The effect of schema therapy and schema-focused mindfulness therapy on marital communication of Iranian women in Malaysia

The aim of this study is to evaluate the effectiveness of schema therapy and schema-focused mindfulness therapy on marital communication among Iranian married women who lived in Malaysia from 2015 to 2016. The qualified participants were assigned randomly into three groups, i.e. two experimental groups which in order received schema therapy and schema-focused mindfulness therapy, and a control group which did not receive any treatment. The treatment sessions lasted nearly three months using marital satisfaction subscale from the ENRICH questionnaire, a demographic questionnaire and Young's schema questionnaire as the instruments. Two-way repeated measures ANOVA and ANCOVA were also employed for data analysis. The findings of the study revealed that schema therapy and schema-focused mindfulness therapy had a significant effect on marital communication of Iranian women in Malaysia. Moreover, the findings showed more improvement for schema-focused mindfulness therapy group at two months follow-up.


Introduction
Marital communication is a very important factor to evaluate the strength and weakness of marriage. There is a significant difference between happy and unhappy couples in term of communication patterns. In fact, constructive communication is a very important indicator in intact and happy marriage. However, Unhappy couples show dysfunctional communication patterns and negative interactions, which lead to distress and difficulties in marriage (Siffert & Schwarz, 2011).Marital satisfaction has different components; one of the most impressive factors in marital satisfaction is good communication. Actually, there is a direct link between a constructive, satisfying and happy marriage and efficient communication. Findings showed there is a strong correlation between marital satisfaction and an effective communication skill. Consequently, for having efficient communication, couples need to discuss about problems clearly, spend time with each other, listen to their partner patiently and give constructive comments (AhmadiGatab & Khamen, 2011). Thus, an efficient communication skill can provide strong ability to solve problems, prevent conflict, increase respect, trust and effective understanding between couples (Gottman & Silver, 2015). Different factors adversely affect marital satisfaction and marital communication during the time. One of the important factors is immigration or study in other countries as an international student. Studies show that moving to other countries has negative effects on the quality of marriages because of different kinds of issues such as adjusting with new conditions and dealing with sociocultural and psychological problems (Myers-Walls, Frias, Kwon, Ko, & Lu, 2011). Shirpak, Maticka-Tyndale and Chinichian revealed that divorce rate increased among Iranian couples after moving to other countries (Shirpak, Maticka-Tyndale, & Chinichian, 2011). Malaysia, as an appealing country in the case of immigration is not excluded from the other target countries. In this regard, some studies showed that international students and immigrants more or less deal with different adjustment problems in Malaysia (Ghoroghi, Hassan, & Baba, 2012;Habil, 2002;Malaklolunthu & Selan, 2011). Unfortunately Iranian students showed low marital satisfaction and communication after moving to Malaysia as the international students as well (Madanian, Mansor, & bin Omar, 2013;Mosavi, 2016). Low marital satisfaction and unhappy marriage has many disadvantages for individuals and society and cause destructive effects on their couple's lives. In order to maintain family life and improve couples' relationship more research in this field is necessary.
In addition, there are some weaknesses on current interventions and educational programs such as lack of workable and useful training skills and low ability of couples in implementing new skills in hard positions and also keeping their relationships in optimal condition after a period of time (Bradbury & Lavner, 2012).
Snyder and Castellani have recommended the therapists to go beyond and try to use the "integrative" models, which are formed by the combination of different aspects and components of the initial methods . Schema therapy and schema-focused mindfulness therapy are two new integrative methods introduced to help psychologists and counselors to prevent divorce and enhance the quality of marriage with increasing knowledge about determinants of marital satisfaction such as marital communication. There seems to be a gap in investigating new methods aimed at finding applied protocols to improve the quality of marital satisfaction and communication skills. As mentioned before, maladaptive schemas and core beliefs play a significant role in causing couples' problems. Schema therapy can be very effective and efficient in solving couples' problems because it can be effective on wide ranges of mental problems such as anxiety, depression, eating disorders, addiction, and difficulties of romantic relationship (J. E. Young, Klosko, J. S., & Weishaar, M. E, 2003). Each of these problems can cause marital distress. This research is very practical and will have a new recommendation for psychologists and counselors doing couple therapy. In fact, it will integrate different aspects of schema therapy with mindfulness techniques and this make it a very new, pragmatic and effective study.

