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Sadeghi M, Moheb N, Alivandi Vafa M. The Effectiveness of Group Acceptance and Commitment Therapy and Cognitive Therapy on Alexithymia and Marital Boredom, Case study: Women Affected by Marital Infidelity in Mashhad, Iran. JCHR. 2021; 10 (4) :316-327
URL: http://jhr.ssu.ac.ir/article-1-670-en.html
1- PhD student of General Psychology, Department of Psychology, Tabriz Branch, Islamic Azad University, Tabriz, Iran
2- Assistant Professor of Clinical Psychology, Department of Clinical Psychology, Faculty of Medicine, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran , moheb.n@yahoo.com
3- Assistant Professor of Psychology, Department of Psychology, Tabriz Branch, Islamic Azad University, Tabriz, Iran
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Introduction: The aim of current paper was to compare the effectiveness of acceptance and commitment group therapy (ACT) and group cognitive therapy (GCT) on Alexithymia and marital boredom (MB) among women affected by marital infidelity in Mashhad.
Method: This clinical trial was a double- blind study with a pretest-posttest design in which two intervention groups and one control group were investigated. The study performed on women who realized their spouse infidelity and referred to Azad University Counseling Center in Mashhad in 2018. The sample consisted of 30 women who were selected by purposive sampling and were randomly assigned to two intervention groups and a control group (n=10 per group). The intervention groups were put under ACT training (twelve 90-minute sessions) and GCT training (twelve 90-minute sessions), but the control group did not receive any intervention. Data was obtained by the Toronto Alexithymia Scale-20 and Pines Marital Boredom Scale and was analyzed by multivariate analysis of covariance with SPSS (version 22) software.
Results: The results showed a significant reduction in the mean score of MB in the ACT group, also there was a significant reduction in the mean score of Alexithymia in the GCT group (P <0.05). So comparing both therapies, ACT was more influential on reducing marital boredom whereas GCT was more effective on reducing alexithymia.
Conclusion: Although both intervention methods were effective on Alexithymia and Marital Boredom in women affected by marital infidelity, it was demonstrated that ACT and GCT have more effect on Marital Boredom and Alexithymia, respectively.
Introduction

As individuals enter the third decade of life, they are faced with new and unique challenges. Marriage has been universally found to meet emotional, economic, sexual, social, reproductive needs (1, 2). One of the most crucial factors in marriage is the belief that one’s spouse is committed and desires a lasting relationship. Commitment is found to have a strong impact on the sustainability of a relationship. When someone perceives that his or her spouse’s commitment has been questioned, it can be considered as a powerful predictor of the termination of a relationship (2, 3). Among all those factors that threat family and marriage structure, infidelity or betraying spouse seems to be the main reason of disagreements, mental harms and finally divorce (4). Marital infidelity is a common phenomenon in western and eastern countries which is defined as passing the limits of marital relationship by having physical or emotional affairs with others (5).
The issue of marital infidelity is also a concern in Iran and is associated with instability of relationships and a high rate of divorce (6). In Iran, there are no specific statistics in this regard, and the percentage of married people who break the covenant varies in different studies. However, in one study in Iran the rate of infidelity among men was reported 42% which was mostly between the age of 26-35 (7). In another study, this rate for women was considered to be 13-15% (8). In recent studies the possibility of its occurrence has raised to 60% (4).These figures are limited and cannot be generalized to all cities and cultures in Iran. the backgrounds related to infidelity indicate a decrease in psychological health (7). It has also been identified as an influential factor in the field of sexually transmitted diseases. Also, awareness of the spouse's infidelity may lead to negative reactions, including physical assault, suicide, or even murder (4).
