Effectiveness of Emotion-Focused Therapy in Reduction of Marital Violence and Improvement of Family Functioning: A Quasi-Experimental Study


Somayeh Shahmoradi 1 , Hossein Keshavarz Afshar 1 , * , Maryam Goudarzy 1 , Masoud Gholam Ali Lavasani 1

1 Department of Educational Psychology and Counseling, University of Tehran, Tehran, Iran

How to Cite: Shahmoradi S, Keshavarz Afshar H, Goudarzy M, Gholam Ali Lavasani M. Effectiveness of Emotion-Focused Therapy in Reduction of Marital Violence and Improvement of Family Functioning: A Quasi-Experimental Study, Iran Red Crescent Med J. 2019 ; 21(11):e97183. doi: 10.5812/ircmj.97183.


Iranian Red Crescent Medical Journal: 21 (11); e97183
Published Online: December 7, 2019
Article Type: Research Article
Received: August 14, 2019
Revised: October 28, 2019
Accepted: November 4, 2019


Background: The rise in marital violence has led to growing concern about people with this condition. Emotion-focused Therapy (EFT) is one of the well-established treatments that consider both family interaction and emotion in the creation of secure attachment.

Objectives: This study aimed to evaluate the effectiveness of EFT in marital violence reduction and family functioning improvement.

Methods: This study was conducted in 2018-2019 among married women with family problems referring to counseling centers in Tehran, Iran. We randomly allocated 32 women with a mean marriage age of 24.27 ± 6.18 years to EFT and control groups. Marital violence and family functioning were measured before and after EFT using a domestic violence questionnaire and the family assessment device scale constructed based on the McMaster Model of Family Functioning (MMFF). Emotion-focused group therapy was conducted in the intervention group for eight 90-min sessions. The control group was exposed to no intervention. The Kolmogorov-Smirnov test was utilized to evaluate the distribution of variables. We used the independent t-test, chi-square test, Friedman test, Mann-Whitney test, ANOVA, ANCOVA, and MANCOVA for data analysis.

Results: Marital violence decreased significantly after the intervention (-11.25 vs. -1.62, P < 0.001). Moreover, family functioning improved after the intervention (6.25 vs. -1.69, P = 0.001) in the EFT group compared to the control group.

Conclusions: The EFT was an effective intervention in this study. The findings implicate the significance of essential interventions for marital violence reduction and family functioning improvement.

Copyright © 2019, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

The rise in marital violence has led to a growing concern about people with this condition. Marital violence is a state in which a person deliberately and permanently inflicts physical or psychological harm to his or her partner (1). Behavioral causes of psychological or physical harm are defined as marital or intimate-partner violence (2) that may be manifested in different forms including significant verbal abuse and physical violence (i.e., slapping, pushing, and use of weapons). These behaviors may lead to serious injuries and sometimes death (2-5). Physical injuries are the main consequences of physical violence in admitted patients. Thus, marital violence negatively affects women’s health (6-10).

Research indicates that the factors contributing to marital violence include financial difficulties, alcohol and substance abuse, poor interpersonal communication skills, and exposure to violence in childhood (11). Furthermore, several studies showed that physical conditions (such as testosterone levels) can be effective in anger management and consequently marital violence (12, 13). While some scholars suggest that controversial factors, such as power struggles between partners, are involved in marital violence (4), others have emphasized the importance of attitudes, cognition, and cognitive errors in the phenomenon of marital violence (14-19).

The followers of attachment theory consider violence as one of the main reasons for unsafe attachment between partners. In other words, one of the ways for an unsafe person to control his/her partner is to subject the partner to violence and aggression (20-26). Since emotional therapy is one of the attachment-focused therapies, some psychotherapists have used it to treat marital violence. The basic assumption of this treatment is that as long as a couple cannot fulfill its satisfaction and security needs, marital conflicts will be formed (27). Emotional couple therapy emphasizes the development of adaptive attachments through caring and reciprocal care for own needs and spouse demands (28). Studies reported the effectiveness of emotion-focused therapy in marital conflicts and problems (29-32).

Recently, family functioning has become a major interest among many researchers and psychologists. It can be affected by injuries such as violence and aggression (6, 7, 10). Family functioning has several dimensions. According to McMaster’s model, it includes six dimensions, as follows: (1) problem solving: the ability of a family to deal with problems to maintain family functioning; (2) communication: information and emotional exchange between family members verbally and non-verbally; (3) roles: recommended and repetitive behaviors found in a set of bilateral activities with other family members; (4) emotional accountability: the ability of family members to respond to a wide range of stimuli (including good and bad feelings such as fear, anger, and depression; family functioning depends on these responses); (5) emotional intercourse: the level of desire, concern, and values of the family for individual and family-specific activities; and (6) behavioral control: the effects of family members on each other (33). Since the family is one of the most significant factors in behavior-shaping and many problems are triggered in its context, numerous therapies focus on the improvement of family functioning.

