Caspian Journal of

1. Introduction
The family is a social institution that plays a significant role in the identity of individuals because one’s family represents one’s characteristics [1]. Marriage is a social agreement in which a man and a woman decide to live together by a legal and moral commitment. Although people get married based on specific goals and wish to have a stable and happy life, but the growing number of divorces necessitates finding solutions to reinforce marital relationships and secure the family institution [2]. 
Psychological factors are among the significant causes of divorce in Iran; they cause marriage conflicts and affect the cognitive, behavioral, and emotional domains of a couple’s relationship [3]. Most couples who end up separated or divorced usually go through a period of marital distress. Marital distress, which some couples may experience after several years of marriage, results from accumulated anger and resentment, lack of mutual understanding, and psycho-emotional distance between couples [4]. Therefore, marital happiness is one of the factors that strengthen and shape marital relations [5]. Happiness is a positive emotional state characterized by satisfaction, joy, and contentment and leads to a positive attitude towards life, positive emotions, and the absence of negative emotions [6]. Schiffrin and Nelson stated that happiness is a mental state that includes experiencing a sense of joy and exhilaration, leading to seeing one’s life as meaningful and valuable [7]. Moreover, several cognitive, social, and emotional factors can influence marital happiness in the family. Accordingly, it is necessary to pay special attention to marital happiness because of its importance and effect on the Quality of Life (QoL) of couples and other family members. Many studies have employed various training and psychotherapeutic approaches and theories to promote marital happiness [8, 9].
One of the new theories that well suits Iranian culture is the Healthy Human Theory (HHT). HHT, proposed by Aghaei, consists of one principle and 12 characteristics (known :::as char:::acteristics of a healthy human) [10]. These characteristics are applied to a range from a healthy person to an ill person. The more of these characteristics and the related traits one possesses, the closer they are to the healthy human end of the spectrum and vice versa. This theory states that there is no healthy or ill individual. According to HHT, the characteristics of a healthy person are as follows: peace, dynamicity, happiness, contentment, unconditional generosity, ability to forgive and forget, satisfaction, hope, ability to enjoy, ability to understand original sadness, communication with the Creator, love of creatures, kindness to oneself, and application of metacognition. This theory posits that a healthy human not only h:::as char:::acteristics such as deep interpersonal relationships and acceptance of fellow human beings (:::as char:::acteristics of self-actualizing individuals based on the humanistic approach) but also has an inseparable and meaningful connection with God [10]. 
Another novel aspect of this theory is the dynamism of a healthy human. It refers to the progressive course of life of a healthy human towards perfection. A healthy human is not static, and lassitude has no place in their life; they do not stop striving to achieve the spiritual goals of life even amid the inevitable crises. They tirelessly persevere in confronting life’s challenges and problems to achieve peace and a sense of happiness and share these feelings with those around them. A healthy human tries to hopefully and optimistically forget or forgive possible challenges and indignation of marital life by finding the meaning of life in achieving personal spiritual goals [11].
As HHT is a new approach, no information was found on this theory in the literature review. However, there have been studies on the effects of training courses and interventions with similar principles as HHT, such as logotherapy, spiritual therapy, positive therapy, Cognitive-Behavioral Therapy (CBT), and Acceptance and Commitment Therapy (ACT) on psychological variables, particularly marital happiness [12, 13, 14]. 
Emotion-Focused Therapy (EFT) is another training approach that has been effective in promoting marital relations and treating marital distress. This approach aims to break negative cycles of emotion and re-establish emotional bonds—the essential elements in increasing the therapeutic effect. This method reprocesses experiences and reorganizes interactions to create attachment or a sense of security. EFT can also be considered both an empirical approach as it reprocesses and develops the experiences of spouses and a systemic approach because it modifies the patterns of interactions in couples [15, 16, 17]. Jafari et al. showed that Islamic ethics-based EFT could make a shift from an insecure to a secure attachment style, regulate emotions, and increase happiness among maladjusted couples [18]. Kian et al. reported that emotion-focused group couples therapy would influence marital attachment and happiness [5]. Thus, marital happiness is one of the factors improving marital relations, strengthening the family structure, and, consequently, reducing the divorce rate.
Given the importance of mental health and the impact of happiness in marital conflicts in couples and the mentioned materials, the present study aimed to investigate the effectiveness of HHT-based training and EFT in marital happiness of couples living in Isfahan City, Iran, in 2020.

