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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 8-14

Effectiveness of cognitive behavioral counseling-based film therapy on the communication skills of females with low sexual Desire

Department of Midwifery, Faculty of Nursing and Midwifery, Arak University of Medical Sciences, Arak, Iran

Date of Submission18-Nov-2018
Date of Acceptance25-Dec-2018
Date of Web Publication1-Apr-2019

Correspondence Address:
Mrs. Naeimeh Akbari Turkestani
Department of Midwifery, Faculty of Nursing and Midwifery, Arak University of Medical Sciences, Arak
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNMS.JNMS_48_18

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Context: Several researchers emphasized to develop cost-effective and easy interventions in this field as communicating about the relationship is the first step of healing.
Aims: This study was aimed to evaluate the effectiveness of cognitive behavioral counseling based on film therapy on the communication skills of females with low sexual function.
Setting and Design: In this clinical trial study, fifty subjects selected among females referred to health centers of Gonbad-e Kavus City-Iran.
Materials and Methods: Samples randomized through permuted block randomization into two intervention (N=25) and control (N=25) groups. The intervention group participated in eight sessions of cognitive behavioral counseling (CBC)-based film therapy while the control group did not receive any intervention. All participants assessed by demographic, Arizona Sexual Experience Scale and Jerabeck Communication Skills Scales in pre and post intervention stages.
Statistical Analysis Used: Data is analyzed using descriptive& independent t-test.
Results: Findings showed that the two groups did not differ significantly in terms of age, education, and duration of marriage. The control (65.65 ± 6.75) and intervention groups (66.18 ± 7.32) were not significantly different in terms of communication skills before the intervention. However, in the postintervention phase, there was a significant difference between the control (66.04 ± 7.29) and intervention (74.95 ± 6.12) groups in term of communication skills (P < 0.05).
Conclusion: Based on the findings of this study, CBT based on film therapy can improve communication skills among females with low sexual function in all aspects. Therefore, it is recommended to use this therapeutic approach to improve couples' relationships with low sexual performance.

Keywords: Cognitive behavioral therapy, Communication skills, Film therapy, Sexual performance

How to cite this article:
Alizadeh M, Akbari Turkestani N, Oohadi B, Mehrabi Rezveh F. Effectiveness of cognitive behavioral counseling-based film therapy on the communication skills of females with low sexual Desire. J Nurs Midwifery Sci 2019;6:8-14

How to cite this URL:
Alizadeh M, Akbari Turkestani N, Oohadi B, Mehrabi Rezveh F. Effectiveness of cognitive behavioral counseling-based film therapy on the communication skills of females with low sexual Desire. J Nurs Midwifery Sci [serial online] 2019 [cited 2021 Mar 8];6:8-14. Available from: https://www.jnmsjournal.org/text.asp?2019/6/1/8/255329

  Introduction Top

Marriage as the longest and most profound type of communication has always been the subject of attention in different research subjects.[1] Marriage satisfaction is generally positively correlated with sexual satisfaction.[2],[3] It is estimated that about 50% of couples experienced sexual dysfunction during their marital life.[4],[5] Existing a sexual dysfunction makes a serious conflict potencies among couples, especially when the communication skills of couples are not adequate.[6]

Sexual function is depended to the quality of couple's relationship, which is strongly depended to communication.[7] Communication skills are based on four basics elements: (1) empathy, (2) language and relationship, (3) emotional expression, and (4) acceptance.[8] Empathy, emotion express, acceptance, and relationship are the vital needs of any intimate relationship.[9] Studies demonstrated that communication and sexual satisfaction independently predict marital satisfaction.[10] However, there is a significant interaction between communication and sexual satisfaction.[11] Effective sexual communication between partners is related not only to improve sexual function but also to improve overall satisfaction with the relationship.[12] On the other hand, poor communication skills decrease the chance of solving conflicts that during time leads to decrease intimacy and sexual relationship.[13]

Sexual communication is associated with higher sexual function in couple's relationship. Commutation about sex and relationship reveals hidden aspects of one's sexuality demands such as preferences, fears, and fantasies.[12] Sexual dysfunction can occur due to various reasons among couples although low communication skills could intensify the problem.[14]

Psychological treatments have been implemented with different approaches to reduce sexual problems and to enhance communication between couples.[15],[16] Among these, cognitive behavioral counseling (CBC) has been one of the most promising approaches. However, some clients did not succeed adequately in therapy due to the high number of sessions, cost, timeliness, and noncomplete treatment.[17] Hence, the new therapeutic approach has been developed, which is called CBC based on film therapy which mixed film therapy with CBC techniques.[18] Watching a film during film therapy is a multivariate experience that not only helps in the training of new skills and concepts but can also be used as a catalyst that exerts emotional excitement. Four stages for film therapy can be considered, which include identification, emotional evacuation, insight, and globalization.[19] In a review study, results showed that film therapy in all areas of treatment could be a cost-effective and effective treatment.[20] Film therapy among people with mental health problems made them able to disclose and speak about their problems.[21]

