1. Introduction
Couples’ attitudes and the manner they interact with each other can ensure the strength, stability, and durability of any family [1]. It is necessary to investigate the relationship between couples to reveal its structural framework. Studies suggest that marital dissatisfaction and emotional breakdown can be the starting point for many couples to get divorced or apply for a divorce [2, 3]. Marital adjustment can bring many positive outcomes for couples, whereas marital maladjustment can have undeniable negative consequences for their health and relationship. Some studies have shown that marital adjustment has a significant relationship with the health of couples (in terms of sleep quality, stress, and depression level), marital satisfaction, family functioning, and parent-child relationships [4, 5]. 
One of the important variables affecting marital relationships is sexual assertiveness. Psychologists define sexual assertiveness as the ability to initiate and communicate about desired sex, refuse unwanted sex, and prevent unwanted pregnancies and sexually transmitted diseases. Courage or self-assertiveness is also defined as an individual’s ability to act on and stand up for personal interests without anxiety and express their rights without violating the rights of others [6]. Sexual assertiveness is considered the ability to have sexual intercourse to meet one’s sexual needs and initiate sexual relationships with a sexual partner or a spouse. Sexual assertiveness is one of the important factors affecting the sexual satisfaction of couples. Studies demonstrate a high correlation between sexual self-esteem, sexual assertiveness, and sexual satisfaction, as the first two can influence sexual satisfaction [7, 8]. 
However, interpersonal relationships are exposed to numerous damages and threats. Some couples may react to such damages and threats through revenge and avoidance, which will adversely affect their relationship. For example, the sense of revenge can lead to reciprocal retaliation, thereby creating a vicious cycle of revenge and reciprocal retaliation that threatens interpersonal relationships, including marital relationships [9]. One way to deal with such damages and their negative consequences is forgiveness, which requires removing recurrent anger and hostility, reluctance to seek revenge, and enhancing a sense of pity, compassion, sympathy, or regret. Forgiveness is a strategy to prevent or control negative emotions, such as anger and resentment during such problems, which can potentially disrupt relationships [10]. According to previous studies, forgiveness can provide important benefits for the health and well-being of individuals as well as the quality of interpersonal relationships. Forgiveness is the basis of a successful marriage and an important element in the process of improving relationships following any problem or damage. It can effectively enhance marital relationships and positively affect the spouses’ health [11, 12].
Marital harmony is another factor affecting marital relationships. Since marital harmony is a dynamic concept, the quality of marital relationships may change over time [13]. Marital harmony is synonymous with concepts, such as marital quality, marital satisfaction, and marital adjustment, and includes all the positive aspects and evaluation of an individual of their marital relationships [14]. Marital harmony is influenced by factors, such as spouses’ expectations of each other, parenting styles, financial issues, sexual relationships, and relationships with relatives and friends. The stress associated with the presence of children and their issues can also affect marital harmony [15]. 
Greenberg’s emotionally focused therapy (EFT) is among the therapeutic approaches developed in recent years to reduce marital problems. This intervention focuses on issues related to couples’ emotional bonds [16]. In EFT, the therapist seeks to deny or distort the mental content by the client and tries to create a new meaning influenced by the client’s physical experience [17]. As it is often a difficult and tedious process for clients to approach their bitter mental and emotional experiences, the therapist tries to effectively communicate with clients and train them in emotion regulation skills [18]. Following the changes in the process of EFT, they can help spouses gain access to and openly express their primary damaged underlying emotions. The disclosure of vulnerable underlying emotions can greatly facilitate breaking the vicious cycle of interactions and leads to deeper intimacy and secure attachment bonds [19]. Studies have proven the effectiveness of EFT in reducing communication problems of couples and families [20]. Johnson [21] reviewed the studies on EFT and reported that EFT leads to an improvement rate of over 86% and marital satisfaction. Wiebe et al. [22] also showed that EFT helps couples facilitate secure attachment bonds and develop their intimacy.
Naman et al. [23] studied the effects of EFT on attachment-related problems and damage of maladjusted couples and showed that this intervention reduced communication conflicts among spouses, especially women. In another study, Tie and Poulsen [24] showed that EFT was effective in developing and improving marital relationships, reducing marital conflicts, and increasing marital adjustment. Soleimani et al. [25] reported that EFT had a significant effect on the enhancement of satisfaction, cohesion, and affectional expression in infertile couples. Sayadi et al. [26] showed that this therapy can improve marital commitment and decrease couple burnout in infertile couples. In addition, Dehghani et al. [27] reported that EFT can be used as an effective intervention in reducing the injuries caused by marital infidelity in injured women with marital infidelity based on the attachment injury resolution model.
Marital maladjustment in the family causes conflict between couples. Any factor that disrupts the family system and affects the proper functioning of the family can have adverse effects on the development of society. Timely training of couples to deal effectively with family problems and difficulties prevents the occurrence of maladjustment and mental disorders. The most important innovations of this study are evaluating and explaining the EFT on improving sexual assertiveness, marital forgiveness, and marital harmony of couples with marital conflicts. Accordingly, this study aimed to determine the effect of EFT on sexual assertiveness, marital forgiveness, and marital harmony in maladjusted couples.

