Journal of Occupational

Introduction
Individual, social, and family functions of a society depend on the health of its members. Nowadays, careers and the family are considered the major aspects of adult life, yet insecurity in one or both of them can endanger a couple's mental health [1, 2]. Marital quality is an important aspect of family life, which shapes health and well-being of individuals. Besides, it is highly correlated with the couple’s physical and psychological health. Marriage problems are a set of factors causing marital conflicts and arguments, thereby reducing the level of marital satisfaction and compatibility, hindering normal marital functions, and sometimes leading to divorce and separation [3]. Delatorre et al [4] emphasized the importance of the impact of conflicts on marriage. They believed that marital conflicts would have great effects on the physical and mental health of family members. Besides, they defined marital conflicts as the spread of a high level of psychological pressure resulting from disagreements, hostile interactions, disrespect, and verbal harassment behaviors in marriage. Conflicts in marital relationships can severely damage marital intimacy and satisfaction because marital conflicts, boredom, and sexual satisfaction are highly correlated variables [5].
Emotion management includes internal and external processes responsible for controlling, evaluating, and changing emotional reactions in individuals to make them achieve their goals. Any disturbances to or deficiencies in emotion regulation systems can make people vulnerable to mental disorders, such as depression and anxiety. This can happen automatically and unconsciously, or in a controlled and conscious manner [6, 7].
The goal of emotion-focused therapy (EFT) is to reconstruct interactions by helping spouses gain access to core emotions and to meet the needs underlying self-supportive reactions in a marital relationship so as to create new cycles of relationship involvements [8, 9]. In emotion-focused couple therapy (EFCT), emotions play a key role in improving interactions among couples, by which people become motivated to talk about their emotions and to discuss related topics during the therapy sessions. This approach emphasizes the recreation of emotions as secure attachment bonds between spouses. Since emotional responses allow people to meet their needs, the most important goal of EFCT is to improve awareness of one's own emotions [10, 11]. Research shows that this type of psychological intervention both reduces marital conflicts and increases marital satisfaction. Results of meta-analyses show that EFCT exerts a promising effect [12, 13, 14]. The recovery rate among couples with marital problems, who participated in 45 to 47 sessions of EFCT was reported to be 70 to 90%. Evidence suggests that EFCT has been the most effective approach adopted [15].
Wagner et al [16] believe that communication problems are predictors of marital dissatisfaction and divorce. In a study on attachment and effects of emotional communication, Forsythe et al [17] found out that spouses who obtained high scores in insecure attachment and low scores in both submissiveness and busyness had the highest levels of communication satisfaction. Therefore, negative and positive emotions are associated with attachment styles and communication among couples. According to the EFCT approach, couples' emotions help them satisfy their needs. This could be realized by providing secure conditions for couples to meet their needs. A couple's attachment style is a factor affecting secure conditions. The attachment style determines the type of communication patterns, and communication patterns allow couples to transfer their emotions [18]. For instance, when couples feel anger, they respond to each other exigently or by avoiding each other. According to the EFCT approach, avoidance is a method of expressing anger. Thus, people may express their anger through avoidance. Among the major innovations of this study, one can refer to the effects of evaluation and explanation of emotion-based couple therapy on psychological characteristics, such as optimism, and on improving communication patterns among working couples. Against this background, the present study aims to investigate the effectiveness of emotion-focused couple therapy in improving optimism and communication patterns among couples working at state offices of the Ramhormoz County.
 
