The Effectiveness of Group Cognitive Behavioral Therapy on Depression and Sense of Security in Women with Marital Distress
Abstract
Objective: The aim of this research was to determine the effectiveness of group cognitive behavioral therapy (CBT) on depression and sense of security in women experiencing marital distress.
Methods and Materials: The research method was quasi-experimental, employing a pre-test and post-test design with a control group. The statistical population of this study included women with marital distress who referred to counseling centers in Tehran in 2022. The sampling method was purposive, and using this method, 28 individuals were selected as the sample and randomly assigned to two groups: experimental (14 individuals) and control (14 individuals). Data were collected using questionnaires on depression and sense of security. Group CBT was conducted in eight 120-minute sessions for the experimental group. After the completion of the group CBT sessions, post-tests were administered to both the experimental and control groups.
Findings: The findings indicated that the mean scores of depression and sense of security in the post-test of the experimental group were significantly different from the pre-test.
Conclusion: Therefore, group cognitive behavioral therapy affects depression and sense of security in women with marital distress.
Introduction
Marriage has always been affirmed as the most important and supreme social tradition for meeting individuals' emotional needs. Major reasons for marriage include love and affection, having a partner and companion in life, satisfying emotional and psychological needs, and increasing happiness and satisfaction (Bernstein & Bernstein, 2019). Additionally, the family is introduced as a social institution arising from the marital bond between a man and a woman. An individual's satisfaction with marital life equates to satisfaction with the family, and satisfaction with the family translates to life satisfaction, facilitating material and spiritual growth and progress in society (Vanick & Gulick, 2011).
Women in any society are considered the main pillars of the family, and their health holds particular importance. Women's health, especially maternal health, is a fundamental concept in socio-economic development and welfare (McKeen, 2008). One of the most significant aspects of a marital system is the satisfaction spouses experience in marriage and the responsibility they have toward their family and later their children. Reflecting on previous studies, it can be concluded that women's responsibility plays a crucial role in preventing divorce and leads to marital satisfaction. It should be noted that divorce rates are the most reliable indicator of marital distress (Abbasi et al., 2016).
Depressive disorder is one of the most common psychiatric disorders, characterized by a depressed mood accompanied by sadness, low self-esteem, and a lack of interest in any activity or daily pleasure, often referred to as the “common cold of mental illness” (Janbozorgi & Garavi, 2016). Depression is defined as a pervasive state of sadness, sorrow, and melancholy. Sometimes, our feelings of sadness are a natural reaction to an unpleasant event. However, this feeling soon subsides, and we resume our normal activities. In contrast, pathological depression is much more severe than occasional mood swings that everyone experiences from time to time (Mosh & Wolf, 2017). Depression is an unpleasant mental state characterized by apathy, hopelessness, and fatigue, often accompanied by varying degrees of anxiety (Wang, Simon, & Kessler, 2015).
Undoubtedly, the feeling of insecurity threatens the fulfillment of many needs that fall under the category of safety needs. Abraham Maslow also places safety needs in a category after primary needs in his hierarchy of needs. Safety is one of the complex concepts that cannot be easily defined. Before it can be defined, security is a perceptual and emotional phenomenon (Bakhshandeh Zahmati et al., 2019). Having a safe environment for living is necessary alongside other basic physiological needs of humans, such as food, housing, health, and treatment (Moradi Siyasari et al., 2019).
After fulfilling human physical needs, safety needs can be considered one of the fundamental structures forming personality, and without feeling secure in daily life, there will be no progress in personality structure (Schultz et al., 2009, as cited in Bapiri, Kamrabegi, & Rezaei, 2020). Women's sense of security is less than that of men, and women transmit their insecurity to their children, raising a fearful and distrustful generation, which adversely affects societal progress (Shaigan & Rostami, 2011). Security has both objective and subjective aspects, with objective safety and subjective security being directly related (Roosta & Ahmadi, 2019).
In the group cognitive-behavioral approach, based on inductive methods, clients learn to view thoughts and beliefs as hypotheses that need to be tested for validity. Ultimately, this approach is educational, wherein cognitive-behavioral techniques are considered skills that must be learned through practice and applied in the client's environment via homework assignments. In this group cognitive-behavioral intervention, skills for assessing irrational and negative thinking are taught, and a range of standard cognitive-behavioral coping skills are instructed, guiding flexibility in choosing appropriate strategies for therapy, leading to increased feelings of security and reduced depression in women (Darvishzadeh & Maghderi, 2018).