2. Methods
This was an experimental study based on a pretest-posttest design with control and experimental groups. The statistical population consisted of all maladjusted couples visiting the counseling centers of Behbahan City, Iran in 2020. The selected population was evaluated via structured clinical interviews to find couples who met the inclusion criteria. Finally, 30 couples were selected as the sample through the convenience sampling method and were randomly assigned to the experimental and control groups (15 couples in each group). In the present study, 15 maladjusted couples were assigned to each group by the G*Power software with an effect size of 0.85, a test power of 0.95, and an α of 0.05. The inclusion criteria consisted of the following items: a score below the average on sexual assertiveness, marital forgiveness, and marital harmony; high school diploma or higher educational level; elapse of at least one year from the marriage; being 20 to 45 years old; willingness to participate in the study; experiencing no stressful event, such as divorce or death of relatives and close friends over the last three months; and not being under other therapies. The exclusion criteria were taking psychiatric drugs during the study and absence in more than two sessions of the therapy. 
Participants in the experimental group attended eight 120-minute sessions of EFT twice a week. The control group did not receive any treatment and was placed on a waiting list. At the end of the study, the control group received a course of Greenberg’s EFT to observe ethical considerations. The EFT intervention was performed according to the protocols proposed by Greenberg [28]. Table 1 provides a summary of the content and structure of EFT sessions [28].

These therapy sessions were performed by the first author who had taken specialized courses and workshops. The participants were assured that their personal information would be kept confidential and the obtained data would be analyzed anonymously. Moreover, a written consent letter was obtained from the participants before the beginning of the study. All participants completed the questionnaire at the beginning (as the pretest) and at the end (as the posttest) of the study after they were briefed by the author. 

Instruments
Sexual Assertiveness Questionnaire
The sexual assertiveness questionnaire is a 25-item measurement tool, developed by Apt and Halbert [29]. The items are scored based on a 5-point Likert scale from 0 (always) to 4 (never). Meanwhile, some items are scored inversely. The total score on this scale ranges from 0 to 100, and higher scores indicate a higher level of sexual assertiveness. NasrollahiMola et al. [30] reported the reliability of this questionnaire to be 0.91 using the Cronbach α coefficient. In this study, the Cronbach α coefficient was obtained at 0.89.

Trait Forgiveness Scale 
The trait forgiveness scale (TFS) is a 10-item scale developed by Berry et al. [31] to measure the extent an individual is willing to forgive interpersonal damages and problems in different situations and times. The items are scored based on a 5-point Likert scale (strongly agree, slightly agree, neither agree nor disagree, slightly disagree and strongly disagree). Meanwhile, some items are scored inversely. The minimum and maximum scores on this scale are 10 and 50, respectively, and higher scores demonstrate a higher level of forgiveness. The reliability of the TFS was estimated to be 0.80 [32], and the Cronbach α coefficient was obtained at 0.83 for the scale in the present study. 