Population and Sampling Method
The population of this research was all married Iranian women who lived in Malaysia in 2015-2016 and showed their interest to be involved in the treatment sessions in order to increase the quality of their relationship. The participant had the following characteristics: 1) Women aged between 24 and 40; 2) Completion of bachelor degree or higher; 3) Married for 10 years or less; 4) Living in Malaysia for more than a year.
In this research, random assignment and random sampling were used to choose the sample. Random sampling in this term refers to the condition in which all individuals of the population have the equal chance to be selected and selecting each one has no effect on the others (Fox, Hunn, & Mathers, 2009). For this purpose, the researcher chose UPM and UM as two most famous Malaysian universities with high rate of Iranian students for installing the announcements. The announcements were also put at Iranian Embassy and Iranian counseling centre in Malaysia. Social media was used as well in order to notice Iranian women who did not live in Kuala Lumpur. It creates a unique situation that each individual had this opportunity to register and selecting the others did not have any effect on his/her chance to be selected. Therefore, the sample was randomly taken from all existing members of the population. During two months, nearly 190 women expressed their interest to participate in the study to increase the quality of their relationships. After that, the researcher conducted short interviews to choose the participants who met the requirements of the study. Actually, some of these women were not qualified for therapy sessions because some of them were involved in major crises or intense psychological disorders and some others had situational problems. Thus, they were omitted from the main study. Other participants were administered the ENRICH questionnaire and those with very high or very poor marital quality scores were eliminated as well.
Selected participants with the average score and under average were randomly assigned to the three groups, i.e. thirty-five women to the schema therapy experimental group, thirty-five to the schema-focused mindfulness therapy experimental group and thirty-five were to the control group. However, three persons in each group decided to drop out due to some personal reasons. In the end, 32 participants remained in each group. Participants of the first experimental group received schema therapy, and those women who were in the second experimental group received schema-focused mindfulness therapy. The treatment lasted for 18 sessions in both experimental groups while the control group did not receive any treatment during this time.

Data Collection Tools
The data collection instruments used in the present study included marital satisfaction sub-scales from the ENRICH questionnaire. Also, a demographic section used to gather participants' age, number of children, education, occupation, length of marriage and income. Young's Schema questionnaire was used to discover each participant's maladaptive schemas as well. A Persian version of ENRICH questionnaire was developed by Asoodeh, with the written permission and under supervisory of Olson (developer of ENRICH questionnaire). The Persian version has 35 questions and 4 sub-scales including marital satisfaction, communication, conflict resolution and ideal distortion. The Young's Schema Questionnaire-Short Form (J. E. Young, 2014) is a self-report instrument to measure maladaptive schemas. YSQ-SF is a 75-item questionnaire and has 15 schema subscales in five areas. The items of SQ-SF are clustered according to specific schemas. There is a two-letter code in front of each cluster, indicating the schema measured by these items. In the therapy sessions, the therapist along with the patient specify the highly-scored (usually scored 5 or 6) items, then the therapist asks questions related to those items to identify the precise schemas. The validity and reliability of SQ-SF have been demonstrated by various studies (Oei & Baranoff, 2007).

Protocol of Treatment
The therapy sessions were held in the form of group therapy, which was developed, by Van Vreeswijk and Broersen (van Vreeswijk & Broersen, 2013). This kind of therapy helps the participants change their thinking and behaviour patterns during the training sessions. The most emphasis of short-term schema CBT protocol is on cognitive and behavioural techniques. The format of treatment is group therapy because in this case, the schemas and modes usually trigger more in a group and during interaction with others. The therapist can observe activated schemas and modes during discussions and challenges in the group. He/she also helps members realize their major problems and weak points in a safe therapeutic atmosphere and gives the members a chance to repair them with the assistance of a supportive group.

