Comparison of the Effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the Sexual Schemas of Religiously Committed Women Who Have Experienced Infidelity

Introduction

The family is one of the most important social and collective structures, formed through the union of two opposite sexes, and its continuity has always been of great importance throughout all eras. Currently, maintaining the foundation of the family is considered essential for the stability of society. Women are the main pillar of the family in society, and their physical and mental health has a direct and significant impact on the physical and mental health of the family and the upbringing of children. The World Health Organization (WHO) has identified women's health as an indicator of a country's development. According to the WHO, health encompasses physical, psychological, and social dimensions, and changes in any of these aspects can impact other areas of life (Yazdian, 2023). The role of women in the family as a social unit can either foster the flourishing or lead to the disintegration of relationships among members. One of the damages related to family dysfunction is infidelity, which can lead to the collapse of this vital structure and drive society towards destruction.

Infidelity can cause severe emotional trauma for spouses. Psychotherapists report that spouses who have been cheated on often experience feelings such as anger, low self-esteem, betrayal, depression, and helplessness. Unfaithful spouses also grapple with feelings of shame, guilt, doubt, anger, and despair. The intense emotional turmoil following the revelation of marital infidelity is often accompanied by cognitive disarray. Any form of secrecy from a spouse and actions outside the marital framework are considered infidelity (Song & Nadarajah, 2022).

On another spectrum, it should be noted that a person who has been cheated on may, despite forgiving their spouse, develop schemas in their mind that affect their future sexual life. Sexual schemas are one of the psychological factors that can influence an individual's sexual attitudes. Accordingly, sexual schemas are defined as fundamental and core beliefs about an individual's sexuality derived from their past experiences, manifesting in present experiences, and significantly affecting their sexual information processing and future sexual behaviors (Nemati, 2021). Sexual schemas consist of two dimensions: 1) Positive dimension includes passionate-romantic schemas and quick-easy schemas; 2) Negative dimension includes shy-cautious schemas. Individuals with positive schemas tend to be comfortable with their sexual attitudes and are generally free from social inhibitions such as self-consciousness or shyness. These individuals report a wide range of sexual activities throughout their sexual life. For women with positive sexual schemas, romantic relationships are central. Women with explicit-easy schemas report sexual desires and behaviors similar to those with passionate-romantic schemas but exhibit weaker commitment and less stable bonds, possibly leading to less commitment in sexual relationships (Yazdian, 2021). Conversely, women with negative sexual schemas perceive themselves as emotionally cold and unromantic, acknowledging that they act in a restrained and cautious manner in sexual and romantic behaviors. They hold negative attitudes and values in this regard and may describe themselves as self-conscious, shy, or insecure in various sexual and social contexts. In this vein, Mojtabai, Saberi, and Alizadeh (2014) stated that sexual schemas have a significant relationship with women's sexual functioning. Additionally, Reisig and colleagues (2005) found that women with fewer positive schemas have negative views on sexual behaviors, which can lead to the decline of marital life (Kamenik, Baidi, Stanton & Meston, 2018).

Some research suggests that individuals with higher religious commitment also have greater awareness and acceptance of their issues. For instance, Mousavi, Rezaei, Ghorbanpour, and Ahadian (2018) mentioned in their study that religious individuals exhibit more commitment and adaptability to life's problems, a notion that is fairly accepted in Iran. However, the crucial point is to choose the best type of intervention that is effective and efficient for all individuals.

Various treatments and interventions have been used to improve the marital life of individuals, but identifying the best type of treatment should be a focus to achieve more effective results. Due to the shortcomings of cognitive-behavioral approaches, experts have proposed Unified Transdiagnostic Treatment (UTT) with an integrative approach, using a unified therapeutic protocol (Barlow et al., 2011). Among the presented protocols in the field of integrative treatment, Barlow's Unified Protocol (UP) is more applicable for treating emotional disorders and emotional divorce (Barlow et al., 2014). This approach is a form of transdiagnostic cognitive-behavioral therapy focused on emotions, specifically designed to treat emotional and mood disorders (Akbari et al., 2015). This treatment emphasizes understanding and responding to the emotional system of individuals with emotional problems and aims to facilitate emotional processing (Norton, 2022).