Emotion-focused Therapy (EFT) is most commonly used to treat depression and infidelity in couples. To date, this method has been less addressed for the treatment of violence in couples.

Here, the researchers of this article tried a new method other than behavioral and drug treatment methods used until now for the treatment of intimate partner violence.

2. Objectives

This study aimed to assess the effectiveness of EFT in reducing marital violence and improving family functioning.

3. Methods

3.1. Sampling

The participants of the study were recruited by a newspaper announcement. They were married women with a history of marital violence. The entire research procedure was explained to them, including their assignment to either treatment or waiting group for eight weeks. The target population of married women was living in Tehran and referred to counseling centers at a public local office named Saraye Mahaleh to resolve their marital and family conflicts in 2018. For this study, by considering α = 0.05, β = 0.1, and d = 1.3, we required 14 participants for each group using the following formula:

Equation 1.n=2Zα 2+Zβ2d2

Accounting for a 25% dropout rate, four participants were added and eventually, 18 women were selected for each group of the study. Overall, 36 women were entered into the study but four of them were excluded from the study. Thus, 32 women were finally selected and randomly divided into control (n = 16) and experimental (n = 16) groups; they remained until the end of the study. The participants were randomly assigned to either waiting or treatment groups. The inclusion criteria were as follow: (1) reporting no history of acute relational conflicts or problems (e.g. depression), (2) living with the partner at the time of study and not being divorced, (3) recording no history of psychotherapy or other medical interventions at the time of the study, (4) having at least a postgraduate degree and aged over 20-years-old, and (5) showing willingness to participate in the study. Individuals who met the following criteria were excluded from this study: (1) absent from more than two sessions, (2) occurrence of acute psychological problems during the study, and (3) lack of motivation for participation in research. Two family counselors (a man and a woman) who had previous experiences in family and couple therapy were recruited for facilitating the groups. Each of them was provided with a copy of EFT text as a guideline for therapeutic intervention. Following the intervention, the posttest was conducted for both groups.

3.2. Research Instruments

A domestic violence questionnaire for women developed by Aghakhani et al. (34) was used in this study to measure marital violence. This questionnaire has 63 questions and measures four types of violence, including psychological-verbal violence, sexual violence, economic violence, and physical violence. According to a previous study, the instrument had high internal consistency with Cronbach’s alpha of 0.72 (34). In the current study, the internal consistency of the questionnaire was 0.83.

The McMaster Model of Family Functioning (MMFF) was utilized to assess family functioning (35). This instrument views family from a systematic viewpoint and conceptualizes family functioning and dysfunction based on the relationship between subsystems within or outside the family. The MMFF includes six subscales of problem-solving, communication, affective responsiveness, roles, affective involvement, and behavior control.

The Family Assessment Device (FAD) is a 4-point Likert scale that includes 60 items and conceptualizes family functioning based on the MMFF (35). The average score of each family was calculated using each member’s score and higher scores indicated more severe family dysfunction.

The validity and reliability of the family functioning scale were assessed in a sample of 503 people after being prepared by Epstein et al. (35). Alpha coefficients from 0.72 to 0.92 indicated its high internal consistency. In the present study, the reliability of FAD was calculated as 0.85 using Cronbach’s alpha method.

3.3. Intervention

All qualified participants who consented to participate in this study were randomized into either EFT or control group. Then, all subjects in the experimental group participated in eight sessions of EFT. In addition to screening and baseline assessments, the participants were asked to complete the questionnaires at the end of the interventional sessions. The protocols of training sessions had multiple parts, including (1) active communicating, listening, and recognizing the attachment style; (2) identification of negative interaction cycle and its severity; (3) identification of underlying and unexplained emotions that are hidden in interactions between spouses; (4) reforming the problem from negative angles, unfulfilled feelings, attachment needs, and redefining attachment; (5) promoting new ways of interacting to create intentional reactions and re-structuring interaction, focusing on nothing else, expressing desires and wishes in the presence of the spouse, and redefining attachment; (6) extending the experience of accepting each partner by another partner; (7) investigating motivational questions, rebuilding interactions, and changing events, facilitating the response to opposing requests, emotional engagement of members with their spouses and experiencing themselves as they are; (8) facilitating new ways to deal with old communication problems, consolidating and reinforcing new and resolved crisis situations regarding the spouse, and trying to extend the therapeutic relationship to other relationships in the individual’s life, especially outside the group meeting.