Therefore, the present study seeks to answer the question of whether group cognitive-behavioral therapy affects depression and sense of security in women with marital distress.
Methods and Materials
Study Design and Participants
The research method was quasi-experimental, employing a pre-test and post-test design with a control group. The statistical population of this study included women with marital distress who referred to counseling centers in Tehran in 2022. The sampling method was purposive, and using this method, 28 individuals were selected as the sample and randomly assigned to two groups: experimental (14 individuals) and control (14 individuals). Data were collected using questionnaires on depression and sense of security. Group cognitive-behavioral therapy was conducted in eight 120-minute sessions for the experimental group. After the completion of the group CBT sessions, post-tests were administered to both the experimental and control groups.
Measures
Depression
This inventory consists of 21 items and, due to its importance in clinical intervention diagnosis, numerous psychometric studies have been conducted on its properties. One of the most significant studies is a meta-analysis conducted by A.T. Beck, Steer, and Garbin in 1988. Beck and colleagues, by reviewing studies that used this tool, found that its reliability coefficient, using the test-retest method, varied from 0.48 to 0.86 depending on the time interval between administrations and the type of population tested. In 1996, Beck and colleagues again found the test-retest reliability coefficient to be 0.93 over a one-week interval. Respondents need at least a fifth or sixth-grade reading level to understand the items. They respond to each item on a four-point Likert scale ranging from 0 to 3. The minimum score is 0, and the maximum is 63. By summing the individual item scores, the direct score is obtained. The following score ranges indicate the overall level of depression: 0-13: minimal or no depression, 14-19: mild depression, 20-28: moderate depression, 29-63: severe depression. To determine the reliability of the questionnaire in this study, Cronbach's alpha coefficient was used, which is employed for the reliability assessment of multiple-choice questionnaires. The reliability coefficient of the Beck Depression Inventory in this study was 0.91, indicating a high level of internal consistency among the variables and satisfactory reliability of the measurement tool.
Psychological Security
The short form of Maslow's Psychological Security Inventory, designed and validated in 2004, consists of 18 items and 4 subscales: self-confidence, dissatisfaction, environmental incompatibility, and others' perceptions of the individual. It is used to assess psychological security. Shams and Khalijian (2013) validated this questionnaire. The self-confidence subscale includes 7 items (items 1-7), dissatisfaction includes 3 items (items 8-10), environmental incompatibility includes 5 items (items 11-15), and others' perceptions include 3 items (items 16-18). According to the scoring key, 1 point is given for each response that matches the key, and 0 points for those that do not. In Shams and Khalijian's (2013) study, the reliability of the questionnaire was calculated using Cronbach's alpha method after a pilot study on 30 individuals, resulting in a coefficient of 0.80. Furthermore, in Shams and Khalijian's (2013) study, the validity of the questionnaires was confirmed based on expert opinions.
Intervention
Group Cognitive Behavioral Therapy
The intervention protocol consists of eight group cognitive-behavioral therapy (CBT) sessions, each lasting 120 minutes. The sessions are designed to address depression and psychological security in women with marital distress. The therapy focuses on modifying cognitive-emotional processes, improving coping skills, and integrating learned techniques into real-life situations. Each session has specific objectives and activities to help participants overcome automatic thoughts, unhealthy habits, and behavioral patterns, thus playing a significant role in emotion regulation and enhancing the sense of security.
Session 1: Introduction and Goal Setting
The first session focuses on introducing the participants to the group and the CBT approach. Therapists explain the objectives of the therapy, outline the structure of the sessions, and establish group rules. Participants share their personal goals and expectations from the therapy. The session includes an overview of cognitive-behavioral principles, emphasizing the connection between thoughts, emotions, and behaviors. Participants are encouraged to identify and discuss specific issues related to their marital distress and depression.
Session 2: Cognitive Restructuring
In the second session, participants learn about cognitive distortions and how these contribute to their depressive symptoms and feelings of insecurity. The therapist introduces techniques for identifying and challenging irrational thoughts. Activities include cognitive restructuring exercises, where participants practice recognizing negative automatic thoughts and replacing them with more realistic and balanced ones. Homework assignments are given to reinforce these techniques outside of the session.
