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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 3  |  Page : 133-140

The efficacy of an online family-based cognitive behavioral therapy on psychological distress, family cohesion, and adaptability of divorced head-of-household women in Iran: A randomized controlled trial

1 Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
2 Department of Psychiatry, Yale School of Medicine; Connecticut Mental Health Center, New Haven; Connecticut Council on Problem Gambling, Wethersfield; Child Study Center, Yale School of Medicine; Department of Neuroscience, Yale University; Wu Tsai Institute, Yale University, New Haven, CT, USA
3 Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran; Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden

Date of Submission21-May-2023
Date of Acceptance23-Aug-2023
Date of Web Publication18-Sep-2023

Correspondence Address:
Amir H Pakpour
Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin; Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping

Zainab Alimoradi
Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/shb.shb_262_23

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Introduction: The family may be negatively impacted by divorce and its adverse outcomes including psychological problems and disturbances in the structure and functioning of families. The present study aimed to determine the efficacy of an online family-based cognitive behavioral therapy (CBT) intervention on psychological distress, family cohesion, and adaptability of divorced head-of-household women. Methods: In this randomized controlled trial, 100 divorced head-of-household women supported by the state welfare organization of Iran participated and were randomly divided into intervention group (n = 50) and active control group (n = 50). Participants in the intervention group received six educational app-based online sessions on family-based CBT. Participants in the control group received an online family-based CBT session and an online information on breast self-examination using the same app. Anxiety, depression, family adaptability, and cohesion were assessed before, immediately after, and 3 months after the intervention. Linear mixed-effects modeling with random intercepts and slopes was used to analyze the data. Results: The mean and standard deviation of measures of anxiety, depression, cohesion, and adaptability scores immediately after the intervention (9.42 ± 1.78, 9.58 ± 2.21, 36.36 ± 3.78, and 36.30 ± 3.97, respectively) and 3 months after the intervention (9.90 ± 1.84, 9.40 ± 1.53, 36.38 ± 4.30, and 36.42 ± 4.38, respectively) in the intervention group differed significantly from those before the intervention (11.30 ± 1.77, 11.56 ± 1.31, 23.82 ± 3.78, and 23.80 ± 3.85, respectively). Changes in the mean scores of anxiety, depression, cohesion, and adaptability variables differed significantly before and immediately after the intervention and before and 3 months after the intervention. Conclusion: Online family-based CBT appears efficacious in improving the psychological status of divorced head-of-household women and the cohesion and adaptability of their families.

Keywords: Adaptability, anxiety, cognitive behavioral therapy, cohesion, depression, divorced women, head of household

How to cite this article:
Golboni F, Alimoradi Z, Potenza MN, Pakpour AH. The efficacy of an online family-based cognitive behavioral therapy on psychological distress, family cohesion, and adaptability of divorced head-of-household women in Iran: A randomized controlled trial. Asian J Soc Health Behav 2023;6:133-40

How to cite this URL:
Golboni F, Alimoradi Z, Potenza MN, Pakpour AH. The efficacy of an online family-based cognitive behavioral therapy on psychological distress, family cohesion, and adaptability of divorced head-of-household women in Iran: A randomized controlled trial. Asian J Soc Health Behav [serial online] 2023 [cited 2023 Sep 23];6:133-40. Available from: http://www.healthandbehavior.com/text.asp?2023/6/3/133/385954

  Introduction Top

The family is an important social institution in different societies, and divorce often disrupts familial structure and functioning. Divorce can generate familial turmoil, disrupting the lives of couples and their children.[1] Today, the incidence of divorce is increasing in different societies. In 2020, about 0.7 million divorces occurred in European countries.[2] Concurrently, in Iran, as the number of marriages decreased, a high number of divorces were observed, so that in the first 20 years of marital life, 11% of marriages ended in divorce, and about 6% were recorded in the 1st year of marital life.[3]

