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A Cognitive-Behavioral Intervention for Marital Adjustment Among Patients with Type 2 Diabetes: Model Development, Implementation, and Mixed Methods Assessment Within the Iranian Cultural Context

Articles in Press

Document Type : Original Article

Author

Department of Nursing, School of Nursing and Midwifery Community Nursing Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

Abstract

 Introduction: Marital adjustment changes after serious diseases such as diabetes mellitus. Psychological therapies and training are required to aid couples in their marital adjustment. To improve marital adjustment in the context of type 2 diabetes within Iranian families, the present study designed and tested a training program centered on the cognitive-behavioral approach.
Methods: Adopting an exploratory mixed-methods approach, this study followed the six-step framework proposed by Talbot and Verrinder for program development. The initial phase involved a conventional qualitative inquiry to identify core themes. Subsequently, through a synthesis of literature, evidence-based practices, and two expert panel reviews, the intervention was developed and finalized. The program was then implemented using a quasi-experimental design involving 40 couples with type 2 diabetes. To assess effectiveness, marital adjustment was measured at baseline and at a one-month follow-up. Using SPSS version 22, independent and paired t-tests, along with ANCOVA, were employed to perform the necessary statistical computations for this study.
Results: A systematic framework was employed to identify the core components of the psycho-educational intervention. The resulting program, consisting of 11 structured sessions, was implemented to achieve measurable therapeutic outcomes. Quantitative analysis revealed that the cognitive-behavioral couple training significantly enhanced marital adjustment. Following the intervention, the treatment group’s total DAS scores (95.9 ± 7.42) showed a marked improvement compared to the control group (62.1 ± 5.49) (t = 0.14, P < 0.001), and the study showed a robust effect size (Cohen’s d = 5.17). Furthermore, statistical significance was maintained across all DAS subscales according to the ANCOVA results, even after neutralizing the influence of baseline variables (P ≤ 0.05).
Conclusion: The evidence presented confirms that marital adjustment can be substantially enhanced through a CBT-informed psycho-educational intervention. Therefore, this approach holds promise as a valuable addition to multi-disciplinary rehabilitation programs for various patient populations.