Figure 1: Protocol of Treatment
The group members included 8-10 persons that participated in 18 sessions, 2 hours each. Doing the assignments were considered very important and all the members had a workbook including explanation of schemas, modes, exercises and also different examples about techniques and strategies. At the beginning of each session, the participants talked about their flip chart that shows their high activated schemas and modes and also the rate of change during the week. Then during the remaining time, members discussed and were challenged about their schemas and modes. Further, the techniques and assignments were practiced in groups; first in small groups (3 persons), then in the whole group. Therapeutic alliance as well as strong, close and supportive relationships among members also plays a key role in major success of SCBT-g (van Vreeswijk & Broersen, 2013). This protocol of treatment has been represented precisely based on schema therapy contents and designed particularly for short-term group therapy. Therefore, it was selected as the protocol of treatment (Figure 1) of the present research.

Results and Discussion
Hypothesis 1 H1: There is a significant difference in marital communication between pre-test, post-test and follow-up test (T1, T2, T3) in the schema therapy experimental group. Table 1 shows the difference of marital communication mean scores between tests (pre-test, post-test and follow-up test) in the schema therapy group. In this regard, the ANCOVA was carried out to compare the mean score of marital communication at three times, i.e. pre-test (before intervention), post-test (after intervention) and follow-up (two months later). Since the age significantly showed coefficient with marital communication, age was considered as a covariate in the analysis in order to exclude the probable effect of age from the final outcome. The result of post hoc test (Bonferroni) revealed that the difference between pre-test, post-test and followup test in marital communication among the schema therapy group was significant, i.e. F=78.579, p<0.05, ƞ 2 =0.633, f=1.31. In fact, the third hypothesis is retained and it suggests that schema therapy has a robust effect on marital communication. The results also show that time had a significant effect on marital communication. The effect size is also calculated to help researcher to evaluate the effectiveness of the treatment using Cohen's formula as follows:

Analysis
The result shows that the effect size is large; therefore, the mean difference is considerable. As it has been depicted in Figure 2 too, the participants' marital communication raised steeply after schema therapy sessions and had a slight growth at follow-up test.

Decision
The result showed that the schema therapy has a significant effect on marital communication among Iranian women in Malaysia. The mean score of pre-test increased considerably after the treatment and there was a significant difference between pre-test and post-test. However, after the two-month follow-up the mean score of post-test remained almost constant. It reveals that the changes were stable and continual. In this case, the decision is to partially accept the hypothesis because the mean scores of post-test and follow-up are almost constant. H4: There is a significant difference in marital communication between pre-test, post-test and follow-up test (T1, T2, T3) in the schema-focused mindfulness therapy experimental group.

Analysis
Table 1 also shows the difference of marital communication mean scores between tests (pre-test, post-test and follow-up test) in the schema-focused mindfulness therapy group. The ANCOVA carried out to compare the mean score of marital communication at three times, i.e. pre-test (before intervention), post-test (after intervention) and follow-up test (two months later). Since the age significantly showed coefficient with marital communication, age was considered as a covariate in the analysis in order to exclude the probable effect of age from the final outcome. The result of post hoc test (Bonferroni) revealed that the difference between pre-test, post-test and follow-up test in marital communication among schema-focused mindfulness therapy group was significant, i.e. F=119.260, p<0.05, ƞ 2=0.724, f=1.62. Therefore, the fourth hypothesis is retained and it reveals that the schema-focused mindfulness therapy has a positive effect on marital communication. The results showed that time had a significant effect on marital communication as well.
The Cohen's formula is used to calculate the effect size in in order to evaluate the effectiveness of treatment as follows: The result of calculation shows that the effect size is large, suggesting that the mean difference is considerable. Moreover, it can be derived from Figure 3 that the schema-focused mindfulness therapy improved the participants' marital communication dramatically; so that, it showed a sharp rise at post-test and had an increasing trend during the two-month follow-up.