Sexual function and communication skills are strongly interrelated. Couples who are skilled in communication experience better sex life and higher marital commitment.[22] While dissatisfaction with sexual relations could lead to serious conflicts in couples' relationship.[19] Couples' communication and interaction is the most important factor influencing the marital life.[23] In addition, in another study, couple communication showed relationship with emotional and sexual intimacy.[24] In another study, the results of the comparison of medication and cognitive behavioral therapy (CBT) indicated that CBT was more effective on sexual problems of couples.[25] Recent study suggests that film-based therapy-based cognitive therapy promotes the ability of communicating in people with social anxiety.[20]

Previous studies suggested link between communication skills and sexual function and necessity of conduction of attractive, short, easy, and cost-effective intervention to help people to speak out about their emotions and problems. Although sexual function is a multidimensional problem, it is related to mental and physical condition. Marital relationship and intimacy is one of the main predictors of sexual dysfunction among woman.[26] On the other hand, it is obvious communication skills and is one of the main factors interrelated with sexual dysfunction considering moderate role of marital relationship satisfaction.[27] Therefore, it is hypothesized that communication skills help woman to solve their marital conflicts in relationship and communicate about sexual feelings and problems. Given there was not found any film-based study in couples therapy filed. Therefore, this study aimed to answer this question, does CBT based on film therapy is effective in improvement of communication skills of females with low sexual function.

  Materials and Methods Top

The current study procedure followed guidelines of the Declaration of Helsinki of 1975 and has been approved with ethical committee of Arak University of Medical Sciences of Iran with cod number of 2014-1-03-1396 and IRCT registration number IRCT20170701034835N1. All participants were informed about the study procedure and signed the written consent form. Further, they also informed that they could withdraw from the study at any point of the study period and there is no need to write down their name in questionnaires. Participants were assured that the data from the questionnaire would remain confidential.

The present study was a clinical trial study with pretest, posttest, and control group. The research population included all married women aged 15–49 years who referred to the health centers of Gonbad-e-Kavoos city during July–December 2017.

The number of samples needed for each group was obtained by the formula below 24, which was estimated 25 cases by considering the drop for each group according to the variances in communication skills scores.[28]

P1=0.85, P2=0.5.

α =0.05, β =0.2.

Gonbad-e-Kavos city, Iran has 15 comprehensive centers of urban health service centers. Five centers were selected randomly. The demographic data of the entire population of the city were recorded in software of health system; according to the inclusion and exclusion criteria, 300 women were selected through cluster sampling method (60 cases from each selected center) and invited to cooperate with them through telephone by staffs of health centers. The participants who met the criteria and signed the consent form completed the Arizona Sexual Experience Scale (ASEX) Questionnaire. Finally, 50 cases who have low sex function (score below 14),[29] met criteria, and agreed to participate were selected as sample. The final samples were randomly divided into two groups, control (n = 25) and intervention (25 cases) groups, through permuted block randomization [Figure 1].
Figure 1: Sampling flowchart

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To avoid patient selection bias, samples were eligible if they were Muslim Shia, 15–49 years of age, married at least for last 1 year, earned below 14 in ASEX Questionnaire,[29] educated at least high school, and nonsmoker. They excluded, according to the recorded history or self-report, if they were pregnant, had traumatic experiences in the last 6 months, and had history of ovary surgery or hormonal disease, menopaused, addicted to any type of medication or alcohol, had history of mental disorder, or were under treatment for any mental or physical conditions.

Because the interviews were conducted separately, the intervention and control group did not know each other. All samples had the same chance to allocation in intervention and control groups. The following questionnaires completed by participants in pre& post intervention stages:

Demographic data included age, marriage duration, health condition, education, occupation, and number of children.