Marital Harmony Scale
The marital harmony scale was developed by Xu and Lai [33] by combining two subscales of marital closeness and marital satisfaction. Marital closeness consists of 5 items that are scored based on a Likert scale: the first two are scored based on a 6-point Likert scale (from 1=totally agree to 5=totally disagree) and the next three are scored based on an 8-point Likert scale (from 1=never to 7=every day). Higher scores on this subscale indicate higher levels of marital closeness. Marital satisfaction consists of 2 items: Xthe first item is scored based on a 5-point Likert scale (from 1=totally disagree to 5=totally agree) and the second item is scored based on a 6-point Likert scale (from 1=totally dissatisfied to 6=totally satisfied). Higher scores on this subscale show higher levels of marital satisfaction. The authors reported the reliability of this tool to be 0.83 [34]. In the present study, the Cronbach α coefficient was 0.89 for the scale.

Statistical analyses
The data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (multivariate and one-way analysis of covariance). All statistical analyses were performed in SPSS-25 at the 0.05 level of significance.

3. Results
The demographic data showed that the Mean±SD participants’ age was 35.05±3.29 years in the experimental group and 36.47±2.74 years in the control group. The Mean±SD marriage duration was 8.12±1.15 years in the experimental group and 8.68±1.08 years in the control group. There was no significant difference between the two groups in educational attainment and economic status. Table 2 provides the pretest and posttest Mean±SD of the research variables in experimental and control groups.

The normal distribution of scores on each research variable in both groups was examined by the Kolmogorov-Smirnov test, and the results confirmed this assumption as the pretest significance level was greater than 0.05 for all three variables. The homogeneity of variances of dependent variables was also tested by the Levene test, and the results confirmed this assumption. Additionally, the results of Box’s M test confirmed the homogeneity of the covariance matrix. Given that the variance inflation factor (VIF) was smaller than 10 for dependent variables, the noncollinearity of dependent variables was also confirmed. The obtained correlation coefficients also confirmed the linear relationship between the dependent variable and the covariate variable (pretest). 
After controlling the pretest effects, the data were analyzed by the multivariate analysis of covariance (MANCOVA) to determine the effects of EFT on sexual assertiveness, marital forgiveness, and marital harmony. Then, the hypotheses were tested. According to Table 3, MANCOVA results showed a significant difference between the experimental and control groups in terms of at least one of the dependent variables (P<0.001). 

Table 4 provides the results of the one-way analysis of covariance (ANCOVA) on the posttest scores of dependent variables. As provided in Table 4, the F value of ANCOVA was statistically significant for sexual assertiveness, marital forgiveness, and marital harmony (P<0.001). This indicates a significant difference between the two groups in the dependent variables. Therefore, it can be concluded that EFT improved all three dependent variables (i.e., sexual assertiveness, marital forgiveness, and marital harmony).

4. Discussion
The present study aimed to investigate the role of EFT on sexual assertiveness, marital forgiveness, and marital harmony in maladjusted couples. The study results showed that EFT improved sexual assertiveness, marital forgiveness, and marital harmony in maladjusted couples, which is consistent with the findings of previous studies [19, 20]. EFT is an evidence-based approach with successful results [20], and many studies have reported the positive effects of EFT on communication problems of couples and families [19]. 
The results showed the positive effects of EFT on the sexual assertiveness of maladjusted couples. As EFT mainly focuses on emotional bonds, it especially addresses the expression and disclosure of unspoken needs. As a result, when couples with marital conflicts exhibit signs of sexual problems, including sexual assertiveness, EFT interventions reduce their conflicts and improve their sexual problems as well. One of the major concerns reported by couples with sexual problems is that their relationships are empty of love or they experience fewer positive emotions toward their spouses. EFT not only helps couples understand that the temporary loss of love is an integral part of relationships but also allows them to improve their sense of support, security, participation, empathy, and sexual intimacy by meeting each other’s psychological needs [35]. Along with the increasing positive experiences of couples in their relationships, couples are expected to improve their sexual relationship and communicate their desires and needs more easily to each other, which can increase their sexual assertiveness.
The results also demonstrated the effectiveness of EFT in improving marital forgiveness of maladjusted couples. Following the changes in the process of EFT, this method can help spouses gain access to and openly express their primary damaged underlying emotions. The disclosure of vulnerable underlying emotions can greatly facilitate breaking the vicious cycle of interactions and also leads to deeper intimacy and secure attachment bonds. Forgiveness is the basis of a successful marriage and an important element in the process of improving relationships following any problem or damage. It can effectively enhance marital relationships and positively affect the health of spouses [11]. Since the caring behaviors proposed by EFT aim to reduce suffering, support individuals in the face of damages, and facilitate the nurture and growth of individuals, EFT can increase the forgiveness level of couples when they are dealing with interpersonal damages and problems in their relationships.
The study findings also showed that EFT improved the marital harmony of maladjusted couples. Couples enjoy high levels of marital harmony when they can solve their problems and conflicts through proper communication. Marital harmony is influenced by various factors, such as spouses’ expectations of each other. EFT is a systemic treatment that forms the key interactions in the family and interrupts negative and repetitive interactive cycles that include problematic behaviors or symptoms [18]. Through emphasizing issues such as empathy, self-disclosure, deep understanding of the needs of oneself and the partner, acceptance, expression of thoughts and emotions, and establishment of an emotional atmosphere, which are all among the essential components of an intimate relationship, EFT can greatly help couples increase their harmony. EFT’s therapeutic strategies help couples pass the layer of superficial emotions in a safer environment, communicate with each other’s deeper emotions, and identify each other’s fundamental attachment needs to gain a common understanding of each other’s needs. This process finally improves marital intimacy and harmony in their cycle of interaction. 
Considering that this study was conducted only on maladjusted couples living in Behbahan City, Iran, the findings should be cautiously generalized to other populations. Future studies are recommended to compare the effectiveness of EFT with similar therapies, such as acceptance and mindfulness couple therapy, cognitive-behavioral couple therapy, systemic therapies, and solution-oriented couple therapy. The counselors and specialists working in the field of family and couple therapy are also recommended to be trained in EFT.