The Unified Transdiagnostic Treatment identifies cognitive dysfunctions and emotional avoidance through meta-cognitive assessment and increases individuals' insight into these dysfunctions, providing a framework for improvement (Weiss, Robinson & Gillan, 2022). This treatment positively affects the improvement of mood and anxiety disorders, facilitating emotional recovery and preventing the exacerbation of symptoms (Schifolo et al., 2022). Compared to classic cognitive-behavioral approaches, this integrative approach is more effective in improving transdiagnostic symptoms in individuals with mood problems (such as psychological fatigue and loneliness) and can be used as a foundational approach to treat these issues (Timmolak et al., 2022).

The Unified Transdiagnostic Treatment identifies maladaptive emotional symptoms and reduces individuals' mental-psychological tensions, enhancing their psychological security (Fujitsu et al., 2021). Weiss and colleagues (2022) emphasized that one of the effective functions of this treatment is helping individuals improve their ability to regulate internal emotions and cope with maladaptive emotional roots, achieved by focusing on both emotional and cognitive structures. Unstable cognitive structures and non-constructive beliefs (which are also evident in early marriages) are among the main causes of various problems, which are addressed in this integrative treatment approach (Akbari et al., 2015) and are expected to be effective for the current group's issues.

Other treatments also exist that allow individuals facing life problems, especially infidelity, to vent their negative emotions and heal their life's wounds. Mentalization-Based Therapy (MBT) has its roots in Bowlby's attachment theory and contemporary developmental psychologists' analyses, focusing on conditional vulnerabilities in childhood (Taboner et al., 2021). This approach was designed by Bateman and Fonagy (2016) and emphasizes that insecurity in attachment mediates failures in empowering individuals' mentalization capacity in various problems. Initially, this treatment focused on borderline personality disorder, attachment-related disorders, and autistic children, and gradually expanded to treat other types of disorders (Kraemer et al., 2021). The fundamental principle of this therapeutic approach is that the mind is a shared asset among humans but is not identical.

Mentalization-Based Therapy is based on four core principles: self versus others (understanding one's inner world and being aware that others also have their own worlds), emotion versus cognition (understanding perceptual emotions and recognizing their cognitive underpinnings), inner world versus outer world (others are not like us, so we must be cautious not to project our intentions and emotions onto them), and automatic versus controlled mentalization (balancing automatic and controlled actions) to guide the therapeutic process (Tahmasebi, 2020). One of the primary therapeutic goals in MBT is to integrate various aspects of mentalization in individuals. In many problems, a person forms an alien or false self and uses projections to avoid emotional experiences, behaving based on their mental hypotheses about the world (Drager, 2020). This treatment aims to balance understanding one's own and others' worlds, emotions and cognition, and internal and external signs. For some clients who experience polarization in either controlled or automatic mentalization, therapists strive to bring them back to an intermediate state (Kraemer et al., 2021).

Drager (2020) emphasized that this therapeutic approach prevents emotional and mood disturbances through appropriate emotional identification, expression, and regulation. The effectiveness of this treatment in reducing cognitive problems alongside other disorders has been demonstrated in functional and clinical studies (Taboner et al., 2021). It is expected that by implementing this therapeutic process and enhancing the ability to see others' perspectives, balance emotions and cognition, and identify the cognitive underpinnings of perceptual emotions, it will effectively improve the sexual schemas of religiously committed women who have experienced infidelity. Thus, the present study aims to answer the question: Is there a significant difference between the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed women who have experienced infidelity?

Methods and Materials

Study Design and Participants

This study is applied research in terms of its aim and a quasi-experimental research design featuring a pre-test and post-test with a control group in terms of its method. The statistical population included all women who visited counseling centers in Shiraz in 2023 and faced marital problems. Regarding sample selection, according to Delavar (2006), 15 participants per group in semi-experimental research can yield statistically valid results. Therefore, the sample comprised 45 religiously committed women who had experienced spousal infidelity and were diagnosed by psychologists at counseling centers in Shiraz (Segal Counseling Center, Afagh Counseling Center, and Avaye Mehr Counseling Center). They were selected through convenience sampling and randomly assigned to three groups of 15 each (a control group of 15 and two experimental groups of 15 each). One experimental group received training in Mentalization-Based Therapy, while the other received training in Unified Transdiagnostic Treatment. The control group received no training.