Keywords

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References
  1. Yang X, Li Z, Sun J. Effects of cognitive behavioral therapy-based intervention on improving glycaemic, psychological, and physiological outcomes in adult patients with diabetes mellitus: a meta-analysis of randomized controlled trials. Front Psychiatry 2020;11:711. doi:10.3389/fpsyt.2020.00711
  2. Velázquez-Jurado H, Flores-Torres A, Pérez-Peralta L, Salinas- Rivera E, Valle-Nava MD, Arcila-Martinez D, et al. Cognitive behavioral treatment to improve psychological adjustment in people recently diagnosed with type 2 diabetes: psychological treatment in type 2 diabetes. Health Psychol Behav Med 2023;11(1):2179058. doi:10.1080/21642850.2023.2179058
  3. Farooqi A, Gillies C, Sathanapally H, Abner S, Seidu S, Davies MJ, et al. A systematic review and meta-analysis to compare the prevalence of depression between people with and without type 1 and type 2 diabetes. Prim Care Diabetes 2022;16(1):1-10. doi:10.1016/j.pcd.2021.11.001
  4. Jenkinson E, Knoop I, Hudson JL, Moss-Morris R, Hackett RA. The effectiveness of cognitive behavioural therapy and third-wave cognitive behavioural interventions on diabetes-related distress: a systematic review and meta-analysis. Diabet Med 2022;39(11):e14948. doi:10.1111/dme.14948
  5. Vlachou E, Ntikoudi A, Owens DA, Nikolakopoulou M, Chalimourdas T, Cauli O. Effectiveness of cognitive behavioral therapy-based interventions on psychological symptoms in adults with type 2 diabetes mellitus: an update review of randomized controlled trials. J Diabetes Complications 2022;36(5):108185. doi:10.1016/j.jdiacomp.2022.108185
  6. Navarro-Flores E, Pérez-Ros P, Martínez-Arnau FM, Julían- Rochina I, Cauli O. Neuro-psychiatric alterations in patients with diabetic foot syndrome. CNS Neurol Disord Drug Targets 2019;18(8):598-608. doi:10.2174/187152731866619100209 4406
  7. Chew BH, Vos RC, Stellato RK, Ismail M, Rutten G. The effectiveness of an emotion-focused educational programme in reducing diabetes distress in adults with type 2 diabetes mellitus (VEMOFIT): a cluster randomized controlled trial. Diabet Med 2018;35(6):750-9. doi:10.1111/dme.13615
  8. Helgeson VS, Van Vleet M, Zajdel M. Diabetes stress and health: Is aging a strength or a vulnerability? J Behav Med 2020;43(3):426-36. doi:10.1007/s10865-019-00106-4
  9. Gonzalez Heredia T, González-Ramírez LP, Hernández- Corona DM, Maciel-Hernández EA. Anxious depression in patients with type 2 diabetes mellitus and its relationship with medication adherence and glycemic control. Glob Public Health 2021;16(3):460-8. doi:10.1080/17441692.2020.181 0735
  10. Owens-Gary MD, Zhang X, Jawanda S, Bullard KM, Allweiss P, Smith BD. The importance of addressing depression and diabetes distress in adults with type 2 diabetes. J Gen Intern Med 2019;34(2):320-4. doi:10.1007/s11606-018-4705-2
  11. Sullivan AB, Domingo S. Interdisciplinary treatment of patients with multiple sclerosis and chronic pain. In: Watson RR, Killgore WD, eds. Nutrition and Lifestyle in Neurological Autoimmune Diseases: Multiple Sclerosis. Academic Press; 2017. p. 213-9. doi:10.1016/b978-0-12-805298-3.00022-0
  12. Fallahchai R. Mediating role of supportive dyadic coping in the association between stress and marital adjustment in women undergoing treatment for breast cancer. Iran J Breast Dis 2018;11(3):21-31. doi:10.30699/acadpub.ijbd..11.3.21
  13. Sarhadi M, Navidian A, Mehdipour-Rabori R, Nuhi E. Exploring the Marital Adjustment Process of Couples Following Myocardial Infarction and Designing and Implementing a Couple Training Program Based on a Cognitive-Behavioral Approach on Marital Adjustment of Couples: A Mixed Methods Study. Kerman: Kerman University of Medical Sciences; 2021.
  14. Pan T, Chen D, Yu Z, Liu Q, Chen Y, Zhang A, et al. Analysis of current situation and influencing factors of marital adjustment in patients with Crohn’s disease and their spouses. Medicine (Baltimore) 2024;103(11):e37527. doi:10.1097/ md.0000000000037527
  15. Tahan M, Saleem T, Moshtagh M, Fattahi P, Rahimi R. Psychoeducational Group Therapy for sexual function and marital satisfaction in Iranian couples with sexual dysfunction disorder. Heliyon 2020;6(7):e04586. doi:10.1016/j. heliyon.2020.e04586
  16. Ahmaditar S, Makvandi B, Sodani M. The effectiveness of family education in cognitive-behavioral approach on marital adjustment, resilience and quality of life in couples. Women and Family Studies 2018;11(41):23-41.
  17. Sharifi M, Fatehizade MS, Bahrami F, Jazayeri R, Etemadi O. The effectiveness of mindfulness-integrated transactional analysis therapy on marital quality of women with interpersonal dependency. Quarterly Journal of Woman and Society 2019;9(36):177-96.
  18. Taheri N, Aghamohammadian Sherbaf H, Asghari Ebrahimabad MJ. The effectiveness of an intimate relationship skills training (PAIRS) on increasing marital adjustment and satisfaction in women with cancer. Nurs Midwifery J 2017;15(4):301-12.