5. Conclusion
Marital dissatisfaction and emotional breakdown can be the starting point for many couples to get divorced or apply for a divorce. The study findings suggested the positive effects of EFT on sexual assertiveness, marital forgiveness, and marital harmony of maladjusted couples. Therefore, the study findings can help us to effectively improve emotional communication and marital intimacy, and harmony, thereby extending them to other aspects of life. Because EFT is a less costly but more effective method, the results of the study show that therapists can use EFT in treating couples with marital conflict to solve couples’ marital problems and improve their sexual assertiveness, marital forgiveness, marital harmony, and family health.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Islamic Azad University, Ahvaz Branch (Code: IR.IAU.AHVAZ.REC.1399.085).

Funding
This article was extracted from the PhD dissertation of Khosro Behrang from the Department of Counseling, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran. 

Authors' contributions
Conceptualization and supervision: Khosro Behrang, Amin Koraei; Methodology: Khosro Behrang, Masoud Shahbazi; Investigation, Writing–original draft, and Writing–review & editing: Amin Koraei, Zabihollah Abbaspour; Data collection: Khosro Behrang, Amin Koraei; Data analysis: Khosro Behrang.

Conflict of interest
The authors declare no conflict of interest.

References 

1. Karimi R, Bakhtiyari M, Masjedi Arani A. Protective factors of marital stability in long-term marriage globally: A systematic review. Epidemiology and Health. 2019; 41:e2019023. [DOI:10.4178/epih.e2019023] [PMID] [PMCID]
2. Ozouni-Davaji R B, Farahbakhsh K, Esmaeily M, Kazemi F. Effect of couple’s schema therapy in decreasing couples’ tendency to divorce among divorce-applicant couples. Journal of Research & Health. 2018; 8 (1):21-31. [DOI:10.29252/acadpub.jrh.8.1.21]
3. DeLongis A, Zwicker A. Marital satisfaction and divorce in couples in stepfamilies. Current Opinion in Psychology. 2017; 13:158-61. [DOI:10.1016/j.copsyc.2016.11.003] [PMID]
4. Lee J-Y, Kim J-S, Kim S-S, Jeong J-K, Yoon S-J, Kim S-J, et al. Relationship between health behaviors and marital adjustment and marital intimacy in multicultural family female immigrants. Korean Journal of Family Medicine. 2019; 40(1):31-8. [DOI:10.4082/kjfm.17.0059] [PMID] [PMCID]
5. Jiménez-Picón N, Romero-Martín M, Ramirez-Baena L, Palomo-Lara JC, Gómez-Salgado J. Systematic review of the relationship between couple dyadic adjustment and family health. Children (Basel). 2021; 8(6):491. [DOI:10.3390/children8060491] [PMID] [PMCID]
6. Sayyadi F, Golmakani N, Ebrahimi M, Saki A, Karimabadi A, Ghorbani F. Determination of the effect of sexual assertiveness training on sexual health in married women: A randomized clinical trial. Iranian Journal of Nursing and Midwifery Research. 2019; 24(4):274-80. [PMID] [PMCID]
7. Zhang H, Yip PSF. Perceived and actual behavior in female sexual assertiveness: A within-couple analysis in Hong Kong. Journal of Sex & Marital Therapy. 2018; 44(1):87-95. [DOI:10.1080/0092623X.2017.1321597] [PMID]