Divorces have resulted in an increase in divorced head-of-household women. This designation may be associated with social, cultural, and economic problems.[4] Divorce may not only adversely impact women's physical health[5] but also generate emotional and psychological problems concerns including anxiety and depression.[6],[7] Sharma stated that divorce led to increased negative emotions such as stress, anxiety, and depression.[8] Hald et al. reported that divorced people experience higher levels of depression and anxiety.[9] Psychological concerns following divorce include increased psychological pressure, social isolation, feeling alone, and not feeling understood, and these factors may aggravate psychological problems in divorced head-of-household women.[10],[11]

After divorce, familial balance may be disrupted, and other components, such as familial adaptability and cohesion, may decrease.[12] Cohesion and adaptability are two components in the family structure that reflect familial health. The existence of adaptability and the continuity of cohesion in the family are considered primary components for optimal familial life.[13] The degree of cohesion and adaptability may be used to evaluate the quality of relationships between the members and the functioning of the family.[14] Chukwu et al. reported that family cohesion plays a vital role in coping with stress, and a problem-oriented approach is more common in people with high levels of family cohesion.[15]

Among efficacious interventions in promoting emotional stability and familial functioning is cognitive-behavioral therapy (CBT). CBT is a psychological treatment focusing on changing thoughts, beliefs behaviors, and improving interpersonal communication.[16] CBT can be as effective as other forms of psychotherapy or psychiatric medications for addressing depression, anxiety disorders, marital problems, interactions with children, and severe mental illness.[17] Cognitive-behavioral family therapy (CBFT) integrates behavioral and cognitive approaches and applies them to family systems, focusing on the thoughts and behaviors of family members, and examines how the behavior and emotions of one family member affect the behaviors, emotions, and cognition of other family members.[18] Due to its flexibility, CBFT can focus on various problems, from promoting changes within individuals in families to changing family interaction styles, behaviors, family members' communication with each other, and interactions with children.[19] The basic principle of CBFT is that the behavior of one family member leads to certain behaviors, cognitions, and emotions in other family members. Then, other family members influence the cognitive and behavioral processes of the main family members in a feedback loop or other interactive manners. Accordingly, the primary goal of CBFT is to help family members recognize distortions in their thinking, reconstruct their thought processes, and modify their behavior in order to improve their interactional patterns.[18] CBFT uses behavioral and cognitive interventions to assess behaviors over time and modify them for more adaptive familial interactions. CBFT is an active and comprehensive approach that emphasizes the importance of each family member in the treatment process.[20]

In a recent systematic review of randomized controlled trials, CBFT was reported as more effective than individual CBT, psychoeducation or waitlist for different conditions including anxiety, obsessive-compulsive, pediatric bipolar, and substance use disorders, anorexia nervosa, and chronic physical problems. Through the improvement of mutual interactions between individuals in family systems regarding the treatment of mental or physical problems, CBFT can lead to improvements and decreased likelihood of relapse. Despite existing promising evidence, the review suggested that while CBFT should be increasingly implemented, more research was also needed.[21]

CBT delivered to families with poor emotional and communication statuses may reduce violence against women and improve family functioning.[22] Öngİder (2013) studied the efficacy of CBT on anxiety and depression in divorced women in Turkey and reported improvements in affective states after CBT interventions.[23] Jalali et al. also found family function training based on Olson's approach to be efficacious in improving family cohesion and adaptability.[24]

Regarding divorced head-of-household women, considering the changing role of divorced women and the vulnerability of family cohesion, a role for online family-based CBT warrants study. Online interventions that have become more widespread during the pandemic may help overcome logistical barriers to treatment including childcare and geographic proximity. Thus, the present study investigated the efficacy of CBT on psychological health (anxiety and depression) and family cohesion and adaptability of divorced head-of-household women.

  Methods Top


This single-blind randomized controlled trial with a multifaceted intervention was conducted among 100 divorced head-of-household women. All women were supported by the state welfare organization of Iran. Participants were eligible for study inclusion if they were women who had gone through a divorce, expressed a desire to participate, owned a smartphone, had children, and were responsible for heading their households. Women who reported drug or psychotropic substance abuse, use of psychiatric drugs, or participation in cognitive or similar training sessions were excluded. The eligibility assessment was done independently by a research associate. All eligible participants were invited to participate in a preliminary session describing the study aims. After obtaining informed consent, participants were provided unique login information to access the app (called Mehr-e Khorshid). The CONSORT flowchart of the study participants is shown in [Figure 1].
Figure 1: CONSORT flowchart of the study

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Sample size estimation

To calculate the required sample size, G*Power 3.1 software Developed at the Institute for Experimental Psychology in Dusseldorf Germany was used, considering a medium effect size (d = 0.5) with a two-tailed test, an error rate of 0.05, and a power of 95%. In addition, a 20% sample size drop was considered during the estimation process, resulting in a total sample size of 100 participants.