Hypothesis 3
H3: There are significant differences among three groups in marital communication in the pre-test (T1). Table 2 shows the marital communication mean difference between experimental groups and control group post-test. The comparison made by two-way repeated measures ANOVA between the effects of the two treatments (schema therapy and schema-focused mindfulness therapy) on marital communication of Iranian women in Malaysia in the post-test (T2) (after the intervention) revealed that there was not any significant difference between the mean scores of schema-focused mindfulness therapy group and schema therapy group at post-test in this regard. However, there are significant differences between marital communication mean scores of schema therapy and schema-focused mindfulness therapy groups post-test and the control group post-test.

Decision
The results of analysis showed that there was not any considerable difference between schema therapy and schema-focused mindfulness therapy groups in post-test. It suggests that mindfulness techniques did not create any observed effect on marital communication especially in a short time period. Thus, the decision is to partially accept the 4th hypothesis of the study because the mean scores of post-test among schema therapy group and schema-focused mindfulness group were almost the same but there was significant differences between control group and two experimental groups regarding marital communication after the treatment.

Hypothesis 5
H5: There are significant differences among three groups in marital communication at follow-up test (T3). Table 2 shows the marital communication mean difference between experimental groups and control group follow-up test. The result of two-way repeated measures ANOVA regarding the effects of two different psychological treatments (schema therapy and schema-focused mindfulness therapy) on marital communication of Iranian women in Malaysia at follow-up test revealed that there was a significant difference between the mean scores of schema-focused mindfulness therapy group and schema therapy group at follow-up test. Therefore, the 12th hypothesis was retained. Moreover, there are significant differences between the schema therapy and schema-focused mindfulness groups' follow-up test scores and the control group follow-up scores as well, i.e. p<0.05. The Cohen's formula was also used to calculate the effect size as follows:

