Predicting Key Change Events in Emotionally Focused Couple Therapy

In emotionally focused couple therapy (EFT), the blamer‐softening event helps individuals express and respond to partners’ unmet attachment needs. This study examined the impact of this event in relation to attachment at intake and changes in marital satisfaction from pre‐ to posttherapy. Thirty‐two couples were provided an average of 21 sessions of EFT. Hierarchical linear modeling revealed that the occurrence of a softening event significantly predicted increased marital satisfaction. Furthermore, the occurrence of a softening event significantly moderated the relationship between attachment avoidance at intake and change in marital satisfaction from pre‐ to posttherapy. For couples who had a softening event, partners with higher levels of attachment avoidance were less likely to have positive changes in marital satisfaction.     

The Impact of Behavioral Couple Therapy on Attachment in Distressed Couples

Emotion‐focused therapy (EFT; Greenberg & Johnson, 1988 Emotionally focused therapy for couples. New York: Guilford Press) is anchored in attachment theory (Johnson, 2003 Attachment processes in couples and families. New York: Guilford) and considers change in attachment schemas essential in the process of improving satisfaction in relationships (Johnson, 1999, Research and couples therapy: Where do we go from here? American Family Therapy Academy Newsletter). However, there are little data on how measures of attachment change over the course of EFT or any other couple therapy. The current study examines whether increases in attachment security predict improvements in marital satisfaction during behavioral couple therapy, which would suggest that change in attachment style is a key process variable even for a non‐attachment‐focused treatment. Multilevel models of data from 134 couples participating in a randomized clinical trial of integrative behavioral couple therapy and traditional behavioral couple therapy (Christensen et al. Journal of Consulting and Clinical Psychology, 72, 2004, 176) indicate that although there is a trend for early change in attachment‐related anxiety and avoidance to predict later change in marital satisfaction, early change in marital satisfaction strongly predicts change in attachment‐related anxiety through the end of treatment and 2‐year follow‐up. These findings suggest that changes in satisfaction may lead to changes in attachment rather than the reverse and that change in attachment may not be the mechanism of change in all efficacious couple therapy.     

Predicting Follow‐up Outcomes in Emotionally Focused Couple Therapy: The Role of Change in Trust,Relationship‐Specific Attachment,and Emotional Engagement

Emotionally Focused Couple Therapy (EFT), an evidence‐based couple therapy (Johnson, Hunsley, Greenberg, & Schindler, 1999), strives to foster lasting change through the creation of secure attachment bonds in distressed couples. Although studies have demonstrated lasting change in follow‐up (Wiebe et al., in press), research is needed to investigate predictors of long‐term outcomes. Our goal was to investigate predictors of long‐term outcomes in relationship satisfaction. Relationship satisfaction was assessed across 24 months in a sample of 32 couples who received an average of 21 EFT sessions. Decreases in attachment avoidance were most predictive of higher relationship satisfaction across follow‐up. These findings support the theoretical assumption that EFT helps couples foster lasting change in relationship satisfaction through the facilitation of secure attachment bonds.     

Two‐Year Follow‐up Outcomes in Emotionally Focused Couple Therapy: An Investigation of Relationship Satisfaction and Attachment Trajectories

Emotionally Focused Couple Therapy (EFT; The practice of emotionally focused couple therapy: Creating connection. New York, NY: Brunner‐Routledge) is an evidence‐based couple therapy that aims to create lasting change for couples (Clinical Psychology: Science and Practice, 6(1), 67–79). Although studies have demonstrated strong results in follow‐up (Journal of Marital and Family Therapy, 28(4), 391–398), less is known about relationship functioning across time after therapy has ended. We modelled change in relationship satisfaction and attachment from pre‐therapy through 24 months follow‐up in 32 couples. HLM results confirmed a significant growth pattern demonstrating increases in relationship satisfaction and secure base behaviour and decreases in relationship specific attachment anxiety over the course of therapy and across follow‐up at a decelerated rate. These findings support the theoretical assumption that EFT helps couples engaged in therapy create lasting relationship satisfaction and attachment change.     