Materials and Methods
The research method was experimental with a pretest-posttest design and a control group. The statistical population included 160 couples working at state offices of the Ramhormoz County in 2019. Using convenience sampling, 50 couples were selected, who were willing to participate in the study. Next, 25 participants were assigned to each group by the use of G*Power statistical software, with an effect size of 2.1, a test power of 0.90, and α = 0.05. The participants were randomly divided into an experimental group who received emotion-focused couple therapy and the control group (n = 25 per group). Randomization was performed by the researcher, and the participants were allocated to the groups by coin tossing. Accordingly, randomization was performed after the participants consented to participate in the study and to complete all baseline measures and eligibility interviews. The intervention task was performed in the experimental group by a psychotherapist. After the training sessions, the posttest was done in the experimental and control groups. The inclusion criteria were being employed at Ramhormoz state offices, holding at least a high school diploma, suffering from no mental illnesses (based on the participants' reports), and having received no psychological or pharmaceutical treatments. In contrast, the exclusion criteria included being absent in two treatment sessions and being reluctant to continue the treatment process. To take ethical considerations into account, the researchers received written consent from the participants for participation in the research. Besides, to take account of ethical considerations, the control group received a course in emotion-focused couple therapy at the end of the study. The study was approved by the Ethics Committee of Islamic Azad University, Yasooj Branch.
Life Orientation Test (LOT): The 10-item LOT was developed by Scheier et al [19]. Items 2, 5, 6, and 8 were fillers, with no score assigned to them. Besides, items 1, 4, and 10 were related to the optimism subscale, and items 3, 7, and 9 were associated with the pessimism subscale. The overall score of optimism was obtained by adding scores of questions 1, 3, 4, 7, 9, and 10. The items were scored on a 5-point Likert scale, which ranged from 0 to 4. In addition, the minimum and maximum scores were zero and 24, respectively. A higher score on this test indicated higher optimism. Factor analysis of dispositional optimism and its related constructs shows that dispositional optimism is an independent factor, which indicates discriminate validity of the scale [19]. Kajbaf et al [20] reported a Cronbach alpha coefficient of 0.72 for the questionnaire.
General Health Questionnaire (GHQ): The GHQ is a multidimensional self-report test designed to identify minor psychiatric disorders in the general population. The original GHQ was developed by Goldenberg et al [21]. The 28-item version of the GHQ was used in the present study. The items in the GHQ-28 examined a person’s mental state in the last month and included symptoms, such as abnormal thoughts, feelings, and aspects of current observable behaviors. The GHQ-28 included four subscales, with each of which being comprised of seven items related to the presence of somatic symptoms (items 1-7), anxiety and insomnia (items 8-14), social dysfunction (items 15-21), and severe depression (items 22-28). All items in the GHQ-28 had one option. The items were scored on a 4-point Likert scale that ranged from 0 to 3. The minimum and maximum scores were zero and 84, respectively. Accordingly, a low score on the scale indicated health, and a high score implied a low level of health. Malekooti et al [22] reported a Cronbach alpha coefficient of 0.94 for the questionnaire.
Communication Patterns Questionnaire (CPQ): Christensen et al developed the CPQ in 1984 to examine mutual communication patterns among couples. The 35-item CPQ required respondents to rate each statement on a 9-point scale ranging from not possible at all (1) to very possible (9). The questionnaire described couples’ behavior in three stages of a marital conflict. These stages include (a) when some problems arise in the relationship (4 items), (b) when discussing the relationship problem (18 items), and (c) after the relationship problem has been discussed (13 items). The CPQ evaluated communication patterns among the couples on three scales of mutual constructive communication, mutual communication avoidance, as well as the demand/withdrawal. The demand/withdrawal scale consisted of the two parts of the man’s demand/the woman’s withdrawal as well as the woman’s demand/the man’s withdrawal [23]. Samadzadeh et al [24] reported an alpha Cronbach coefficient of 0.76 for the whole questionnaire.
The experimental group attended 10 sessions (each lasting 90 minutes) of emotion-focused couple therapy. The intervention sessions were held at the Ramhormoz Psychotherapy Center by a researcher who had attended specialized courses and workshops. These sessions were held once a week by practicing emotionally focused couple therapy developed by Johnson [25]. Table 1 presents a summary of emotion-focused couple therapy sessions presented in this study.
 

Data were analyzed by descriptive and inferential statistics, including the mean, standard deviation, and multivariate analysis of covariance. In addition, the Kolmogorov-Smirnov test was performed to examine normal distribution of the pretest and the posttest. Next, the Levene's test was performed to examine equality of variances. In addition, multivariate analysis of covariance (MANCOVA) was performed to examine the effects of the intervention programs on optimism and communication patterns among the couples. Furthermore, SPSS V21.0 was used for data analysis. The significance level of the research was considered to be α = 0.05.
 
Results
The participants included 50 couples working at state offices of the Ramhormoz County, who aged 30 to 48. Table 2 shows demographic variables of the participants.