Criteria for participation in the study included: participants must reside in Shiraz, have religious commitment, have been married for at least four years, provide informed consent to participate, and not suffer from specific physical or psychological illnesses (assessed through an initial interview). Exclusion criteria included: incomplete responses to questions, unwillingness to participate, and simultaneous participation in other studies or interventions.

Measures

Women's Sexual Self-Schema

This questionnaire was developed by Carol R. Anderson and Jeanne M. Cyranowski to assess women's sexual self-schemas, which are core beliefs and feelings about their sexuality. It comprises 50 items, including 24 attributes as cover items to mask the true nature of the test and 26 main attributes. The items are divided into three components: Passionate-Romantic, Explicit-Easy, and Shy-Cautious. Participants respond to each item on a Likert scale ranging from 0 to 6, with higher scores indicating a greater presence of the characteristic being measured. To calculate the score for each factor, the scores of the individual items related to that factor are summed. The total score is obtained by summing all item scores, with a minimum score of 0 and a maximum score of 156. Content validity, face validity, and criterion validity have been evaluated and deemed appropriate in previous studies. Specifically, Mojtabai and colleagues (2010) confirmed the content and face validity of the questionnaire. The reliability of the instrument has been demonstrated with Cronbach's alpha coefficients above 0.70, indicating good internal consistency and reliability.

Interventions

Mentalization-Based Therapy

Mentalization-Based Therapy (MBT), designed by Bateman and Fonagy (2018), focuses on enhancing patients' ability to understand and interpret their own and others' mental states. This therapeutic approach aims to improve emotional regulation, reduce impulsivity, and enhance interpersonal sensitivity through a structured program of group sessions. Each session has specific therapeutic goals and content aimed at gradually building the patients' mentalization capacity.

Session 1: What is Mentalization and the Mentalizing Stance?

The first session introduces the goals of the group therapy, emphasizes active participation, and introduces the group members and reasons for referral. The therapist explains the specific aspects, dimensions, and benefits of mentalization, distinguishing it from misinterpretations. A homework assignment is provided.

Session 2: What is the Problem with Mentalization?

This session aims to identify the characteristics of poor and good mentalization. It addresses problems in self and others' mind reading, issues in emotional regulation, impulsivity, and interpersonal sensitivity. Participants are given homework assignments to reinforce learning.

Session 3: Why Do We Have Emotions and What Are the Primary Emotions?

The goals of this session include understanding primary and social emotions and differentiating between primary and secondary emotions. The session describes various emotions and individual differences in emotional control, followed by a homework assignment.

Session 4: Mentalizing Emotions

This session covers how to deal with emotions and feelings, interpret internal emotional signals in oneself and others, and self-regulate emotions. It also discusses how others can help regulate our emotions and manage highly distressing non-mentalized feelings. Relaxation techniques are introduced, and a homework assignment is given.

Session 5: The Importance of Attachment Relationships

The session discusses attachment and adult attachment strategies. The importance of attachment relationships is highlighted, and a homework assignment is provided.

Session 6: Attachment and Mentalization

This session explores attachment conflicts and provides a homework assignment to deepen understanding and application.

Session 7: Mentalization-Based Therapy (MBT)

This session explains MBT, its specific characteristics, and objectives. It includes training and practicing mentalization within the group, with a homework assignment.

Session 8: Mentalization-Based Therapy (MBT)

This session focuses on the importance of creating connections with others and establishing attachment relationships with the therapist and other group members. A homework assignment is given.

Session 9: Anxiety, Attachment, and Mentalization

This session provides education on anxiety and fear, types of anxiety disorders, and their treatment strategies, emphasizing that helping another person is a key component of therapy. A homework assignment is provided.

Session 10: Depression, Attachment, and Mentalization

The session offers an educational approach to depression, its course, and treatment. It discusses depressive thinking and provides a homework assignment.

Session 11: Summary and Conclusion

This session summarizes and concludes the group's discussions, emphasizing key learnings.

Session 12: Support and Empathetic Validation

A review of previous group discussions, stating the goals of group sessions, and asking group members about issues they want to address. Empathetic validation is emphasized.