The Impact of Blamer‐softening on Romantic Attachment in Emotionally Focused Couples Therapy

Emotionally Focused Couples Therapy (EFT; Johnson, 2004 ) treats relationship distress by targeting couples' relationship‐specific attachment insecurity. In this study, we used hierarchical linear modeling (Singer & Willett, 2003 ) to examine intercept and slope discontinuities in softened couples' trajectories of change in relationship satisfaction and relationship‐specific attachment over the course of therapy from a total sample of 32 couples. Softened couples (n = 16) reported a significant increase in relationship satisfaction and a significant decrease in attachment avoidance at the softening session. Although softened couples displayed an initial increase in relationship‐specific attachment anxiety at the softening session, their scores significantly decreased across post‐softening sessions. Results demonstrated the importance of the blamer‐softening change event in facilitating change in EFT.     

Exploring the influence of the attachment organizations of novice therapists on their delivery of emotionally focused therapy for couples

Clinicians' own internal resources for understanding relationships--that is, their attachment organizations--have been found to influence the process and outcome of treatment. The current study addressed whether the attachment organizations of novice couple and family therapists were associated with couples' experiences of their therapists, therapeutic alliance, session impact, and emotionally focused couple therapy (EFT) fidelity (i.e., especially as related to targeting and working with attachment needs and overt and underlying emotions). Novice couple and family therapists delivered EFT, an attachment-based approach, to couples in a simulated session and an embedded multicase study design guided a cross-case analysis. Findings indicated that secure therapists, when compared to their insecure peers, were more competent at working with attachment needs, as well as the overt and underlying emotions of their clients. Secure therapists perceived themselves as being more skilled in emotion regulation, which may have contributed to their abilities to remain attuned to their clients' attachment needs and emotional expression, even in the face of emotional arousal in session. Couples of insecure therapists also reported greater alliance splits. Future research is needed to further explore the dyadic influences of both therapists' and clients' attachment organizations, as well as the training and supervision practices these findings implicate.     

Forgiveness and Reconciliation in Emotionally Focused Therapy for Couples: The Client Change Process and Therapist Interventions

This article presents psychotherapy process research findings related to the forgiveness and reconciliation model, known as the Attachment Injury Resolution Model (AIRM), within the context of emotionally focused therapy for couples (EFT). Outcomes for EFT as an intervention for general relationship distress and AIRM have been successfully tested. Audiotapes of nine resolved and nine nonresolved EFT couple cases were used to study the client change process, the validity of AIRM, and EFT interventions used at each stage of the model. Study findings suggest resolved couple clients engaged deeply with their internal experience were more deliberate and controlled in their processing and more affiliative in their interpersonal responses in comparison with nonresolved couples. Resolved versus nonresolved client in‐session performances were discriminated on the basis of four model components. These were associated with significant shifts from secondary reactive emotions to primary attachment–related emotional processing of the injurious incident and with interactions that focus on shaping emotional responsiveness. Key EFT interventions employed in successful attachment injury resolution are also identified.     

Changes in Relationship‐Specific Attachment in Emotionally Focused Couple Therapy

Emotionally focused couple therapy (EFT; Johnson, The practice of emotionally focused couple therapy (1st/2nd edition). Brunner‐Routledge, New York, 2004) is an effective treatment of relationship distress (Johnson et al., Clinical Psychology: Science and Practice, 1999; 6, 67). However, less is known about EFT's impact on couples' relationship‐specific attachment bond. Using hierarchical linear modeling with a sample of 32 couples, we examined session‐by‐session changes in couples' relationship‐specific attachment anxiety and avoidance and pre‐ to posttherapy changes in their relationship‐specific attachment behaviors. Couples significantly decreased in relationship‐specific attachment avoidance, and those who completed a blamer softening significantly decreased in relationship‐specific attachment anxiety. Couples' attachment behavior significantly increased toward security. Finally, session‐by‐session decreases in relationship‐specific attachment anxiety and avoidance were significant associated with increases in relationship satisfaction across sessions. These results provide empirical support for the attachment‐based assumptions of EFT. Video abstract accessible by clicking here     