2. Materials and Methods
Study design and participants
The research has a pretest-posttest control group design. The statistical population included all couples referring to mental health centers in Isfahan in 2020. Using the convenience sampling method, we selected 78 people (39 couples) willing to participate in the study and assigned each couple a two-digit number. We randomly allocated the participants into two experimental groups (training based on healthy human theory and emotion-focused therapy) and one control group (n=13 couples per group). Using a random number table. In this way, even numbers were considered for the experimental groups and odd numbers for the control group. The inclusion criteria were being 18-40 years old, obtaining a score of 85-122 on the 47-item ENRICH marital satisfaction scale, being monogamous, not being under similar psychological or psychiatric treatments, were willing to participate in the study, having at least one and at most three children, and being married for a minimum of five years. The exclusion criteria were more than two absences from the treatment sessions and reluctance to continue the treatment process. Ethical considerations of the study included confidentiality of all personal information of participants and participants’ ability to withdraw from the study at any time. Besides, the participants were informed about the aim and procedure of the research before obtaining their written consent. They were also assured that obtained data would be used only for research purposes. In addition, based on the ethical criteria recommended in scientific studies, those in the control group were free to choose and undergo one of the interventions, i.e., HHT-based training or EFT, at the end of the study.

Study procedure
The marital happiness of participants in three groups was measured three times: the pretest, the posttest, and three months later, as the follow-up. The first intervention program consisted of twelve 120-min sessions of training package based on HHT. A training package based on HHT was developed and prepared for the first time after several months of thematic and content analysis of the cognition literature in a complex and lengthy process using thematic network analysis [19]. To assess the content validity of this package, five psychologists specialized in psychological training and therapies elicit their comments. After applying the corrective opinions of the reviewers, the finalized package was sent to them to approve it. The interrater agreement was obtained 0.91 using the kappa statistic. Next, the feasibility and effectiveness of this new package were tested in a pilot study on a group of couples, and it was approved for the final sample [20]. The second intervention program consisted of ten 90-min sessions of EFT. The EFT intervention was conducted based on the method proposed by Johnson [21]. The first author conducted the intervention programs for the experimental groups in Tabesh Mental Health Center in Isfahan City. A summary of HHT and EFT training sessions is presented in Tables 1 and 2, respectively.


Research instruments
Marital Happiness Scale (MHS)
Azrin developed the 10-item Marital Happiness Scale (MHS) in 1973 to measure marital happiness [22]. The scoring is based on a 10-point Likert scale (from 10: completely happy to 1: completely unhappy). In addition, the subject’s opinions can be measured in nine domains separately, or the subject’s scores can be added up to examine the overall state of marital happiness. The minimum and maximum scores obtainable by this scale are 10 and 100, respectively, and a higher score indicates a higher level of marital happiness. Sanaii et al. [23] reported a Cronbach αcoefficient of 0.90 for the whole questionnaire. In the present study, the Cronbach α coefficient was 0.87 for the questionnaire.

Statistical analyses
The baseline characteristics between groups were compared using the independent t-test, paired t-test,  and Chi-square test. Training effects on marital happiness were examined using 2-way repeated-measures ANOVA, with the training group as the between variable and time as the within variable. Data analysis was performed using SPSS version 24.0, statistical software, and P<0.05 was considered significant.

3. Results 
The participants included 39 couples, with a Mean±SD age of 33.68±4.22 years. There was no significant difference between the groups in terms of age, education level ad duration of marriage (P>0.05). The demographic variables of the participants are presented in Table 3.