The revised Communication Skills Test of Jerabeck (2004) has been used to evaluate communication skills. The questionnaire has 34 items that are responsive to completing its terms on a 5-point Likert scale (1 = never and 5 = always). The communication skills that examined on this scale include five subscales listening, emotional regulation, message comprehension, insight, and determination. Each responder has a separate score in each of the subskills, and the total score of each individual in the 34 items represents the total score of the individual's communication skills. The minimum possible score is 34 and maximum is 170. The reliability of this questionnaire in the research of Hossein Chari and Fadakar (2005) in a sample of 733 Iranian students was reported to be 0.71 and 0.69, respectively. The construct validity tested through factor analysis and five factors (listening, emotional regulation, message comprehension, insight, and determination) was supported.[30] In the study of Jaberi et al., this value was obtained to be 0.86.[31]

The ASEX was used to measure sexual performance. The questionnaire is a short 5-item scale that evaluates sexual performance in terms of sexuality and arousal orgasm's ability with Likert options. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. A questionnaire for the evaluation of sexual dysfunction resulting from the side effects of drug interventions in patients with depression or anxiety disorders is applicable. According to the previous studies, the score <14 was considered as a cutoff. Those who score <14 mean less sexually explicit.[29] McGahuey (2000) has evaluated the ASEX. The results showed that scale items are relatively good with other options such as the decreased sexual performance index. In addition, this tool has internal firmness and reliability of 0.7045. Test reliability is valid.[32] In Iran, Bayrami et al. reported alpha 0.9, and the correlation of the questionnaire with other brief index of sexual function was equal to 0.28.[33] This scale was used before intervention in sampling stage to find out the sexual function level of participants. The cases who reported score below 14 in this scale selected as a subject of study.


The sessions took place in the conference room of main health center of Gonbad-e-Kavoos city. Researcher hold all sessions and a clinical psychologist supervised the sessions. Researcher attended for CBC-based film therapy for 3 months before conducting the study. The movies selected and protocol designed by psychiatrist who is an experienced film therapist and revised by two nurses and psychologists. The movies included marital and communication axis. Individuals in the intervention group were divided into two groups. The sessions were administered in eight weekly sessions (120 min).[16] The participants were provided a notebook, and they were asked to write their thoughts and impressions about the film in some lines. Then, group met at a group every week. Participants shared their experience with group each session. Researcher referred to main part of the film and that part of movie watched in-group. Each session started with review of previous sessions speaking about home tasks. In every session, participants read their statements and discussed about their feelings. All members were asked to listen empathically and give their comment in their turn. The researcher noted down the marital relationship-related points expressed by participants and encouraged the group to share more feeling more detailed in added in [Table 1]. The researcher used CBC steps (identifying automatic thoughts, evaluating automatic thoughts, challenging automatic thoughts, and replacing thoughts). This process was repeated until the sessions were completed for each movie. During this period, the control group did not receive any intervention from the research team. After posttest, the same movies were provided for cases in the control group.
Table 1: Session content of film therapy.based cognitive behavioral counseling

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Descriptive statistics methods included frequency, mean and standard deviation. The inferential statistics included K-square and t-test for independent groups. Normality of data was tested by Kolmogorov–Smirnov test. Data were analyzed using SPSS20 software (SPSS 20, IBM, Armonk, NY, United States of America). The significance level was considered as below 0.05.

  Results Top

The final samples included 23 cases in intervention and 22 cases in control groups. Totally, five cases (three from intervention and two in control groups) were excluded due to the incomplete questionnaire and incomplete sessions [Figure 1].

The findings indicated that most of the participants were home keepers, and the education level of 29 percent were academic degree. The majority have two children. The mean age of participants was 30.64 ± 7.10 years, and marriage duration was equal to 5.36 ± 5.09 years. In term of sexual function, there was no significant difference between control and intervention groups (P = 0.26). Meanwhile, the Chi-square test revealed no significant difference of control and intervention groups in terms of education level, age, and marriage duration [Table 2]. According to the results, there was no significant difference between the mean score of communication skills in the intervention and control groups in the preintervention stage (P > 0.05). Significant differences were observed between mean score of communication skills and all subscales (listening, emotional regulation, message comprehension, insight, and determination) in the intervention and control groups after intervention (P < 0.05) [Table 3].
Table 2: Comparing film therapy and control group in demographic characters

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Table 3: Comparison of communication skills between and within the film therapy and control group

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  Discussion Top

The aim of this study was to investigate the effectiveness of CBC-based film therapy on communication skills of females with low sexual function. Results indicated the promotion of communication skills in the intervention group compared to the control group. This means that the participants in the intervention group after participating in sessions were able to communicate more resolutely in relationships; they were more successful in managing emotions and showed a better understanding of themselves and others.