Analysis
The calculation shows that the effect size is large; thus, the mean difference is significant.
The quality of marital communication is deeply affected by cognitive contents and structures (Karney & Gauer, 2010). Actually, cognitive structure has a significant relationship with the quality of couples' interaction. When couples deal with a new communicational problem, cognitive content identifies the bias of couples towards the issue whereas cognitive structure indicates how partners should deal with a new situation in the first step. Some people do not accept different and new ideas and stick to their own beliefs; they are highly rigid and inflexible to change their perspectives while some spouses try to evaluate alternative options and develop a solution, based on cooperating with their partners. Spouses with more cognitive complexity showed higher communication skills and marital adjustment. For example, findings showed that people with more complicated cognitive structure are more successful in solving problems and increasing the quality of marriage (Karney & Gauer, 2010).
Interestingly, schema therapy plays a key role in changing cognitive content and structure. Using different cognitive techniques, schema therapy tries to change maladaptive schemas, modes and cognitive errors by reinforcing rational thinking. The cognitive content and structure both are influenced by early maladaptive schemas, modes and coping styles. During the schema therapy, clients were able to recognize their maladaptive schemas, coping styles and schema modes; they can also broaden their knowledge about the process of activating schemas, coping and response styles as well (J. E. Young, Klosko, J. S., & Weishaar, M. E, 2003). During the sessions, maladaptive schemas, coping styles and dysfunctional modes were gradually changed. Actually, there is a direct link between this progress, and changing cognitive content and structure. The findings of present research are in agreement with those of studies that indicated that cognitive content and structure have positive effects on marital communication (Karney & Gauer, 2010;Riso, du Toit, Stein, & Young, 2007).
Further, some individuals with communication problems are not willing to accept new or different ideas and stick to what they believe and they are highly inflexible to change their perspectives (Karney & Gauer, 2010). It can be related to some maladaptive schemas such as entitlement/grandiosity, unrelenting standards/hypercriticalness. The communication problems related to these schemas can be solved revising them. Actually, most of the dysfunctional modes such as child modes, dysfunctional coping modes, and dysfunctional parent modes caused communicational problems and distress among couples. During the sessions, the therapist tried to help the participants to recognize them and increase their knowledge to convert them to healthy adult mode and happy child mode.
On the other hand, some spouses try to consider alternative options and work out a solution through cooperating with their partners. Spouses who possessed higher cognitive complexity demonstrated higher communication skills and marital adjustment (Karney & Gauer, 2010). In fact, schema therapy techniques and mindfulness strategies help couples increase their cognitive complexity. During the group therapy sessions women practiced different Young and his colleague's cognitive techniques such as testing the validity of schema, reframing the evidence supporting the schema, evaluating the advantages and disadvantages of the their coping responses, conducting dialogues between the "schema side" and the "healthy side" and constructing schema flash cards. These techniques increase the knowledge of participants, broaden their horizons, make them familiar with different points of view, give them fresh and wider perspective, and develop the potential to analyse issues with a new viewpoint. The techniques are very effective and useful specially when discussed in the group and members challenge each other about advantages and disadvantages of schemas, copying styles and dysfunctional modes. All of these techniques, challenges, discussions and observations can increase the participant's cognitive complexity. This is at reemphasis on those studies, which stated cognitive complexity has positive effects on marital communication (Karney & Gauer, 2010).
Moreover, assumptions and standards are closely related to marital difficulties and distress. Assumptions are general beliefs about how relationships should be and standards are about correct and incorrect feelings, behaviours and emotions during close relationships (Riso et al., 2007). During the group therapy, the researcher discovered that the assumptions and standard were to a great extent related to different early maladaptive schemas, dysfunctional modes or coping styles. For example, members with unrelenting standards/ hypercriticalness schema (the most common schema among members) were very perfectionist to the extent that deficits and mistakes did not have any place in their marriages, relationships or lives. They lived with hard rules and obligations and everything had to be completely perfect. In fact, they were highly inflexible and controlling in their relationships. Usually, they show the dysfunctional coping modes such as overcompensator or dysfunctional parent modes, e.g. demanding parent mode. They showed low marital communication in their close relationship. During group therapy, they revised and changed dysfunctional assumptions and standards via changing early maladaptive schemas and modes and over time, their marital communication improved. Thus, the results obtained in this study confirm those of the studies, which showed that cognitive complexity, assumptions and standards have positive effects on marital communication (Riso et al., 2007).