Table 3 shows the mean and standard deviation (SD) of the studied variables in the experimental and control groups in the pretest and posttest. Accordingly, the mean ± SD values of optimism for experimental and control groups in the posttest were 19.48 ± 3.47 and 18.63 ± 3.86, respectively. However, the mean ± SD values of the communication patterns for the experimental and control groups in the posttest were 17.67 ± 2.79 and 27.40 ± 4.26, respectively (Table 2).

Assumptions of analysis of covariance (ANCOVA), including normality of data distribution (examined via the Kolmogorov-Smirnov test), homogeneity of variance (examined via the Levene's test), and homogeneity of regression slope coefficients were confirmed. Results of multivariate analysis of covariance (MANCOVA) showed significant differences in all dependent variables between the experimental and control groups.
As Table 4 shows, the results of ANCOVA in the
MANCOVA context indicate that the scores of all communication pattern scales were statistically different between the two experimental and control groups (P = 0.0001). These differences indicated effectiveness of the emotion-focused couple therapy. Moreover, the optimism score was significantly different between the experimental and control groups (P = 0.001), which indicated effectiveness of the emotion-focused couple therapy.

Discussion
The present study aimed to investigate effectiveness of emotion-focused couple therapy (EFCT) in improving optimism and communication patterns in couples working at state offices of the Ramhormoz County. The results of this study showed that the EFCT approach could improve optimism and communication patterns among couples. Additionally, emotion-focused couple therapy increased the use of mutual constructive communication patterns and reduced the use of mutual avoidance of demand/withdrawal communication patterns among the couples. This finding was consistent with the research findings of Alavi e al [26], Jalali et al [27], Havaasi et al [28], and Sayadi et al [29].  The EFCT approach focuses on relationships, attachment styles, and interaction cycles. Once an attachment problem occurred in a marital relationship, the relationship would be endangered. Besides, since emotional and sexual needs are associated with the variable of attachment, emotions could affect sexual and marital satisfaction among the couples either directly or indirectly [30]. Javidi et al [7] reported that teaching EFT-based emotion management strategies to married couples led to an increase in their sexual satisfaction. In line with the results of the present study, they showed that EFCT improved communication patterns among the couples they studied.
Therapeutic changes in the EFCT approach occurred by acquiring and reprocessing the underlying emotional experiences. Creating new elements in emotional experiences and designing novel methods for expressing emotions could affect interactive conditions and redefine attachment bonds among couples. In an emotional situation, if one of the partners perceives their own unfulfilled needs differently, a different response will be produced between them. It seems logical to expect that experiencing a secure attachment style increases spouses’ commitment to each other, which strengthens their marriage bonds [31, 32]. Thus, EFCT can contribute to a significant improvement in marital relationship and commitments as well as a raise in the awareness of emotions and correct ways of emotional expression in spouses. If both spouses work, they will need to support and understand each other’s emotions to prevent the feeling of loneliness, enjoy communicating with each other, and spend time together. In this case, commitment and emotional bonds between spouses will become stronger, and their relationship gaps will be less observed. Since emotions play a key role in boosting relationships between couples, special attention should be paid to them. Accordingly, since EFCT is a couple therapy branch that focuses on emotion-based occupational therapy, it can be used as a short-term structured therapeutic approach. This therapeutic approach addresses disorders and inconsistencies in the relationships between couples and encourages them to talk about their emotions.
Married couples using mutual constructive communication patterns have higher levels of mental health. In contrast, those couples who use mutual avoidance of communication as well as demand/withdrawal communication patterns have lower levels of mental health [33]. Thus, by improving communication patterns in the subjects in the experimental group, decreased levels of communication stress and increased levels of mental health were expected in the investigated couples [34, 35]. In fact, mutual avoidance of communication is associated with lower levels of marital satisfaction. Accordingly, restriction of the use of this communication pattern in the experimental group increased marital satisfaction in the studied couples.  In fact, EFCT has been designed based on the attachment theory. Thus, some studies, including that of Domingue et al [36] reported that couples with a secure attachment style showed a mutual constructive communication pattern. In contrast, those with an insecure attachment style showed mutual avoidance of communication. Accordingly, their findings were in line with the results of the present study, in which an improvement in communication patterns of the studied married couples led to the decreased level of communication stress and the increased level of mental health among them. Siffert et al [37] showed that women’s demanding behavior was associated with men’s psychological well-being. Besides, they reported that couples’ conflicting behavior was indirectly associated with their psychological well-being and marital satisfaction. Tashiro et al [38] reported that couples with negative moods showed more demanding withdrawal behaviors and used more negative strategies for problem-solving purposes compared with couples with positive moods. Besides, they reported that negative moods could cause self-centeredness through focusing on one’s inner experiences, needs, and concerns. 