An independent researcher randomized the study participants into two groups (intervention n = 50, active control n = 50) with a 1:1 ratio using a computer-generated online random number generator software.


App design

The content of the app for the participants in the intervention group was designed based on family-based CBT. The intervention was delivered through a dedicated mobile application.

At first, qualitative research on the type of content analysis was conducted to discover the basic needs of divorced women in the field of psychosocial health.[25] To provide online family-based CBT education, an application called Mehr-e Khorshid was designed. The educational items presented through this application were designed to be straightforward and understandable. Educational materials and messages were evaluated in terms of correctness, lack of contradiction and integrity, clarity, appropriateness with the audience, attractiveness, acceptability, and creativity. The materials were also evaluated in terms of content and the message's presentation. Before the implementation of the intervention, the designed educational materials were piloted on 10 divorced women independent from the final study participants and were evaluated in terms of ability to understand the materials and their attractiveness and acceptability.

Procedure for Study Groups

Intervention group

The app included six sessions aimed at addressing psychological distress, enhancing family cohesion, and promoting adaptability among divorced head-of-household women in Iran.

The sessions were held weekly with the following structure: in session 1, psychoeducation and goal setting (describing the impact of divorce on mental health and family dynamics, collaboratively setting goals related to reducing distress, improving family cohesion, and enhancing adaptability) were provided. In session 2 (cognitive restructuring), identifying negative thought patterns and irrational beliefs related to divorce and family functioning were discussed. Cognitive restructuring techniques aimed to challenge and replace maladaptive thoughts with more adaptive ones. In session 3, stress management and coping skills included presentation of relaxation exercises and mindfulness techniques. Session 4 (communication skills training) focused on improving communication within the family unit. Active listening, assertiveness, and conflict resolution skills to enhance family cohesion were taught. Problem-solving and decision-making were considered in session 5. In session 6 (consolidation and relapse prevention), strategies for maintaining progress, preventing relapse, and seeking support when needed were discussed. After each intervention session, a per-arranged video call was established with the participant, and at least 45 min was spent reviewing the training session, addressing questions and providing answers, considering the training items presented in the session, and reviewing the assignments of the previous session. At the end of each session, daily breathing exercises were conducted for 10 min, and the app did not allow participants to enter the new stage until the person completed these.

Active control group

Participants in the active control group received psychoeducation regarding the impact of divorce on mental health and family dynamics as outlined in session 1 in the intervention group. The remainder of the sessions focused on breast self-examination (BSE) based on the Health Action Process Approach model. In session 2, an overview of breast self-examination and its importance for early detection of breast abnormalities was introduced. Risk perception and outcome expectancies for early detection of breast cancer were explored in session 3.

Session 4 focused on self-efficacy and skills training to address barriers and challenges that may hinder BSE practice. Action planning and environmental support for regular BSE were presented in session 5. In the final session (maintenance and relapse prevention), the importance of sustaining BSE behavior over time was discussed.


Data collection tools included the demographic characteristics checklist, Hospital Anxiety and Depression Scale (HADS), and Olson's Family Adaptability and Cohesion Evaluation Scale (FACES)-III.