Table 4 presents the Mean±SD of studied variables in the experimental and control groups at pretest, posttest, and follow-up.

According to the results, the baseline values were not significant between the three groups; also, the mean scores of marital happiness in the control group in the posttest and follow-up stages did not significantly improve compared to the pretest stage. The mean of the abovementioned variables significantly increased in the HHT-based training and EFT in the posttest and 6-months follow-up compared to that of the pretest stage. According to the results, there was a significant difference in the mean score of marital happiness in the posttest-pretest (mean difference=15.40, SE=2.28, P<0.001), and followup-pretest (mean difference=14.67, SE=2.11, P<0.001) in the HHT-based training group. Moreover, there was a significant difference in the mean score of marital happiness in the posttest-pretest (mean difference=11.42, SE=2.08, P<0.001), and followup-pretest (mean difference=9.83, SE=1.94, P<0.001) in the EFT group.
The results of the Shapiro-Wilk test confirmed the hypothesis of normal distribution of marital happiness scores at the significance level of 0.55. Levene’s test confirmed the null hypothesis of the equality of variances of the three groups at the pretest, posttest, and follow-up stages with a significance level of 0.99, 0.06, and 0.05, respectively. The results of the Ljung–Box test confirmed the homogeneity assumption of the variance-covariance matrices of the three groups in the dependent variable with a significance level of 0.06. We performed Mauchly’s test to check the equality of within-subject variance differences. The results indicated that the sphericity assumption was rejected for the dependent variables (P<0.05). Consequently, a repeated-measures ANOVA test with Greenhouse-Geisser correction was employed to examine the research questions (Table 5).

According to Table 5, the within-subject effects of time and the time-group interaction and the between-subject effects were significant. There was a statistically significant group by time interaction for marital happiness (F=117.23, P=0.001, η2=0.87) with the HHT-based group indicating significantly higher score of marital happiness over time compared to control group (mean difference=14.58, SE=2.05, P<0.001). Moreover, there was a significant difference between the EFT and the control group (mean difference=7.78, SE=2.05, P=0.002). However, there was no significant difference between the two intervention groups (mean difference=3.28, SE=2.05, P=0.105). The results showed that 87% of the differences in marital happiness were due to the the interaction effect of group and three phases of pretest, posttest, and follow-up. 