Session 3: Emotional Regulation
The third session focuses on emotional regulation strategies. Participants learn about the importance of managing emotions and are introduced to techniques such as mindfulness, relaxation exercises, and deep-breathing exercises. The session includes guided practice of these techniques, helping participants understand how to apply them in stressful situations. The therapist emphasizes the role of emotional regulation in improving mood and enhancing psychological security.
Session 4: Behavioral Activation
In the fourth session, the emphasis is on behavioral activation to combat depressive symptoms. Participants are encouraged to engage in pleasurable and meaningful activities that they have been avoiding due to depression. The therapist helps participants identify specific activities and set achievable goals. The session includes planning and scheduling these activities, and discussing potential obstacles and solutions. Participants share their experiences and progress in subsequent sessions.
Session 5: Problem-Solving Skills
The fifth session focuses on developing effective problem-solving skills. Participants learn a structured approach to solving interpersonal and intrapersonal problems contributing to their marital distress and depression. The session includes role-playing exercises and group discussions to practice these skills. The therapist guides participants in identifying problems, generating potential solutions, evaluating the options, and implementing the chosen solutions.
Session 6: Communication Skills
In the sixth session, participants focus on improving their communication skills, which are crucial for resolving marital conflicts and enhancing psychological security. The therapist introduces effective communication techniques, such as active listening, assertiveness, and non-verbal communication. Participants engage in role-playing scenarios to practice these skills, receive feedback, and discuss their experiences. Homework assignments reinforce the application of these techniques in real-life interactions.
Session 7: Coping with Stress
The seventh session addresses stress management techniques. Participants learn about the impact of stress on their mental health and marital relationships. The therapist introduces coping strategies such as time management, prioritization, and relaxation techniques. The session includes practical exercises and group discussions on how to handle stress more effectively. Participants are encouraged to share their experiences and strategies that have worked for them.
Session 8: Review and Relapse Prevention
The final session focuses on reviewing the progress made during the therapy and developing a relapse prevention plan. Participants reflect on their personal growth, share their achievements, and discuss any remaining challenges. The therapist reinforces the skills learned throughout the sessions and provides additional resources for continued practice. The session concludes with creating a personalized relapse prevention plan, helping participants maintain their improvements and cope with future stressors effectively.
Data Analysis
The data were analysed via SPSS-26 and analysis of covariance method.
Findings and Results
The information in Table 1, showing the mean scores of depression and psychological security for the experimental and control groups in the pre-test and post-test, indicates that the pre-test and post-test scores differ in the experimental group.
Variables | Group | Pre-test Mean | Pre-test SD | Post-test Mean | Post-test SD |
|---|---|---|---|---|---|
Depression | Control | 22.37 | 3.12 | 24.64 | 3.38 |
Experimental | 23.69 | 3.35 | 15.52 | 2.45 | |
Psychological Security | Control | 8.37 | 1.53 | 7.12 | 1.72 |
Experimental | 8.78 | 1.78 | 13.53 | 1.34 |
The results of the Kolmogorov-Smirnov test indicated that the distribution of the research variables is normal. Given that the distribution of the research variables in the pre-test and post-test was normal and the measurement scale of the variables was interval, parametric analysis of covariance (ANCOVA) was used to analyze the data (p > 0.05).
Source | Sum of Squares | df | Mean Square | F | p-value | Effect Size |
|---|---|---|---|---|---|---|
Pre-test | 59.543 | 1 | 59.543 | 2.154 | 0.621 | 0.069 |
Group | 196.954 | 1 | 196.954 | 11.658 | 0.159 | 0.457 |
Error | 292.325 | 25 | 11.693 | |||
Total | 384.654 | 27 |
As shown in Table 2, the effectiveness of group cognitive behavioral therapy (CBT) on depression in women, in terms of differences between the groups (control and experimental), is statistically significant after adjusting the means of the two groups based on the pre-test scores. Thus, it can be concluded that group CBT affects depression in women with marital distress.
Source | Sum of Squares | df | Mean Square | F | p-value | Power |
|---|---|---|---|---|---|---|
Pre-test | 0.611 | 1 | 0.611 | 0.089 | 0.811 | 0.061 |
Group | 58.867 | 1 | 58.867 | 7.325 | 0.024 | 0.512 |
Error | 181.245 | 25 | 7.249 | |||
Total | 238.873 | 27 |
As shown in Table 3, the effectiveness of group cognitive behavioral therapy (CBT) on the psychological security of women, in terms of differences between the groups (control and experimental), is statistically significant after adjusting the means of the two groups based on the pre-test scores. Thus, it can be concluded that group CBT affects the psychological security of women with marital distress.