Hospital Anxiety and Depression Scale

The HADS has 14 questions, 7 of which measure anxiety, and the other seven measure depression. Questions are rated on a 4-point Likert-type scale from 0 to 3. The total score of each of the two anxiety or depression scales ranges from 0 to 21, with a higher score indicating higher anxiety and depression. This scale has been translated into Persian and validated in Iranian individuals.[26]

Olson's Family Adaptability and Cohesion Evaluation Scale-III

Olson's FACES-III is a measure of the degree of family cohesion and adaptability. This scale has 40 questions that measure two dimensions of family functioning: cohesion (20 questions) and adaptability (20 questions). This measure is rated on a 5-point Likert-type scale. The total score is calculated by summing the scores of all items, with higher scores reflecting better familial functioning. The psychometric properties of this tool have been confirmed in various studies including ones involving Iranian individuals.[27],[28]

Study measures were completed before and after the interventions and at 3-month follow-up.

Ethical considerations

All procedures were conducted in compliance with the Helsinki Declaration. The study was approved by the Qazvin University of Medical Sciences Ethical Committee (IR.QUMS.REC.1399.121) and preregistered at IRCT.ir (IRCT20200923048813N1). The necessary permission was obtained. After explaining the purpose and method of conducting the study, written informed consent was obtained from participants.

Statistical analysis

The data analysis was conducted using SPSS version 25 (IBM Corp. Armonk, New York, United States) and MLwiN software (Centre for Multilevel Modelling, University of Bristol, Bristol, United Kingdom). An intention-to-treat two-level linear mixed model was employed, with participants considered at level 2 and time at level 1. The models were estimated using restricted iterative generalized least square (RIGLS) estimation. This approach allowed for the assessment of the intervention's effect while accounting for the hierarchical nature of the data.

  Results Top

[Table 1] summarizes participant characteristics by the study group. The average age was 38.96 years (standard deviation [SD] =7.74) for the active control group and 39.64 years (SD = 7.02) for the intervention group. The average mean age of divorce was 30.24 years (SD = 6.49) and 31.24 years (SD = 6.0) for the active control and intervention groups, respectively.
Table 1: Demographic characteristics by group (n=100)

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[Table 2] presents the means and standard deviations of anxiety, depression, cohesion, and adaptability scores at different times for both the active control and intervention groups. At postintervention and follow-up, the intervention group showed lower anxiety and depression scores compared to the active control group. The intervention group also exhibited higher cohesion and adaptability scores at postintervention and follow-up.
Table 2: Means and standard deviations of anxiety, depression, cohesion, and adaptability scores at different times by group (n=100)

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The results of two-level hierarchical linear models statistically predicting anxiety, depression, cohesion, and adaptability scores as primary outcomes are presented in [Table 3]. Anxiety decreased significantly at the postintervention assessment as compared to the active control group. However, this significant difference was not maintained at the follow-up assessment (i.e. month 3). In addition, depression scores decreased at both the postintervention and follow-up assessments in the intervention group compared to the active control group. Cohesion and adaptability increased at both the postintervention and follow-up assessments compared to the active control group.
Table 3: Two-level hierarchical linear models predicting primary outcomes of anxiety, depression, cohesion, and adaptability

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  Discussion Top

This study examined the efficacy of CBFT on psychological health and family cohesion and adaptability in divorced head-of-household women in Iran. The results supported the intervention's efficacy in reducing anxiety and depression, complementing other interventions with support for improving the psychological condition of divorced women. For example, in divorced women, mindfulness approaches have reduced anxiety and improved cognitive flexibility and resilience,[29] and teaching life skills reduced depression.[30]

Effective approaches to helping individuals achieve emotional and behavioral changes often involve strategies that change maladaptive patterns. Accordingly, CBT has demonstrated efficacy. Depression, anxiety, and loneliness levels were reduced after CBT sessions in divorced women,[23] consistent with the results of the present study. Furthermore, CBT reduced symptoms of depression in low-income women.[31] Since divorce can affect the entire family structure and the cognitive and behavioral processes of other family members, CBFT should be given more attention as a connection between family therapy and CBT. Consistently, CBFT reduced children's behavioral problems in families having experienced divorce.[32] CBT combined with listening to relaxing music, breathing exercises, and body relaxation techniques reduced anxiety and depression in divorced women, resonating with findings that music therapy, as a low-cost and accessible method, may increase happiness and reduce depression in women with depression.[33] Combining CBT with stress-management interventions, including body relaxation techniques, may improve the mental health of divorced women.[34] Taken together, multiple studies suggest that using techniques such as body relaxation, breathing exercises, and music therapy, along with other interventions, can improve the psychological status of individuals, including divorced women.