  19. Santos C, Costa ME, Pedro J, Higginbotham BJ, Martins MV. Marital adjustment in remarriage: a systematic review. Fam Transit 2024;65(4):291-322. doi:10.1080/28375300.2024.23 55001
  20. Zheng M, Wang H, Li C, Ouyang Y, Yan L, Gong F, et al. Marital adjustment as a mediator between emotional suppression and self-compassion in women aged 35 + undergoing in vitro fertilization-embryo transfer: a cross-sectional observational study. Depress Anxiety 2025;2025:2100969. doi:10.1155/ da/2100969
  21. Khatibi A. Measuring the effectiveness of adjustment components on family consolidation. Women’s and Family Education Cultural Quarterly 2018;12(42):7-31.
  22. Salimi H, Mohsenzadeh F, Mohammad Nazari A. Prediction of marital adjustment based on family solidarity, time for togetherness and financial sources in female teachers. Quarterly Journal of Woman and Society 2017;7(27):175-92.
  23. Sarhadi M, Navidian A, Mehdipour-Rabori R, Nouhi E. Explaining positive couple interactions after myocardial infarction: a qualitative study. J Qual Res Health Sci 2022;11(4):224-30. doi:10.34172/jqr.2022.10
  24. Sabre K. Marital adjustment among women: a comparative study of nuclear and joint families. Int J Indian Psychol 2016;3(2):26-32.
  25. Sasanpour M, Azizi A, Dehghan Manshadi SM. The effectiveness of sexual cognitive restructuring on marital satisfaction and mental health of the couples in Esfahan. Community Health Journal 2016;10(2):1-10.
  26. Sarhadi M. Effectiveness of cognitive-behavioral training on marital adjustment of couples with type 2 diabetes. Iran J Endocrinol Metab 2023;25(1):16-24.
  27. Pirfalak M, Sodani M, shafiabadi A. The efficacy of group cognitive behavioral couples therapy (GCBCT) on the decrease of couple burnout. Family Counseling and Psychotherapy 2014;4(2):247-69.
  28. Bélanger C, Laporte L, Sabourin S, Wright J. The effect of cognitive-behavioral group marital therapy on marital happiness and problem solving self-appraisal. Am J Fam Ther 2015;43(2):103-18. doi:10.1080/01926187.2014.956614
  29. Mohammadi M, Sheykh Hadi Siruii R, Garafar A, Zahrakar K, Shakarami M, Davarniya R. Effect of group cognitive behavioral couples therapy on couple burnout and divorce tendency in couples. Armaghane Danesh 2017;21(11):1069-86.
  30. Shafiee Z, Tavoli A. Effectiveness of training program based on cognitive- behavior approach on couples marital adjustment referring to counselling centers in Delijan. Clinical Psychology and Personality 2020;17(1):71-7. doi:10.22070/ cpap.2020.2885
  31. Bahrammasiri A., Kiyan-Ersi F. The Effectiveness of Mindfulness Training on Reduction of Obsessive Compulsive Disorder Symptoms and Increase Marital Satisfaction of Married Women. J Arak Uni Med Sci 2019;21(7):18-27.
  32. Lee S, Lee E. Effects of cognitive behavioral group program for mental health promotion of university students. Int J Environ Res Public Health 2020;17(10):3500. doi:10.3390/ ijerph17103500
  33. Taylor J, O’Hara L, Talbot L, Verrinder G. Promoting Health: The Primary Health Care Approach. Elsevier Health Sciences; 2020.
  34. Farokhzadian J, Nematollahi M, Dehghan Nayeri N, Faramarzpour M. Using a model to design, implement, and evaluate a training program for improving cultural competence among undergraduate nursing students: a mixed methods study. BMC Nurs 2022;21(1):85. doi:10.1186/s12912-022- 00849-7
  35. Gorman AS. Couple Therapy Clinical Guide. Tehran: Bu-Ali Sina University Publishing Center; 2014.
  36. Pirzadi H, Fathi-Ashtiani A, Shokoohi-Yekta M. Effectiveness of group cognitive-behavioral training on physiological indicators and communication skills in the hospital staffs. J Nurs Educ 2015;4(1):60-71.
  37. Dastan N. Investigate the Comparison Effects of Narrative Couple Therapy and Integrative Behavior Couple Therapy on Improvement of Conflict Solving Tactics and Increasing Marital Adjustment. Ahvaz: University of Shahid Chamran of Ahvaz; 2015.
  38. Houghton K, Krak J, Klark D. Cognitive Behavior Therapy A Practical Guide in the Treatment of Mental Disorders. Tehran: Arjomand Publications; 2012.
  39. Farzaneh A. The Effect of Enrichment Training for Couples Based on Enrich Model on Marital Commitment. Bojnord: University of Bojnord; 2015.
  40. Bigdelimojarad F, Entesar Foumany G, Hejazi M. The effectiveness of sex therapy based on cognitive-behavioral (sexual relationship) training on reducing marital burnout and increasing marital quality of married nurses. Iran J Nurs Res 2020;15(4):1-9.
  41. Mokari Z. Effectiveness of Sexual Skills Education (Based Cognitive-Behavioral) Sexual Function, Marital Adjustment and Outcome of Treatment Infertile Women in Kermanshah. Razi University; 2016.
  42. Hoseinnejad M. Study of Parents’ Incompatibility of Mentally Retarded Children. Tehran: Allameh Tabataba’i University; 2001.