4. Discussion
The present study aimed to investigate the effectiveness of HHT-based training and EFT in marital happiness on couples living in Isfahan in 2020. The findings revealed that HHT-based training improved marital happiness in couples. Since the HHT training package is novel, no research records were found on this theory. Nonetheless, similar studies that have applied logotherapy, spirituality therapy, positive therapy, CBT, and ACT on various statistical populations could be discussed [24, 25, 26].
In this study, the effectiveness of HHT-based training in increasing couples’ marital happiness could be explained in four ways. First, in this package, training communication with the Creator and loving the creatures strengthens the help-seekers relationship with the Creator, their ability to establish a correct, strong, logical, emotional, and genuine spiritual relationship with God, besides promoting interpersonal relationships with the creatures [20]. Improper and inefficient communication and interaction between spouses, as well as lack of understanding of one’s partner, are among the major causes of marital conflicts [27]. This training package promotes the spouses’ positive emotions towards each other. Consequently, the couple’s interpersonal relationships improve, and they forgive the other partner’s shortcomings. As a result, couples experience more happiness in their marital relationship.
The second reason is the teaching of self-compassion. So, the couples can be kind to each other because misconceptions, biased perceptions, cognitive distortions, and cumbersome “do’s and don’ts” do not accumulate in their minds. The help-seekers are assisted in identifying and modifying their negative, irrational, and incorrect beliefs and thoughts about their spouses. Thus, by leaving negative emotions and thoughts to gain high spiritual qualities, they can develop the ability to forgive and forget the difficulties caused by the incorrect relations with their spouse. 
The third reason for the effectiveness of the HHT training is teaching techniques to gain peace and happiness in life. Through teaching positive self-talk techniques besides self-entertaining, the therapist trains how to control negative emotions like anger and annoyance or sadness. Also, the therapist facilitates the negative emotions control, the ability to forgive and forget anger caused by the spouse and achieve peace in life, consequently improving marital happiness in the client. 
The fourth reason is teaching spouses some techniques to see what their marital relationship has and what others’ marital relationship does not have to increase their sense of satisfaction with their relationship. Happiness is a relatively lasting inner feeling of pleasure coming from the peace of mind and satisfaction with QoL, which consequently increases the couple’s marital happiness [28]. Also, since this training package was developed based on Iranian culture, its teaching to the clients is easier, and they satisfactorily practiced the assignments in the provided worksheets [20]. Accordingly, the training materials were orderly organized in learners, leading to the repetitive practice of the training techniques, which resulted in its effectiveness in couples’ marital happiness.
Other findings showed that EFT significantly increased couples’ marital happiness. This finding is consistent with the findings of studies carried out by Kian et al. [5]and Jafari et al. [18]. The quality of attachment is the basis of every individual’s emotional and social relationships. Those who communicate with their spouse with a more open, secure attachment and without intermediaries will not experience cognitive and emotional distortions but feel a happier life through expressing their emotions logically [29]. Since the spouses’ positive feeling towards each other is one of the influential factors in marital happiness, if the quality of marital attachment increases in spouses, marital happiness will also increase. In this study, EFT discovers the damaged emotions of childhood attachment in relation to primary significant others and its relationship with blocked or exaggerated emotions in married life in relation with the spouse and discerning defective interactive cycles in couples’ relationships. Accordingly, this therapy may resolve couples’ communication and emotional problems and providing them with more satisfaction and happiness [30]. 
All of the couples participating in the study reported a low level of marital happiness in the beginning. Their voluntary participation in EFT training sessions focusing on the spouses’ underlying feelings, reforming attachment needs and relationship fears solidified the new conditions by reshaping the couple’s attachment cycle, facilitating expression, and discovering new ways to solve old problems to increase the quality of their marital attachment and consequently more marital happiness.
According to the results, happiness scores in the HHT training package were higher than EFT, but this difference was not significant. The nature of these therapies could explain the difference. EFT requires identifying the attachment type and needs, redefining attachment, and establishing a secure attachment to the spouse. These practices need a proper understanding of the topics and practicing with the spouse over time. If a participant does not learn the content correctly, does not practice them, and if the spouse does not cooperate, it is impossible to achieve the study’s goals. The lower number of sessions and less training time in EFT (ten 90-min sessions) than HHT training (twelve 120-min sessions) is another possible explanation. In this case, the clients may have benefited from more training and more psychological techniques.

5. Conclusion
Based on the results of the present study, HHT-based training and EFT improve marital happiness in couples. Given the effect of HHT-based training on marital happiness in couples, it is suggested that psychotherapists use HHT training, which is based on Iranian culture, alongside other training and treatment methods to improve interpersonal relationships in couples with marital conflicts.
The first limitation of this study is the use of a self-reported questionnaire. This method may provide superficial data mixed with social desirability bias in the measurement process. The second limitation is the low number of couples participating in the research. The number of couples employed in this study for the three groups was 39 (13 couples in each group). The sample size is considered relatively small for quasi-experimental or experimental studies and may influence the results. Accordingly, it is recommended that future studies assess the effectiveness of HHT training with larger samples and using interviews to achieve more in-depth information along with the self-reported questionnaire. 


Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Islamic Azad University, Isfahan (Khorasgan) branch (Code: IR.IAU.KHUISF.REC.1399.070). The study was registered in the Iranian Registry of Clinical Trials (No.: IRCT20200423047180N1).

Funding
This article was a part of the PhD dissertation of Sara Moradi in the Department of Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan (Khorasgan), Iran.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgements
The researchers wish to thank all individuals who participated in the study.


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