In the present, CBFT improved familial cohesion and adaptability by reports of divorced head-of-household women. Along these lines, empowerment training and CBFT have demonstrated efficacy in improving family cohesion by reports of divorced head-of-household women,[35],[36] and emotion-oriented therapy based focusing on interpersonal forgiveness in families about to divorce reduced the likelihood of divorce and improved familial cohesion and adaptability.[37] Regarding other situations, CBFT in families with children with sickle cell anemia improved overall familial functioning,[38] and CBFT in people who have attempted suicide reduced suicidal thoughts and depression symptoms and improved familial cohesion.[39] Given that family cohesion may help manage familial stress more adaptively,[15] further research and implementation of CBFT appears warranted.

A central tenet of family therapy is that the basis of family problems may be more interpersonal than intrapersonal. Therefore, addressing familial concerns likely requires interventions that manage and improve relationships between family members.[40] Based on the components of cohesion and adaptability of family members, the quality of relationships between family members and overall familial functioning may be examined. High family cohesion promotes family members experiencing life situations in nonthreatening ways, preparing them to overcome problems. Warm and accepting familial emotional atmospheres may protect individuals from psychological harms and promote the use of adaptive coping strategies when encountering stress.[41] A basic principle of CBFT is that behaviors of one family member lead to certain behaviors, cognitions, and feelings in other family members. On the other hand, other family members also influence the cognitive and behavioral processes of the same person in the family. Therefore, by integrating behaviorism and cognitive approaches and applying them to family systems, CBFT provides principles and techniques for improving familial functioning.[19] CBFT focuses on interactive aspects of the family more so than on individuals' internal processes for increasing skills, such as facilitating positive family interactions for divorced families to maintain family cohesion and adaptability.

The present study supports the efficacy of CBFT, in line with the results of a recent systematic review and meta-analysis suggesting that CBFT is more effective in improving psychological disorders than individual CBT and that CBFT can be used to improve disorders experienced by one member and its effect on other family members. In addition, CBFT may reduce the risk of the recurrence of psychological disorders in these families.[21]


A study limitation is the relatively short (3-month) follow-up period. Future family-centered studies with longer-term follow-up periods should be conducted. In addition, the study was conducted in Iran, so the extent to which the findings extend to other jurisdictions or cultures warrants investigation. Further, the study focused on women who were heads of households. The extent to which the findings apply to other divorced individuals warrants study.

  Conclusion Top

This study showed that the CBFT was linked to improved psychological states and familial cohesion and adaptability as experienced by divorced head-of-household women. Since familial cohesion and adaptability reflect emotional ties and familial relationships, interventions focusing on familial interactions may be associated with more favorable results than those focusing on individual betterment. Thus, considering the efficacy of CBFT in improving familial cohesion and adaptability in divorced head-of-household women, it is suggested that this intervention be studied with respect to other aspects of this group of people and other familial measures.


This article is the result of a research project approved at Qazvin University of Medical Sciences, and the authors now thank the respected Research Deputy of Qazvin University of Medical Sciences for their financial support, as well as the Tehran State Welfare Organization and the Iranian Family Health Association and all head-of-household women participating in the study.

Financial support and sponsorship

This study was financially supported by the Research and Technology Deputy of Qazvin University of Medical Sciences.

Conflicts of interest

Zainab Alimoradi and Amir H. Pakpour are the editors of the Asian Journal of Social Health and Behavior. The paper went through formal and anonymous reviews. Dr. Potenza has consulted for Opiant Pharmaceuticals, Idorsia Pharmaceuticals, Baria-Tek, AXA, Game Day Data, and the Addiction Policy Forum; has been involved in a patent application with Yale University and Novartis; has received research support (to Yale) from Mohegan Sun Casino, Children and Screens and the Connecticut Council on Problem Gambling; and has consulted for and/or advised gambling and legal entities on issues related to impulse control, internet use, and addictive disorders.

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  [Table 1], [Table 2], [Table 3]


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