Discussion and Conclusion
The findings showed that the mean scores of depression in women in the post-test of the experimental group were significantly different from the pre-test. Therefore, group cognitive behavioral therapy (CBT) affects depression in women with marital distress. However, this research finding is implicitly consistent with the results of Dehghani et al. (2022), Zohrabnia et al. (2021), and Khanal et al. (2020).
Group CBT changes the emotional responses of clients with depression by modifying cognitive-emotional processes, resulting in lower scores on problems related to cognitive emotion regulation, fear, and avoidance of emotions. Additionally, it helps clients with depression to overcome automatic thoughts, unhealthy habits, and behavioral patterns, thus playing a significant role in emotion regulation.
In explaining this finding, it can be said that the main idea in cognitive models of emotional disorders is that it is not the events themselves that are responsible for generating negative emotions such as anxiety, anger, or sadness, but the individuals' expectations and interpretations of those events. In anxiety, these interpretations or cognitive perceptions relate to perceived physical or psychosocial threats. Beck (1996) argues that in depressive states, individuals consistently overestimate the danger related to a specific situation, which leads to automatic and involuntary activation of anxiety, including changes in autonomous arousal to prepare for fight or flight and selective environmental scanning for potential threats.
The findings showed that the mean scores of psychological security in women in the post-test of the experimental group were significantly different from the pre-test. Therefore, group cognitive behavioral therapy (CBT) affects the psychological security of women with marital distress. However, this research finding is implicitly consistent with the results of Taherpour et al. (2020), Khalili and Heidari (2019), and Saffari Nia and Azizi (2019).
CBT, by modifying cognitive evaluations and improving coping skills through practiced techniques integrated into real-life situations, can reduce perceived stress. CBT, a type of psychotherapy aimed at changing moods, behaviors, and thought patterns, is based on the belief that negative actions or feelings are the result of current distorted beliefs or thoughts, not unconscious forces from the past. Therefore, cognitive therapy focuses on the individual’s mood and thoughts, while behavioral therapy specifically targets actions and behaviors.
Security is one of our fundamental needs, and the sense of security is among the factors leading to stability. The sense of security means freedom from anxiety and danger, bringing mental and physical tranquility to the individual.
Limitations and Suggestions
The study has several limitations that must be acknowledged. Firstly, the sample size was relatively small, with only 28 participants, which may limit the generalizability of the findings. Additionally, the study relied on self-reported measures for assessing depression and psychological security, which can be subject to bias and inaccuracies. The quasi-experimental design, while valuable, does not allow for the same level of control over confounding variables as a true experimental design. Furthermore, the intervention was conducted in a specific cultural context (Tehran), which may affect the applicability of the results to other populations or cultural settings. Finally, the short duration of the intervention and follow-up period may not capture the long-term effects of group cognitive-behavioral therapy.
Future research should consider expanding the sample size to enhance the generalizability of the results and include a more diverse population to examine the intervention's effectiveness across different cultural contexts. Employing a randomized controlled trial design would provide stronger evidence of causality and help control for confounding variables. It is also recommended to incorporate a mixed-methods approach, combining quantitative and qualitative data to gain a deeper understanding of participants' experiences and the mechanisms underlying the observed changes. Longitudinal studies with extended follow-up periods would be beneficial in assessing the long-term sustainability of the therapy's effects. Additionally, exploring the impact of individual CBT sessions compared to group sessions could provide insights into the most effective delivery methods for different populations.
The findings of this study suggest that group cognitive-behavioral therapy can be a valuable intervention for reducing depression and enhancing psychological security in women with marital distress. Practitioners should consider integrating group CBT into routine therapeutic services for this population, offering it as a cost-effective and supportive option. Training programs for therapists should include modules on group CBT techniques and emphasize the importance of cultural competence. Policymakers and mental health service providers should allocate resources to support the implementation and evaluation of group CBT programs in diverse settings. Additionally, developing community-based support networks that offer ongoing group CBT sessions can help sustain the benefits of therapy and provide continuous support to individuals facing marital distress and related psychological challenges.
Acknowledgments
The cooperation of all participants in the research is thanked and appreciated.
Declaration of Interest
The authors of this article declared no conflict of interest.
Ethics principles
In this research, ethical standards including obtaining informed consent, ensuring privacy and confidentiality were observed.