Marital infidelity is a shocking issue for couples and families and a common phenomenon for counselors and therapists. Infidelity or extramarital affairs may cause a great amount of anxiety for couples. Marital infidelity is a phenomenon with the most severe emotional consequences for couples. The majority of people affected by infidelity may experience anger, low self-esteem, depression, and helplessness (9). Marital infidelity plays a significant role in an emotional breakdown between couples and may cause marital boredom (10). Marital Boredom includes a set of symptoms such as emotional, physical, and mental exhaustion that causes significant consequences in a couple's life. This phenomenon occurs when the couple realizes that their relationship is unable to meet some basic needs, so the parties suffer from painful states of fatigue, monotony, depression, and feeling of failure in their marital life (11). Alexithymia is one of the traits that received less attention in the field of mood problems of women affected by infidelity and is closely associated with depression and anxiety (12). Alexithymia is a concept which stemmed from the field of psychosomatics and can broadly be defined as the inability to understand and describe one’s feelings (13, 14). It is difficult to estimate the prevalence of alexithymia due to the fact that there are no clear diagnostic criteria, however various studies have estimated the prevalence between 10 and 19% (13, 15). Emotional disabilities and skills are considered important and impressive in adjusting with the environment and others, including the ability to recognize and express emotions appropriately, making a sense of security, improving a cordial relationship, and improving the ability to cope with negative experiences (16). So, there is an inverse relationship between Alexithymia and marital satisfaction (17, 18).
Since marital satisfaction is greatly reduced due to the experience of infidelity among affected women, the psychological well-being of individuals is significantly affected by intimate interpersonal relationships, and the ability to create and maintain a romantic and satisfying relationship requires the ability to recognize emotions and expressing them (19). The increasing number of infidelity and marital conflicts in the contemporary world and the risk of separation and its negative impact on the mental health of couples and children, has led therapists to offer theories and plans to help couples with conflicts and those on the verge of divorce. Cognitive therapy is one of the popular theories in this field. From a cognitive perspective, the causes of most behavioral problems and interpersonal conflicts, including marital conflicts, should be sought in cognitive errors and irrational beliefs of individuals (20). The purpose of identifying and challenging negative thoughts in the cognitive therapy approach is to seek help for finding alternative ways of thinking (21). The group cognitive therapy program aims to use all aspects of the Beck treatment method (1979) without its behavioral components, which is used not only for mood disorders but also for anxiety and anger disorders (22). The results of the present research confirm the effectiveness of group cognitive therapy based on the model of Michael Free (1999) in reducing marital conflicts (23). In other words, studies indicate that group cognitive therapy can reduce depression, cognitive distortion, anger and hopelessness (24) and also may act as an effective treatment in reducing Alexithymia (25). This treatment may trigger a type of cognitive review that leads to reducing marital conflicts among couples by challenging their negative thoughts and cognitions (26).
In addition to group cognitive therapy to solve the problems of people affected by infidelity, the use of Third Wave cognitive-behavioral therapies that target the process of thoughts (rather than their content, as in GCT), may also be effective. One of these treatments is acceptance and commitment therapy. The main goal of the treatment is creating mental flexibility; That is, the ability to make a practical choice between different options that is more appropriate, not just a practical one to avoid disturbing thoughts, feelings, memories or desires (27). It is assumed that in ACT, human beings find many of their inner feelings, emotions, or thoughts annoying and constantly try to change or get rid of these inner experiences (28). These attempts are ineffective in controlling inner experiences and they exacerbate the feelings, emotions, and thoughts that one initially has tried to avoid in a paradoxical way (29). This treatment has six central nuclei, which includes fault, acceptance, momentary contact, self-observation, committed action, and values (30). In other words, the main reason for choosing this treatment in comparison with other treatments is that the client is trained to accept her emotions for the first step and to have more flexibility here and now (31). So, this treatment combined the traditional cognitive therapy techniques with mindfulness which focuses on here and now rather than past or even future (32).
Research has shown that acceptance and commitment therapy can increase marital satisfaction, improve marital turmoil and communication variables between couples, marital adjustment, and reduce psychological and interpersonal distress between incompatible and troubled couples (33). It is similarly effective in reducing the anxiety of anxious couples (34), women with post-traumatic stress disorder (35), and depression among housewives with HIV (36).