3.4. Ethical Considerations

This research was registered and approved by the Medical Ethics Committee of the University of Tehran (IR.UT.PSYEDU.REC.1398.020). The research procedure started after obtaining permission from the committee. Informed consent forms were completed by the participants and the confidentiality of the identification information was observed throughout the research process.

3.5. Statistical Analysis

We used descriptive statistics (i.e., frequency, percentage, mean, and standard deviation) and inferential statistics (correlation, chi-square test, independent t-test, Mann-Whitney test, repeated-measures ANOVA, Friedman test, analysis of covariance, Multivariate Analysis of Covariance (MANCOVA) and Univariate Analysis of Covariance (ANCOVA)). The normal distribution of numeric variables was assessed with the Kolmogorov-Smirnov test. The analysis of data was done using IBM SPSS software for Windows, version 21.0. A P value of less than 0.05 was considered significant.

4. Results

Overall, 36 individuals were entered into the study, four of whom were excluded from the study. Finally, 32 women remained until the end of the study (Figure 1). The demographic characteristics of the participants in each group and their baseline information are presented in Table 1. According to Table 1, the age and basic information of the participants in both groups had normal distributions. Table 2 shows the mean and standard deviation of all studied variables before and after the study. The mean scores of marital violence and family functioning in the intervention group showed significant changes compared to the control group.

Table 1. Baseline Variables in Two Groups (N = 16)a, b
Categorical VariablesGroupP Value
BSc14 (88)13 (81)
MSc1 (6)2 (13)
PhD1 (6)1 (6)
Marriage age24.37 ± 3.9624.18 ± 8.40.933
Husband’s marriage age41.06 ± 10.941.25 ± 10.760.962
Problem solving12.56 ± 4.4013.69 ± 5.510.528
Communication17.00 ± 3.8317.38 ± 5.180.817
Roles23.75 ± 2.3223.69 ± 3.960.957
Affective responsiveness19.88 ± 3.6721.00 ± 4.240.429
Affective involvement21.50 ± 5.1422.06 ± 5.510.767
Behavior control26.13 ± 6.2127.88 ± 6.980.460
General family functioning34.13 ± 7.0538.50 ± 6.960.087
Psycho-verbal21.38 ± 5.9222.81 ± 6.750.527
Sexual13.38 ± 3.0511.88 ± 3.240.188
Economic13.94 ± 4.8114.06 ± 5.630.947
Physical8.63 ± 4.877.81 ± 2.290.550
Total57.31 ± 12.9556.56 ± 12.690.870

Abbreviation: SD, standard deviation.

aValues are expressed as mean ± SD or No. (%).

bThe P values were calculated using the chi-square test for categorical variables and t-test or Mann-Whitney test for continuous variables.

Table 2. Mean Scores of Study Variables Before and After Treatment
VariablesPretestPosttestDifferenceP ValueP Value
Problem solving0.176
Experimental12.56 ± 4.4015.75 ± 3.423.190.006
Control13.69 ± 5.5114.94 ± 4.401.250.40
Experimental17.00 ± 3.8320.13 ± 2.703.130.003
Control17.38 ± 5.1817.44 ± 5.400.060.664
Experimental23.75 ± 2.3226.13 ± 2.452.380.005
Control23.69 ± 3.9623.25 ± 3.99-0.440.162
Affective responsiveness0.020
Experimental19.88 ± 3.6721.69 ± 2.941.810.156
Control21.00 ± 4.2419.00 ± 4.82-2.000.091
Affective involvement0.002
Experimental21.50 ± 5.1424.94 ± 4.283.440.014
Control22.06 ± 5.5120.06 ± 6.28-2.000.076
Behavior control< 0.001
Experimental26.13 ± 6.2131.69 ± 5.155.560.001
Control27.88 ± 6.9826.13 ± 7.90-1.750.064
General family functioning0.001
Experimental34.13 ± 7.0540.38 ±
Control38.50 ± 6.9636.81 ± 7.56-1.690.008
Psycho-verbal violence< 0.001
Experimental21.38 ± 5.9216.75 ± 4.88-4.630.002
Control22.81 ± 6.7523.06 ± 6.950.250.340
Sexual violence0.284
Experimental13.38 ± 3.0510.38 ± 1.31-3.00< 0.001
Control11.88 ± 3.2410.06 ± 2.64-1.820.001
Economic violence0.058
Experimental13.94 ± 4.8111.69 ± 5.34-2.250.046
Control14.06 ± 5.6314.00 ± 5.87-0.060.679
Physical violence0.014
Experimental8.63 ± 4.877.25 ± 2.82-1.380.042
Control7.81 2.29±7.81 ± 2.230.00> 0.999
Violence (total)< 0.001
Experimental57.31 ± 12.9546.06 ± 11.17-11.250.002
Control56.56 ± 12.6954.94 ± 13.64-1.620.020

Abbreviation: SD, standard deviation.

aValues are expressed as mean ± SD.

bP values were calculated based on independent t-test, paired sample t-test, Mann-Whitney U test or Wilcoxon rank test.