From the perspective of EFCT, marital disturbances are caused and continued by pervasive states of negative emotions and attachment injuries. EFCT seeks to increase marital commitment, integration, and emotional expression among working couples by improving interactions through solving emotional problems, identifying unexpressed or repressed emotions, correcting attachment styles, and increasing intimacy. To this end, emotional expression as well as identification of emotional and affective needs of both partners are taken into consideration. Research shows that optimism is closely associated with happiness, adjustment, satisfaction, and some other important variables. Married couples, with positive attitudes towards themselves and others, experience less severe depression symptoms and higher levels of marital happiness [39]. Zhang [40] reported a significant positive relationship between optimism and stress resistance and found out that optimist participants were more resistant to stressors than pessimist ones. Besides, he found a significant positive relationship between optimism and marital satisfaction, indicating that optimist couples experienced higher levels of marital satisfaction. Heyrat et al [39] found out that self-regulatory EFCT positively affected optimism levels among couples. In this regard, optimism was addressed in the therapy process, and couples were taught the ways of fostering optimism and changing their attributional styles. Moreover, couples received instructions on how to be more optimistic when dealing with marital conflicts or solving marital problems. Because optimism is a way of thinking, the current study found it necessary to examine the participants’ thoughts and cognitive traits to make them learn how to identify irrational thoughts and to replace them with more optimistic ones by raising their awareness of such thoughts.
This research had some limitations, among which one can refer to the low number of the studies on the effectiveness of EFCT in the literature. Another limitation was the use of couples with disturbed marital relationships in the Ramhormoz County, as the only study sample, which made generalization of the results to other geographic regions difficult. Besides, some of the subjects showed no interest in participating in the current study or any relevant studies. Thus, encouraging them to participate needed great efforts. Although EFCT is one of the most effective approaches to couple therapy, little attention has been paid to examining this approach in research conducted in Iran. Thus, researchers are recommended to conduct similar studies with larger sample sizes, more socioeconomically diverse subjects, and various dependent variables with a follow-up period to make marital life as bearable as possible. To save time and money, it is recommended to use EFCT in group therapies and compare its effectiveness in reducing depression and marital conflicts, as well as in improving communication patterns and optimism among couples with that of individualized EFCT. Furthermore, it is suggested to compare the effectiveness of EFCT to that of other therapeutic approaches for couples and families to get a clearer picture of the usefulness of EFCT among the Iranian population. Besides, it is recommended to examine the effects of EFCT on other marital variables, such as marital commitment, the quality of marital relationships, and the like.
 
Conclusion
Promising results were obtained in the present study in terms of the use of EFCT. What made EFCT an effective approach was that insecure relationships among couples turned into secure ones during the therapy sessions? In EFCP, it is assumed that the levels of feelings of security or instability of attachment bonds in marital relationships among spouses form the basis of their marital satisfaction or dissatisfaction. In the initial sessions of the therapy, the studied couples did not get involved in emotional conflicts caused by the feeling of insecurity. Thus, they began to feel more secure in their marital relationships; in other words, they found each other responsive and available. During the last sessions, they were able to express their needs and desires to get emotionally engaged with each other. EFCT is not costly, yet it is an effective approach. Accordingly, it is recommended that therapists use EFCT for the treatment of patients to solve marital problems among couples as well as promoting their family health.
 
Acknowledgement
This article was extracted from some parts of the PhD dissertation of Mr. Alireza Momeni at the Department of Psychology, Yasooj Branch, Islamic Azad University, Yasooj, Iran (Code 12020705971011). The researchers would like to thank all individuals who participated in this study.
 
Conflict of interest: None declared.