Therefore, considering the prevalence and importance of marital infidelity and preventing the progression of divorce seems that one of the main problems of these individuals is Alexithymia or Marital Boredom, which has been less studied. Therefore, due to the progress of third-wave cognitive-behavioral therapy, there was no study to compare these therapies. Therefore, the researchers decided to conduct a study comparing GCT and ACT on Alexithymia and MB of women affected by marital infidelity.
Method
The research method was experimental with a pretest-posttest design and control group. The statistical population of this study included   women who were affected by marital infidelity and had referred to Counselling Center of Educational Sciences Faculty in Mashhad Azad University in 2018 and were selected by purposive sampling based on the inclusion and exclusion criteria. However, only 30 of them agreed to participate in the study, eventually. Inclusion criteria were willingness to participate, At least two years of living together, age range of 25-45 years, minimum diploma education and exclusion
criteria were suffering from a physical illness or other psychiatric disorders simultaneously, unwillingness to continue the study, absence for more than two sessions in the intervention groups. Randomization for selecting the members of each group was performed through rolling a dice which is a suitable way of assignment for interventions including three groups. Numbers 1 & 2 of a dice were dedicated to the first intervention group, numbers 3&4 were given to the second intervention group and finally those with numbers 5 & 6 were assigned in the control group. Each group was consisted of 10 members. Afterwards, Toronto Alexithymia Scale-20 and Marital Boredom Scale were provided to them. Finally two groups of ACT & GCT were present in addition to a control group.
Instruments
Toronto Alexithymia Scale-20
The Toronto Alexithymia Scale, a 20-item test, was used to measure mood distress. It was initially developed by Taylor in 1986 and then revised by Parker, Taylor and Bagby in 1994 (37). It has three components: Difficulty Identifying emotions, Difficulty describing emotions, and externally oriented thinking. The questions are on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A total score is also calculated from total scores of the three subscales for emotional malaise .Psychometric properties of The Toronto Alexithymia Scale have been reviewed and validated in numerous studies such as assessing TAS-20 psychometric properties and factorial invariance in nonclinical and psychiatric samples (37). Furthermore, in Persian version of Besharat and Ganji study which was about the relationship between marital satisfaction and Alexithymia, Cronbach's alpha coefficients were reported 0.85 for Alexithymia, 0.82 for difficulty Identifying emotions, 0.75 for difficulty describing emotions, and 0.72 for externally oriented thinking. Also, they obtained the validity of the whole scale of the Iranian sample by using test-re test method (after one month) 0.74 and 0.72 (38).
Marital Boredom Scale
The purpose of the Marital Boredom Scale is to measure the degree of marital boredom among couples, which was developed by Pines in 1994 (39).The questionnaire includes 21 questions which incorporates the three main components of physical fatigue, lethargy and sleep disorders. Evaluating the validity coefficient of the marital boredom scale showed that there is an internal consistency between variables in the range of 0.84 to 0.90 (39). In Iran, Marital Boredom Scale was localized by Navidi (40). He estimated the reliability coefficient of this questionnaire by using 0.86 Cronbach's alpha.