Couples who reported high marital communication have positive standards and characteristics such as spending a lot of time together, cooperating for making decisions, and openly expressing their thoughts and emotions while other standards such as mind reading have a negative relationship with marital communication. These types of couples suffer from poor communication skills and they do not talk openly and do not share feelings and emotions in a correct way (Baucom et al., 1996). During the discussions in group therapy, it was clearly demonstrated that some schemas play key roles in this kind of behaviour and attitudes. For instance, women with "emotional inhibition" schemas (J. E. Young, Klosko, J. S., & Weishaar, M. E, 2003) in the group did not show their feelings and emotions such as anger, sadness, happiness and sexual desire. They show less communication skills, they always do mindreading and block their feelings and emotions. They do not care about the emotions and instead highlight rationality. Most of them showed dysfunctional coping modes such as detached protector and compliant surrender mode. During the sessions, the therapist helped them increase their knowledge about the early maladaptive schemas, factors that trigger and activate the schema. Members helped each other by sharing ideas, discussing and challenging each other about their behaviour and attitudes. Cognitive and behavioural techniques was surprisingly effective. During the sessions, they gradually improved their communication patterns by changing errors and modification of maladaptive schemas and mode cycles as well. This re-emphasized the findings of those studies, which reported cognitive complexity and assumptions&& have positive effects on marital communication (Riso et al., 2007).
In addition, the other area relevant to schema and cognition is attachment styles. There are four types of attachment styles including secure, preoccupied, fearful-avoidant and dismissing. All differences are about how people think about themselves and others, positive or negative, trusty or untrustworthy (Riso et al., KONSELOR, Open Access Journal: http://ejournal.unp.ac.id/index.php/konselor 2007). Some schemas are related to different attachment styles; for example, mistrust/abuse. Individuals with this schema do not trust others because from their point of view people are wicked, jealous, dishonest and unfaithful (J. E. Young, Klosko, J. S., & Weishaar, M. E, 2003). Individuals with defectiveness/shame schema have feelings of inferiority, worthlessness, unpopularity and unpleasantness. Individuals with entitlement/grandiosity this schema think that they are very important and valuable compared to others and this superiority allows them to humiliate and control others. Individuals with approval-seeking/recognition-seeking this schema extremely need the affection and validation of others so they try to get confirmation, approval and attention of others at any cost. During the sessions, members became familiar with their schemas and mindfulness techniques helped them learn about the activation time of the schema to increase their awareness and be mindful at that time. They were familiarized with their weak points and cognitive errors; they also changed their negative beliefs about people and themselves. These perspectives were related to the attachment styles, which can reform dysfunctional mode cycles and maladaptive schemas. The positive results of this research were congruent with studies that confirmed attachment styles have a relationship with marital communication (Riso et al., 2007). Satir (1988) attributed communicational problems to some important factors such as low self-esteem, inflexible rules or dysfunctional typology of communication in the family system (Griffin & Greene, 2013). Satir believed that the backbone of dysfunctional communication is low self-esteem or self-worth among family members. The models that she developed are in conformity with different maladaptive schemas and modes. For example, the first type is "placatory". The characteristics of this type are close to approval-seeking, self-sacrifice and subjugation schemas and also their dysfunctional coping modes such as compliant surrendered, detached protector. The second type is "blamer" which is very similar to entitlement/grandiosity schemas; they also show Overcompensator coping modes and dysfunctional parent mode. The third type is "super-reasonable" that is very close to emotional inhabitation schema with compliant surrendered, detached protector dysfunctional modes. The last type is "irrelevant" type that show highly avoidance coping style and detached protector dysfunctional mode. During the group therapy sessions, members revealed different types of communication styles and talked about their experiences. They understood that early maladaptive schemas and mode cycles are very effective in their attitudes and behaviour. Members shared their ideas and were challenged about their behaviour and thoughts. The therapist tried to control and manage them to talk with schemas and modes languages. Mindfulness strategies and different schema therapy techniques such as cognitive, behavioural and experiential techniques were discussed during the group therapy. Overall, the members increased their knowledge about dysfunctional mode cycles and communication styles. This research was in agreement with Satir's ideas that low self-esteem and inflexible rules in the family system or dysfunctional typology of communication cause problems and distress in the interaction and communication in the family (Griffin & Greene, 2013).
During the group therapy, members gradually changed their attitude toward communication process through discussing different cognitive, behavioural and experiential techniques and practicing mindfulness strategies. The message process stages were including message production, message reception skills, spousal perception skills, and message and interaction skills (Burleson, 1992). Actually, all of these skills are highly related to early maladaptive schemas, dysfunctional modes and coping styles. For example, one of the main maladaptive interaction patterns is "demand-withdraw" which means one of the partners criticizes and complains a lot, while the other one shows passive action and avoids dispute in this kind of situations. This pattern is significantly related to dysfunctional mode cycles among couples, which is always repeated and triggered by their maladaptive schemas. The couples are usually trapped in this kind of inefficient cycles, which is influenced by their modes. During the group therapy, they learnt to break the cycle and replaced it with new behaviour to increase their communication skills. The positive results of this research were congruent with studies suggesting that the communication processes in relation to cognitive approaches have a relationship with marital communication (Burleson, 1992;Burleson & Denton, 1997;Greene & Burleson, 2003).

Conclusion
The goal of this research was to assess the effect of the schema therapy and schema-focused mindfulness therapy on marital communication. The findings showed that schema therapy had a significant effect on marital communication in post-test and follow-up test compared to the control group. In addition, the effect of schema-focused mindfulness therapy on marital communication of the second experimental group was considerable in the post-test and follow-up test in comparison with the control group. Interestingly, marital