5. Discussion

The primary purpose of this randomized trial was to add to the body of research and literature by examining the effectiveness of EFT in the reduction of marital violence and improvement of family functioning. The findings of the study provided additional support for the use of EFT in the treatment of marital violence. After the eight-session intervention, women in the EFT group experienced statistically significant decreases in several dimensions of marital violence such as psycho-verbal violence, economic violence, and physical violence, which is in line with the first hypothesis of the EFT that states “The most effective factor in establishing and maintaining marital intimacy is depended on the type of emotional chains presented in a relationship”. Our findings of reduced marital violence in the EFT group supported Johnson’s statements (16, 17, 28, 36). When the relationship is associated with positive emotions, intimacy will spontaneously emerge. Since an increase in intimacy is directly related to the decrease in violence, violence reduction is expected to occur. Emotion-focused treatment emphasizes “empathy” as the main catalyst and the rate of violence decreases with increasing empathy in couples. The ultimate goal of EFT is to strengthen and establish a safe attachment between spouses, which was very effective in this study.

Partners have the ability to articulate emotions that, if “repressed” and “accumulated”, are the sources of marital conflict and violence. When these emotions are identified and expressed, the likelihood of anger and aggression is decreased. This is an important explanation for the effectiveness of EFT. When a person has less insight and aristocracy to his/her emotions, he/she has less ability to process and accept them. In such circumstances, they are more likely to drown in negative emotions without knowing their clues. Emotional therapy helps people recognize their emotional states and their underlying attachment needs and learn the safe communication and expression of their attachment needs, thereby reducing conflicts and violence.

In addition, our results indicated that EFT was effective to improve communication, role-playing, emotional attachment, affective attachment, behavioral control, and overall family functioning, except for the problem-solving subscale. The finding is in line with previous studies (27-31, 37, 38). It can be concluded that the re-processing of past emotional experiences leads to new perceptions of one’s self, the spouse, and relationship. The transformation of emotional experience and changes in inflexible interactive patterns are two main goals of EFT. The fifth to ninth steps of treatment are specified to manipulating and rebuilding previous interactive patterns and reinforcing new patterns. It seems plausible that improving interactive patterns would lead to higher family functioning.

One of the primary goals of EFT is to achieve and rebuild the underlying emotions of the psyche layers and then to develop interpersonal relationships. According to the findings of this study, it can be concluded that if emotions, especially attachment-related emotions, are properly identified and used, marital relationships can be secured and improved, which is in line with previous studies (22, 23, 39).

The quality of relationships in a family is one of the primary factors in predicting family functionality. For example, emotional attachment, one of the subscales of family functioning, improved in this study. It is clear that the main focus of EFT is on emotions and feelings and repairing of damaged emotions and restoring of couples’ emotional relationships can enhance the quality of emotional interactions and emotional investment in the family. The EFT emphasizes the importance of restoring emotions so strongly that it is even believed it directly or indirectly affects the whole family system. If the loving and emotional relationships between the husband and wife are favorable, this positive feeling spreads throughout the family, and this is one of the most important reasons justifying the impact of EFT on family functioning. The basic improvement of various aspects of family functioning, such as behavioral control, power struggles, and role-setting, roots in the feeling of security in a secure attachment environment. The presence of inflexibilities in some couples is due to their unsafe attachment. The improvement of their unsafe attachments and relationships can positively change their daily interactions and mitigate conflicts, power struggles, and aggression.

In this study, further analysis of the family functioning subscales showed that the lowest mean score in both experimental and control groups was related to the problem-solving subscale and the highest average score was related to the subscale of overall family functioning. Problem-solving involves the careful identification and analysis of conflicts and conflict resolution, and ultimately the most efficient solution is chosen. It can be said that problem-solving ability is a “cognitive” skill rather than an emotional skill, and since our treatment was emotionally charged in this study, it had little impact on this dimension. This subscale seems to require more time allocation; thus, it is suggested that other approaches, including CBT, be taught in further group meetings.

5.1. Conclusions

The findings of this study support the effectiveness of EFT for women in the simultaneous improvement of marital violence and family functioning. This study provides important additional information regarding the mechanism by which EFT reduces marital violence and improves family functioning. Furthermore, the results of this study implicate the significance of essential interventions in the reduction of marital violence and the improvement of family functioning among Iranian couples.




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