Sessions 14 and 15: Clarification

The therapist clarifies the issues raised by group members, combines problems, explores issues, and, if necessary, challenges them.

Session 16: Emotional Identification and Focus

This session focuses on identifying and concentrating on the emotional issues raised by group members.

Session 17: Training to Mentalize Content to Facilitate Epistemic Trust

The session aims to enhance the ability to mentalize content, thereby facilitating epistemic trust among participants.

Sessions 18 and 19: Mentalization and Communication

These sessions focus on mentalizing communication with attention to transfer trackers.

Session 20: Preparing for Therapy Termination

This final session prepares participants for the end of therapy, focusing on feelings of loss related to the end of therapy, and officially concludes the therapy process.

Unified Transdiagnostic Treatment

Unified Transdiagnostic Treatment (UTT), developed by Barlow et al. (2011), aims to address a range of emotional disorders using a single therapeutic protocol. This approach focuses on increasing emotional awareness, promoting cognitive reappraisal, and reducing emotional avoidance. The therapy is structured to enhance patients' emotional and cognitive regulation through systematic sessions.

Session 1: Increasing Motivation for Therapy Participation

This session focuses on increasing patients' readiness and motivation for behavioral change and enhancing self-efficacy through belief in personal ability to achieve the desired change.

Session 2: Psychoeducation and Emotional Experience Exploration

This session provides psychoeducation about the nature of emotions, the main components of emotional experience, and the concept of learned responses.

Session 3: Emotional Awareness Training

The session identifies how individuals react and respond to emotions, promoting non-judgmental, present-focused awareness of emotional experiences.

Session 4: Cognitive Appraisal and Reappraisal

This session identifies the role of maladaptive automatic appraisals in creating emotional experiences and teaches methods to recognize and modify maladaptive thinking patterns.

Session 5: Emotional Avoidance and Emotion-Driven Behaviors

The session identifies patterns of emotional and behavior-driven maladaptive responses and increases awareness of how behaviors perpetuate distress, promoting efforts to change current emotional response patterns.

Session 6: Awareness and Tolerance of Physical Sensations

This session increases awareness of the role of physical sensations associated with emotional experiences and enhances tolerance towards these sensations.

Session 7: Emotional Exposure (Internal and Situational)

This session emphasizes internal and external emotional triggers, increases tolerance towards them, and promotes new contextual learning.

Session 8: Relapse Prevention

The final session reviews therapeutic concepts, discusses treatment progress, anticipates potential future problems, and encourages the continuation of learned methods.

Data analysis

The spirituality therapy was conducted in 14 ninety-minute group sessions based on the specified package. Initially, a briefing session was held to familiarize the sample individuals with the research plan, highlight the topic's importance, and obtain their cooperation. Participants completed the test anxiety and problem-solving skills questionnaires and were randomly assigned to the experimental and control groups. The experimental group attended all sessions, while the control group received no intervention. Finally, both groups were assessed using a post-test.

Findings and Results

Table 1 presents the descriptive statistics, including mean and standard deviation, of the sexual schema scores for the control, Mentalization-Based Therapy (MBT), and Unified Transdiagnostic Treatment (UTT) groups at both pre-test and post-test stages. As observed, the mean scores in both pre-test and post-test stages do not show significant changes across the control and experimental groups.

To compare the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed women who have experienced infidelity, a Multivariate Analysis of Covariance (MANCOVA) was employed. The results of this analysis are presented below. It is noteworthy that all assumptions for covariance analysis were confirmed, and the use of covariance analysis was justified. To examine the differences between groups in each sexual schema, the test of between-subjects effects was used, with the results shown below.

Table 2 shows the results of the test of between-subjects effects for comparing sexual schemas among the experimental and control groups in the post-test phase. Based on the results in Table 5, the F value for all three schemas is greater than 0.05 (p > .05). Therefore, it is concluded that there is no significant difference in the mean scores of sexual schemas between the control group, Unified Transdiagnostic Treatment group, and Mentalization-Based Therapy group in the post-test phase, indicating that these two therapeutic methods were not effective on the sexual schemas of religiously committed women who have experienced infidelity.