8. Haghparast Z, Riazi H, Shams J, Ahmadi F, Montazeri A. Sexual assertiveness in women with and without substance-dependent partners: A comparative study. Women & Health. 2021; 61(7):680-8. [DOI:10.1080/03630242.2021.1954579] [PMID]
9. Alipour Z, Kazemi A, Kheirabadi G, Eslami AA. Marital communication skills training to promote marital satisfaction and psychological health during pregnancy: A couple focused approach. Reproductive Health. 2020; 17(1):23. [DOI:10.1186/s12978-020-0877-4] [PMID] [PMCID]
10. He Q, Zhong M, Tong W, Lan J, Li X, Ju X, et al. Forgiveness, marital quality, and marital stability in the early years of Chinese marriage: An actor-partner interdependence mediation model. Frontiers in Psychology. 2018; 9:1520. [DOI:10.3389/fpsyg.2018.01520] [PMID] [PMCID]
11. Pronk TM, Buyukcan-Tetik A, Iliás MMAH, Finkenauer C. Marriage as a training ground: Examining change in self-control and forgiveness over the first 4 years of marriage. Journal of Social and Personal Relationships. 2019; 36(1):109-30. [DOI:10.1177/0265407517721065] [PMID] [PMCID]
12. Fincham FD, May RW. Prayer and forgiveness: Beyond relationship quality and extension to marriage. Journal of Family Psychology. 2017; 31(6):734-41. [DOI:10.1037/fam0000331] [PMID]
13. Hendrati F. Improving marital harmony for husband-wife of different cultures in the early marriage. International Journal of Social and Local Economic Governance. 2015; 1(2):6. [DOI:10.21776/ub.ijleg.2015.001.02.8]
14. Muluhya Keverenge E, Kipnusu RC, Tarus P, Karimi J. The relationship between premarital counselling and marital harmony among families in Lugari, Kakamega County, Kenya. Counselling and Psychotherapy Research. 2020; 20(3):556-61. [DOI:10.1002/capr.12319]
15. Sevinç M, Garip ES. A study of parents’ child raising styles and marital harmony. Procedia-Social and Behavioral Sciences. 2010; 2(2):1648-53. [DOI:10.1016/j.sbspro.2010.03.252]
16. Wiebe SA, Johnson SM. A review of the research in emotionally focused therapy for couples. Family Process. 2016; 55(3):390-407. [DOI:10.1111/famp.12229] [PMID]
17. Najafi M, Soleimani AA, Ahmadi K, Javidi N, Kamkar EH. The effectiveness of emotionally focused therapy on enhancing marital adjustment and quality of life among infertile couples with marital conflicts. International Journal of Fertility & Sterility. 2015; 9(2):238-46. [DOI:10.22074/ijfs.2015.4245] [PMID] [PMCID]
18. Wiebe SA, Johnson SM, Lafontaine MF, Burgess Moser M, Dalgleish TL, Tasca GA. Two-year follow-up outcomes in emotionally focused couple therapy: An investigation of relationship satisfaction and attachment trajectories. Journal of Marital and Family Therapy. 2017; 43(2):227-44. [DOI:10.1111/jmft.12206] [PMID]
19. McKinnon JM, Greenberg LS. Vulnerable emotional expression in emotion focused couples therapy: Relating interactional processes to outcome. Journal of Marital and Family Therapy. 2017; 43(2):198-212. [DOI:10.1111/jmft.12229] [PMID]
20. Burgess Moser M, Johnson SM, Dalgleish TL, Lafontaine MF, Wiebe SA, Tasca GA. Changes in relationship-specific attachment in emotionally focused couple therapy. Journal of Marital and Family Therapy. 2016; 42(2):231-45. [DOI:10.1111/jmft.12139] [PMID]
21. Johnson SM, Brubacher LL. Emotionally focused couple therapy. In: TL Sexton, JL Lebow, editors. Handbook of family therapy. New York: Routledge; 2015. [DOI:10.4324/9780203123584-17]