Intervention
This study was a double- blind experimental one in which both participants and trainer had no idea about the group each person was going to be placed in because in double- blind clinical trials, the result assessor was not included in the intervention team. The study followed the ethical standards provided by the Helsinki Declaration. The participants were reassured about their identity, and that other personal information would remain confidential, then the informed consent form was signed by them voluntarily. In the present study, the ACT program was designed based on the model of Peterson and colleagues in 2009 for distressed couples, which was held in 12 sessions (34) and GCT treatment program was based on Michal Free cognitive protocol which has been published in a form of a book and included 12 group sessions of 90 minutes per week (41).The qualified trainer performed both treatments in the counseling center of the Islamic Azad University of Mashhad in 2018. The control group was placed in the waiting list until the end of data collection. After gathering the demographic information of the participants, for descriptive statistics the mean and standard deviation of research variables in two intervention groups and one control group were shown. At the next level, The normality of the data distribution was checked by Kolmogorov- Smirnov, homogeneity variances was approved by Levine’s test. Analysis of variance and covariance and finally Bonferroni's post hoc test were also used. Data collection was carried out in four stages of pre-test, post-test. Data analysis was carried out by using SPSS-22 and MANCOVA test was performed with a confidence interval of 95% and α = 0.05. The assumptions of the analysis of covariance model were all examined according to the Tutorial article (42). ACT and GCT sessions are described in Tables 1 and 2, respectively
Statistical analyses
Data was analyzed by descriptive and inferential statistics such as mean and standard deviation scores. Data normality was examined by Kolmogorov- Smirnov test. Levene's test was also utilized to examine the equality of variances. The analysis of variance was utilized to test the assumption of homogeneity of line slope. Bonferroni's post hoc test was used to determine the mean difference between different training sessions. Data analysis was conducted by using the analysis of covariance. SPSS version 22 was further used for analyzing the data. The significance level of research was considered to be α=0.05.
Results
The present study was performed on 30 individuals with affected by marital infidelity in three groups of ACT (n = 10), GCT (n = 10), and Control (n = 10). The mean ± SD age of participants of ACT group was 26.8 ± 4.9, the mean ± SD age of GCT was 27.35 ± 6.0 and finally it was 28.2 ± 5.6 for the control group. There was no significant difference between three groups in terms of demographic information of the participants (P>0.05) (table3).
In Table 4 the mean and standard deviation of the variables in each group were showed.
Before using covariance analysis, its pre assumptions were estimated. For checking the homogeneity of variances Levene test was utilized. The results indicated that the assumption of the equality of variances was true and the use of analysis of covariance was permitted. Furthermore, the analysis of variance was utilized to test the assumption of homogeneity of line slope. This interaction was not significant, so covariate was considered as the secondary dependent variable and as a result analysis of covariance (ANCOVA) was applied (42). Before testing the assumptions, normality of error distribution should be checked by Kolmogorov- Smirnov test.
 
The results of Multivariate Analysis of Covariance (MANCOVA) according to table 6 showed that there was a significant difference between the intervention groups and control group in terms of Alexithymia mean score and its subscales in stage of post-test (P=0.001). Also, there was a significant difference between two intervention groups and a control group in the mean score of total Marital Boredom in stage of post-test (table 6). The results of Bonferroni follow-up test comparing two groups of intervention and control are presented in table 7. And finally in table 8, the modified means were summerized.

Discussion
According to the increasing rate of marital infidelity and women who are suffering from being betrayed, in this study two different interventions were examined and compared in order to focus on Alexithymia and marital boredom of these women . Therefore, The main purpose of the present study was to compare the effectiveness of ACT and GCT on Alexithymia and Marital Boredom of women affected by marital infidelity in Mashhad. The results showed that both GCT and ACT methods are effective in improving Alexithymia and MB in the participants of the present study. On the other hand, the results of the comparison between two therapeutic methods showed that GCT was more effective than ACT during the post-intervention phase in reducing the mean total score of Alexithymia, subscale of Difficulty describing emotions, and externally oriented thinking. But both intervention groups showed no significant difference between the sub-components of Difficulty Identifying emotions. On the other hand, the results showed that ACT had a greater effect on reducing the mean score of MB than GCT. In support of this hypothesis, it has to be mentioned that the results of the present study similar to the results of previous studies confirm the therapeutic effects of ACT on forgiveness and marital adjustment of women exposed to infidelity (35), reducing the signs of stress, depression and anxiety among women who were suffering from extra marital affairs of spouses (35), improvement of alexithymia among women on the verge of divorce and finally having positive effects on emotion regulation and meaning of life for these women (36).