Attachment Change in the Beginning Stages of Therapy: Examining Change Trajectories for Avoidance and Anxiety

The purpose of this study was to investigate the nature of self‐reported attachment change (avoidance and anxiety) in the context of six sessions of couple therapy designed to emphasize both therapist‐centered and couple‐centered (i.e., enactment‐based) clinical process during the beginning stages of therapy. A total of 48 couples with at least one partner who reported clinically significant relationship dissatisfaction participated in this study. Findings confirmed that some couples experience positive attachment‐related change (anxiety or avoidance), while also identifying a subset of individuals who may not experience optimal levels of attachment‐related change. In addition, findings point toward both differences and similarities between change trajectories for avoidance and anxiety. Finally, there was evidence that socio‐demographic factors may be associated with attachment change.     

CREATING HEALING RELATIONSHIPS FOR COUPLES DEALING WITH TRAUMA: THE USE OF EMOTIONALLY FOCUSED MARITAL THERAPY

Emotionally focused marital therapy (EFT), a marital therapy that particularly focuses on the creation of secure attachment, has proven in empirical studies to be effective for distressed couples. This paper discusses the application of EFT in couples where one or both of the partners have experienced significant trauma. EFT, in this context of trauma, incorporates the nine steps of conventional EFT and also encompasses the three stages of the "constructivist" self development theory of trauma treatment. This paper illustrates how the integration of EFT and trauma treatement can prove effective in treating not only relationsip distress but also the individual symptoms of posttraumatic stress disorder (PTSD).     

The feminist/emotionally focused therapy practice model: an integrated approach for couple therapy

Emotionally focused therapy (EFT) is a well-developed, empirically tested practice model for couple therapy that integrates systems, experiential, and attachment theories. Feminist family therapy theory has provided a critique of biased assumptions about gender at play in traditional family therapy practice and the historical absence of discussions of power in family therapy theory. This article presents an integrated feminist/EFT practice model for use in couple therapy, using a case from practice to illustrate key concepts. Broadly, the integrated model addresses gender roles and individual emotional experience using a systemic framework for understanding couple interaction. The model provides practitioners with a sophisticated, comprehensive, and relevant practice approach for working with the issues and challenges emerging for contemporary heterosexual couples.     

Emotion-Focused Couples Therapy and the Facilitation of Forgiveness

The goal of this study was to evaluate the effectiveness of an emotion-focused couple therapy intervention for resolving emotional injuries. Twenty couples acting as their own waitlist controls were offered a 10–12-session treatment to help resolve unresolved anger and hurt from a betrayal, an abandonment, or an identity insult that they had been unable to resolve for at least 2 years. Treated couples fared significantly better on all outcome measures over the treatment period compared to the waitlist period. They showed a significant improvement in dyadic satisfaction, trust, and forgiveness as well as improvement on symptom and target complaint measures. Changes were maintained on all of the measures at 3-month follow-up except trust, on which the injured partners deteriorated. At the end of treatment, 11 couples were identified as having completely forgiven their partners and six had made progress toward forgiveness compared with only three having made progress toward forgiveness over the waitlist period. The results suggest that EFT is effective in alleviating marital distress and promoting forgiveness in a brief period of time but that additional sessions may be needed to enhance enduring change.     

A randomized trial of emotion-focused therapy for couples in a training clinic

Forty married couples participated in a randomized trial comparing 8 weekly sessions of emotion-focused therapy (EFT) for couples to a group of couples who were placed on an 8-week waiting list. A composite marital satisfaction score was created from scores on the Dyadic Adjustment Scale, Positive Feelings Questionnaire, and Personal Assessment of Intimacy in Relationships scale. Controlling for pretest scores, participants in the treatment group had significantly higher levels of marital satisfaction after 8 weeks than wait-list participants. Supplementary analyses identified variables associated with gains in therapy and with dropping out of the study.     