22. Wiebe SA, Johnson SM, Burgess Moser M, Dalgleish TL, Tasca GA. Predicting follow-up outcomes in emotionally focused couple therapy: The role of change in trust, relationship-specific attachment, and emotional engagement. Journal of Marital and Family Therapy. 2017; 43(2):213-26. [DOI:10.1111/jmft.12199] [PMID]
23. Naaman S, Pappas J, Makinen J, Zuccarini D, Johnson-Douglas S. Treating attachment injured couples with emotionally focused therapy: A case study approach. Psychiatry. 2005; 68(1):55-77. [DOI:10.1521/psyc.68.1.55.64183] [PMID]
24. Tie S, Poulsen S. Emotionally focused couple therapy with couples facing terminal illness. Contemporary Family Therapy. 2013; 35(3):557-67. [DOI:10.1007/s10591-013-9238-6]
25. Soleimani AA, Najafi M, Ahmadi K, Javidi N, Hoseini Kamkar E, Mahboubi M. The effectiveness of emotionally focused couples therapy on sexual satisfaction and marital adjustment of infertile couples with marital conflicts. International Journal of Fertility & Sterility. 2015; 9(3):393-402. [DOI:10.22074/ijfs.2015.4556] [PMID] [PMCID]
26. Sayadi M, Shahhosseini Tazik S, Madani Y, Gholamali Lavasani M. Effectiveness of emotionally focused couple therapy on marital commitment and couple burnout in infertile couples. Journal of Education and Community Health. 2017; 4(3):26-37. [Link]
27. Dehghani M, Aslani K, Amanelahi A, Rajabi G. [The effectiveness of emotionally focused couples therapy based on attachment injury resolution model on forgiveness among the injured women with marital infidelity (Persian)]. Family Counseling and Psychotherapy. 2019; 9(1):143-60. [Link]
28. Greenberg LS, Goldman RN. Clinical handbook of emotion-focused therapy. Washington: American Psychological Association; 2019. [DOI:10.1037/0000112-000]
29. Apt C, Hurlbert DF. The female sensation seeker and marital sexuality. Journal of Sex & Marital Therapy. 1992; 18(4):315-24. [DOI:10.1080/00926239208412856] [PMID]
30. NasrollahiMola N, Bahrami N, Ranjbaran M, Alimoradi Z. Predictors of sexual assertiveness in a sample of Iranian married women of reproductive age. Sexual and Relationship Therapy. 2020:1-13. [DOI:10.1080/14681994.2020.1740672]
31. Berry JW, Worthington EL Jr, O’Connor LE, Parrott L 3rd, Wade NG. Forgivingness, vengeful rumination, and affective traits. Journal of Personality. 2005; 73(1):183-225. [DOI:10.1111/j.1467-6494.2004.00308.x] [PMID]
32. Khojasteh-Mehr R, Koraei A, Rajabi G. [A study of a proposed model for some precedents and outcomes of forgiveness in marriage (Persian)]. Journal of Modern Psychological Researches. 2010; 4(16):155-84. [Link]
33. Xu X, Lai S-C. Gender ideologies, marital roles, and marital quality in Taiwan. Journal of Family Issues. 2004; 25(3):318-55. [DOI:10.1177/0192513X03257709]
34. Eslahi N, Arefi M, Alsadat Hoseini S, Amiri H. [Study on the effectiveness of emotionally focused couple therapy and gottman’s systemic couple therapy on marital harmony in conflicting couples (Persian)]. Journal of Psychological Science. 2019; 17(71):849-56. [Link]
35. Potki R, Ziaei T, Faramarzi M, Moosazadeh M, Shahhosseini Z. Bio-psycho-social factors affecting sexual self-concept: A systematic review. Electronic Physician. 2017; 9(9):5172-8. [DOI:10.19082/5172] [PMID] [PMCID]