In harmony with the present study in one recent study film, therapy sessions were held with six participants seeking professional help for relationship problems (e.g., frequent conflicts, dissatisfaction, and sexual problems). Content analyses of questionnaire responses and therapy session transcripts indicated that clients improved in their relationships.[34] Conducting study on 36 female university students who had lost a close family member for 8 weeks showed higher maintenance of efficacy of film therapy in comparison to support group.[35] In another study, film therapy leads to emotional purging, purification, and could reduce stress.[36] A significant effect of film therapy has been indicated on the mood state as well as on the explicit social attitudes.[37] Researchers believed that the film therapy could easily be used as a tool in connection with other therapies. Some researchers directly connect positive psychology and the use of films with each other.[38]

Finally, we can say the film therapy is effective in learning skills as a well-chosen video can help clients learn “reel” life lessons from their world. They can watch the characters develop, destroy, and rebuild relationships; exercise problem-solving (and in some cases problem causing) skills; pursue different solutions based on a variety of values; and experience the short-term and long-term consequences of their choices.[39] This approach allows the patient to distance himself/herself from a problem by providing a relatively nonthreatening means of addressing the problem. Subsequently, the move can potentially reduce resistance in the therapy process.[39] Watching a movie in a group, followed by group discussion over shared personal experiences is a pleasant activity for participants beside their social skills improved.[35] Apart from advantages, film therapy has several therapeutic goals that can be reached by viewing films, especially when mixed with other approaches.[39]

As in this study, CBC techniques also included further clarification of this finding, it can be mentioned that CBT-based film therapy researcher attempted to make participants aware from their thoughts and actions. During sessions, participants engaged writing their feelings about movie, which was targeted marital conflicts and communication. They have shared their notes in sessions and presented their thoughts.

Participants filled the identifying automatic thought sheets and watched the movies, and in next step, they have evaluated and challenged with identified thoughts, while another movie provided for them, and finally, they encouraged replacing thoughts with adaptive thoughts. This process during sessions including watching movies, sharing experiences, and emotions helped females to share their feelings and improved commutations. In fact, modifying automatic thoughts decreased the unrealistic expectations, and false attribution of couples from each other reduces and increased understanding of positive aspects of each other's behavior, which eventually leads to better communication.[40] According to the cognitive approach followers, some common mental errors can mislead our interpretation of reality and can display themselves in our mentalities through inappropriate behaviors. Therefore, the depth of intimacy between two people in their relationship depends on their ability to transfer thoughts, feelings, needs, and demands clearly, correctly, and effectively.[41] Finally, the participants during session learned to listen deeply and emphatically and spend more time to communicate with their couples.

Researchers showed verbal skills and empathy have a significant effect on the couples sexual performances.[42] Because Enhanced communication helps couples to solve the conflicts and boost intimacy which is related to sexual function.[8] Communication skills make people to openly express sexual wishes and concerns with a partner which is a main step for solving sexual-related problems.[43]

This trial has some strengths including the randomized trial design, the comparison of the intervention group with a control group, considering several inclusion and exclusion criteria to reduce bias in selection, and conducting and introducing an easy and cost-effective counseling intervention.

This trial also has some limitations. The study included relatively low number of samples. In addition, in romantic relationships, communication skill and sexual performances are very complicated, and there is a need to spend long time to fundamentally treatments. The research focused on women without their spouse, which is another limitation of the study. We have included women based on their self-report about physical and hormonal problems, and we did not have laboratory testing facilities. Time limitation also was there, as we could not set a follow-up to find the maintenance of effectiveness of sessions.

  Conclusion Top

Several studies have been conducted to evaluate the effectiveness of CBT targeting communication skills and sexual functioning. However, researches on CBT-based film therapy interventions are rare. In the current trial, we are investigating the efficacy of a CBT-based film therapy targeting enhancement of communication. According to the findings of this study, it can be concluded that CBT-based film therapy is a successful program that has not led to any complications and it is very cost-effective. On the other hand, it can be used in all people and conditions to increase social communication.

Conflicts of interest

There are no conflicts of interest.

Authors contribution

This manuscript is part of MSc thesis of Mrs, Nahnaz Alizadeh under supervising of Mrs Akbari- Turkestani and consultant of Dr Behnam Oohadi and Dr Fateme Mehrabi Rezveh. Mrs Akbari- Turkestani contributed in concept, design, and manuscript preparation and supervised the procedure of study, Mrs Alizadeh contributed in data acquisition, definition of intellectual content and manuscript editing and manuscript review, literature search. Dr Mehrabi contributed in data analysis, procedure, and interpretation. Dr Oohadi contributed in intervention desighn, conducting intervention and drafting of report. The manuscript has been read and approved by all the authors and that each author believes that the manuscript represents honest work.

Financial support and sponsorship

This study was supported financially by Arak University of Medical Sciences.


Authors are thankful to all females who had participated in this study. The cooperation of Arak University of Medical Sciences, Golestan University of Medical Sciences, and staffs of health centers is appreciated.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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