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; Finance Code 001), Brazil.

ORCID iD

Ricardo Silva Santos Durães

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Measures	Preintervention	Postintervention	Six-Month Follow-Up	p Value
Measures	M (SD)	M (SD)	M (SD)	p Value
DAS	38.1 (14.5)	33.5 (16.7)	32.4 (13.9)	.001
BDI-II	14.3 (5.9)	10.4 (5.9)	9.97 (3.8)	.000
BAI	14.34 (7.18)	9.19 (7.93)	8.69 (4.81)	.000
IHSC	111.9 (15.0)	109.5 (17.9)	106.5 (16.8)	.001