Discussion and Conclusion

As the test of between-subjects effects indicates, there is no significant difference in the mean scores of sexual schemas between the control group, Unified Transdiagnostic Treatment group, and Mentalization-Based Therapy group in the post-test phase. Therefore, these two therapeutic methods were not effective on the sexual schemas of religiously committed women who have experienced infidelity.

In terms of the non-significant impact of the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed women who have experienced infidelity, research findings show that this result partially aligns with the combined results of studies by Aini and colleagues (2018), Soleimani and colleagues (2020), Aliyari-Ghazaz (2020), and Beck and colleagues (2020).

To explain the non-significant impact of the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed women who have experienced infidelity, both empirical background and theoretical explanations from the researcher are used. Schemas are deep-rooted beliefs stemming from childhood experiences and subsequent life confirmations (Choupani & Karami, 2022). Modifying individuals' schemas, especially sexual schemas, requires a deep focus on cognitive and experiential structures (Liu & Kent, 2021). Such focus is absent in both mentalization and Unified Transdiagnostic Treatment approaches. Both present approaches focus on modifying the emotional system and primary beliefs without attention to the cognitive systems and underlying mental interpretations behind sexual schemas. Beck and colleagues (2020) emphasized that Mentalization-Based Therapy, through changes in members' mental interpretations, plays a significant role in improving mood, psychological, and even personality disorders; however, its impact on deep cognitive foundations and maladaptive schemas in various domains, such as sexual, is unlikely. Modifying deep-rooted and schema-based beliefs requires a focused approach on the root of these schemas in both past and present contexts, which is not observed in either mentalization or Unified Transdiagnostic Treatment approaches. Soleimani and colleagues (2020) confirmed the effectiveness of Unified Transdiagnostic Treatment in improving emotional expression and fear of intimacy, highlighting that this therapeutic approach alone cannot create fundamental schema changes and needs to be combined with other therapeutic approaches to achieve schema modification.

Mentalization-Based Therapy and Unified Transdiagnostic Treatment, with their emphasis on modifying the emotional system and enhancing emotional regulation capabilities and cognitive reappraisals, play a significant role in improving psychological security, reducing mood disorders, and even improving interpersonal relationships (Aliyari, 2020; Aini & colleagues, 2019). However, the ability to create schema changes, especially in the sexual domain, is beyond the therapeutic focus of these cognitive-emotional, relational approaches. To modify individuals' sexual schemas, it is necessary to use schema-focused and more root-based approaches alongside these therapeutic approaches. Only in this way can these therapeutic approaches be expected to have a significant impact on improving sexual schemas.

Limitations & Suggestions

The generalizability of research findings is influenced by various factors, one of which is the cultural context where the research is conducted. This study was conducted in Shiraz, limiting the generalizability of the findings to other social contexts and cultural backgrounds.

The sample in this study consisted solely of women who had experienced infidelity, and men who had experienced infidelity were not included. Thus, the generalizability of the findings is limited by gender and applies only to women who have experienced infidelity.

The sample in this study included only religiously committed women who had experienced infidelity, and non-religious women who had experienced infidelity were not included. Therefore, the generalizability of the findings is influenced by the intervening variable of religious commitment and cannot be generalized to all women who have experienced infidelity.

Future research should focus on comparing the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed women who have experienced infidelity in other cities and cultural contexts.

Future research should compare the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed men who have experienced infidelity.

Future research should compare the effectiveness of Mentalization-Based Therapy and Unified Transdiagnostic Treatment on the sexual schemas of religiously committed men and women who have experienced infidelity, with gender-specific comparisons.

It is recommended that counseling centers active in the field of marriage and family use either Mentalization-Based Therapy or Unified Transdiagnostic Treatment to improve the tensions caused by infidelity, including sexual schemas and other psychological variables in the target group. Improving these problems in women or men who have experienced marital infidelity can significantly enhance adjustment to the bitter experience and allow couples to return to their normal lives.

One of the main reasons for the tendency towards divorce is the experience of marital infidelity. Counseling centers active in the field of family and divorce, especially divorce counseling centers in courts, can use Mentalization-Based Therapy and Unified Transdiagnostic Treatment to reduce the tensions caused by infidelity. Using these approaches can improve sexual schemas and marital forgiveness, preventing the breakdown of marital life and providing the basis for improving relationships and strengthening family stability.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

All authors equally contributed in this article.