According to the results and experimental evidence, it can be stated that the main goal of treatment is based on acceptance and commitment to create mental flexibility; that is, the ability of practical choice between different options that are more appropriate. In other words, it tries to accept the annoying feelings, thoughts and emotions (which are common in people with marital boredom) (31). Thus acceptance provides a hypothesis for immediate exposure to emotions that, while annoying, are real. This acceptance leads to an increase in responsibility (43). This treatment helps people to build their lives full of acceptance and bold action (31). Research has shown that acceptance and commitment therapy increases marital satisfaction, improves marital turmoil and communication variables between couples, marital adjustment, and reduces psychological and interpersonal distress between incompatible and troubled couples (33). Acceptance and commitment therapy guides couples to correct their behavior through increasing the security and support and availability, responding to their spouse's needs, developing safe behaviors, training proper communication skills and ways of increasing intimacy, and creating a desirable sexual relationship (44). Overall, it seems that acceptance and commitment therapy can be closer to the patterns of MB compared to better cognitive therapy. This treatment can encourage the person to engage in effective behavior in order to reduce MB through acceptance of adversity and conciliatory action.
Based on the results of the present study, it seems that GCT can be effective in reducing Alexithymia. The results of the present study was consistent with the results of previous studies on the effect of GCT on Alexithymia (24), on depression and negative thinking (45),self-talk and marital conflict reduction (23), and it was also consistent with reducing marital conflicts between couples (46). The purpose of the cognitive therapy approach is to identify and correct the maladaptive and inefficient thinking that causes dysfunction (45). Therefore, the central point and main focus of cognitive therapy is on mood disorders. Its purpose is to change fundamental beliefs and negative spontaneous thoughts and negative emotions caused by them. Cognitive therapy can be a tool for diagnosing and describing emotion. That is, if understanding beliefs, thoughts, and emotions are areas of cognitive therapy. The problem of individuals with emotional dyslexia is the weak emotional awareness that manifests itself in the inability of recognizing and verbally describing personal emotions, and also the extreme poverty in symbolic thinking (12). The purpose of cognitive group therapy was identifying, challenging, and changing the negative thoughts and cognitions of people with conflicting relationships. It led to identifying these distortions and intellectual biases and ultimately changing them by alleviating existing symptoms, replacing positive emotions, behavior, thinking, and eventually returning communication to a better and healthier level. Therefore, group cognitive therapy can be used to reduce emotional problems such as Alexithymia.
One of the limitations of the present study was the small sample size, which could not be increased due to group meetings and time constraints. Therefore, it is suggested to repeat this study with larger sample size and individually in prospective studies. ACT and GCT techniques can be used along with other psychological therapies to reduce mood distress and marital boredom in women affected by marital infidelity.
Conclusion
Due to the increasing number of marital infidelity and emotional and real divorce, it is necessary to carry out some measures in this regard, so according to the research findings, it seems that both Group Cognitive Therapy and Acceptance and Commitment Therapy methods were effective alternatives in improving Alexithymia and Marital Boredom in betrayed women. However, Acceptance and Commitment Therapy was more effective on Marital Boredom and Group Cognitive Therapy was more effective on improving Alexithymia of these individuals.
Acknowledgments
This article was extracted from a part of the Ph.D. dissertation of Maryam Sadeghi in the
Department of Psychology, Islamic
Azad University of Tabriz (code: 102481380054893162279477). We also appreciate all those who participated in present study for their patience and cooperation. This study did not receive any special financial support from any organizations.
Conflict of interests
The authors declare no conflict of interests for this study.
Author contribution
M.S was responsible for the idea, performing the analysis and drafting the manuscript. And N.M & M.A.V were involved in planning and supervising the work. All authors aided in interpreting the results, working on the manuscript, discussion and final comments.
Review: Research | Subject: General
Received: 2020/08/19 | Accepted: 2021/12/29 | Published: 2022/01/10

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