  43. Hosseini Tabaghdehi M, Keramat A, Khosravi A. Prevalence of female sexual dysfunction in Iran: a meta-analysis study. Shahroud J Med Sci 2016;2(4):10-3. doi:10.22100/ijhs. v2i4.158
  44. Sanaei B, Alaghband S, Falahati S, Homan A. Family and Marriage Measurement Scales. Tehran: Besat Publications; 2010.
  45. Araghian Mojarad F, Sanagoo A, Jouybari L. Critical appraisal of the quality of grounded theory studies. Nursing Development in Health Journal 2018;8(1):37-45.
  46. Schneider Z, Whitehead D, LoBiondo-Wood G, Faan R, Haber J. Nursing and Midwifery Research: Methods and Appraisal for Evidence Based Practice. 5th ed. Elsevier; 2016.
  47. Spanier GB. Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976;38(1):15-28. doi:10.2307/350547
  48. Spanier GB, Thompson L. A confirmatory analysis of the dyadic adjustment scale. J Marriage Fam 1982;44(3):731-8. doi:10.2307/351593
  49. Hashemi SF, Hamzehgardeshi Z, Nataj AH, Ganji J. Factors associated with marital adjustment in couples: a narrative review. Curr Psychosom Res 2024;2(2):73-86.
  50. Tessier A, Croteau C, Voyer B. Exploring the usability of the andragogical process model for learning for designing, delivering and evaluating a workplace communication partner training. J Workplace Learn 2021;33(8):577-90. doi:10.1108/ jwl-10-2020-0163
  51. Durães RS, Khafif TC, Lotufo-Neto F, de Pádua Serafim A. Effectiveness of cognitive behavioral couple therapy on reducing depression and anxiety symptoms and increasing dyadic adjustment and marital social skills: an exploratory study. The Family Journal 2020;28(4):344-55. doi:10.1177/1066480720902410
  52. Ostadi N, Badeleh M, Mohseni Birjandi R. The effectiveness of cognitive behavioral group training on attachment and dysfunctional attitudes and marital adjustment of married. Fundamentals of Mental Health 2014;16(62):150-61. doi:10.22038/jfmh.2014.3272
  53. Salimi C, Kachooei M, Dadashi M, Farahani H. Effects of integrative behavioral couple therapy on communication patterns and marital adjustment. J Educ Health Promot 2024;13(1):276. doi:10.4103/jehp.jehp_201_23
  54. Fischer MS, Baucom DH, Cohen MJ. Cognitive-behavioral couple therapies: review of the evidence for the treatment of relationship distress, psychopathology, and chronic health conditions. Fam Process 2016;55(3):423-42. doi:10.1111/ famp.12227
  55. Ussher JM, Perz J. Evaluation of the relative efficacy of a couple cognitive-behaviour therapy (CBT) for premenstrual disorders (PMDs), in comparison to one-to-one CBT and a wait list control: a randomized controlled trial. PLoS One 2017;12(4):e0175068. doi:10.1371/journal.pone.0175068
  56. Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York: Guilford Press; 2011.
  57. Epstein NB, Zheng L. Cognitive-behavioral couple therapy. Curr Opin Psychol 2017;13:142-7. doi:10.1016/j. copsyc.2016.09.004
  58. Çag P, Yildirim I. The mediator role of spousal self-disclosure in the relationship between marital satisfaction and spousal support. Educ Sci Theory Pract 2018;18(3):701-36.
  59. Mousavi S, Fatehizadeh M, Jazayeri RS. The effect of couple training based on personality-systemic couple therapy model on marital adjustment. Research in Cognitive and Behavioral Sciences 2018;7(2):83-106. doi:10.22108/cbs.2017.86698.0
  60. Parseh M, Naderi F, Mehrabizade Honarmand M. Efficacy of cognitive-behavioral family therapy on marital conflicts and sexual satisfaction in couples referred to psychological centers. Clinical Psychology Achievements 2015;1(1):125-48. doi:10.22055/jacp.2015.11510
  61. Epstein NB, Baucom DH. Enhanced Cognitive-Behavioral Therapy for Couples: A Contextual Approach. 2nd ed. American Psychological Association; 2002.
  62. Zahrakar K, Lavafpoornori F. Investigating the effectiveness of Cognitive Couples Therapy (CCT) in improving the level of marital adjustment of married students. Family Counseling and Psychotherapy 2014;4(2):317-39.
  63. Şafak Öztürk C, Arkar H. [Effect of cognitive behavioral therapy on sexual satisfaction, marital adjustment, and levels of depression and anxiety symptoms in couples with vaginismus]. Turk Psikiyatri Derg 2017;28(3):172-80. [Turkish].
  64. Mokari Z, Momeni K, Yazdanbakhsh K, Jaliliyan N. The effectiveness of cognitive-behavioral based sexual skills education on marital adjustment in infertile women. Journal of Counseling Research 2017;16(64):55-73.
  65. Miri MR, Alizadeh M, Moasheri N, Ataee M, Moodi M. The effects of relationship enrichment program on compatibility and marital satisfaction of infertile couples. J Health Lit 2016;1(1):53-60.
  66. Shamohammadi S DA, Poor Shahriari Z. Increasing the marital compatibility of addicts’ wives and preventing the return of male addicts in Isfahan. Addiction research 2008;2(7):3-28.

 

 

 

Journal of Kerman University of Medical Sciences

Articles in Press, Accepted Manuscript
Available Online from 04 May 2026
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