PREDICTORS OF SUCCESS IN EMOTIONALLY FOCUSED MARITAL THERAPY

This study examined client variables expected to predict success in emotionally focused marital therapy (EFT), now the second most validated from of marital therapy after the behavioral approaches. The relationship of attachment quality, level of emotional self-disclosure, level of interpersonal trust, and traditionality to the therapy outcome variables, marital adjustment, intimacy, and therapist ratings of improvement, was examined. These variables were chosen for their relevance to the theory and practice of EFT and to intimate relationships in general. Overall, therapeutic alliance predicted successful outcome; the task dimension of the alliance in particular predicted couples' satisfaction. More specifically, one dimension of female partners' trust, their faith in their partner, predicted couples' satisfaction at follow-up. Females' faith also significantly predicted males' level of intimacy at follow-up. Males who were most likely to be nondistressed at termination indicated higher levels of proximity seeking on an attachment measure at intake, and older males and males whose partners had higher levels of faith in them were more likely to be nondistressed at follow-up. Traditionality was not found to be significantly related to outcome. Couples who made the most gains at follow-up also indicated lower initial marital satisfaction and included males who indicated lower levels of use of attachment figure on the attachment measure at intake. Males who made the largest gains at termination were older and were rated as less expressive by their partner on self-disclosure measures at intake. Age was the only variable significantly related to males' gains in satisfaction at follow-up, Implications for the practice of marital therapy and future research are delineated.     

Enactments in Emotionally Focused Couple Therapy: Shaping Moments of Contact and Change

Emotionally focused couple therapy (EFT) uses enactments to shape responsive attachment‐significant contact and to change couple interaction. In this article, we show how EFT enactments differ from enactments in other therapy approaches, present a theory of EFT enactments, a model for creating EFT enactments, and an extended case example of an EFT enactment. Video Abstract     

Randomized controlled trial of emotionally focused couple therapy compared to treatment as usual for depression: Outcomes and mechanisms of change

This randomized controlled trial examined the effectiveness of Emotionally Focused Therapy (EFT) for depression and relationship satisfaction versus usual care (i.e., couple therapy other than EFT), and explored mechanisms of change. Mixed model trajectory analyses of 16 couples indicated EFT was associated with greater improvement in relationship satisfaction among men and women. Men receiving EFT reported greater improvements in depressive symptoms compared to usual care. Unified structural equation modeling revealed changes in relationship satisfaction preceded changes in depressive symptoms in one cluster of partners, while changes in depression preceded changes in relationship satisfaction in a second cluster. Two other clusters reported simultaneous changes in satisfaction and depression. This study provides encouraging results on the effectiveness of EFT for depression, and insight into mechanisms of change.     

RELATING PROCESS TO OUTCOME IN MARITAL THERAPY

Although there are a growing number of outcome research studies in marital therapy, there is a complete absence of research on change processes, and how such processes relate to outcome. This study attempts to analyze the process of change in the "best" sessions of Emotionally Focused Marital Therapy (EFT) (Greenberg & Johnson, 1986). Client performance in therapy was rated on depth of experiencing and the quality of interpersonal interactions. The occurrence of particular change events arising from the theoretical principles of EFT was also noted. Results confirmed hypotheses that higher levels of experiencing and more autonomous and affiliative interactions characterized "best" sessions of couples who were successful in therapy. The implications for treatment are discussed.     

Examining Attachment Avoidance and Attachment Anxiety Across Eight Sessions of Couple Therapy

This study examined initial levels of attachment anxiety and avoidance, as well as their patterns of change, across eight sessions of couple therapy. Participants were 461 couples in a treatment‐as‐usual setting. Dyadic latent growth modeling was used to determine whether couples started therapy at similar levels of attachment anxiety and avoidance and whether attachment anxiety and avoidance changed. An actor partner interdependence model was used to see whether partner attachment anxiety was related to avoidance. Results showed relative stability of attachment anxiety and avoidance over the course of therapy, with the only change being a slight decline in attachment anxiety among women. Results showed that a person's attachment anxiety was not related to their partner's avoidance and vice versa.     

Toward a mini-theory of the blamer softening event: tracking the moment-by-moment process

In this article we present the results of a discovery-oriented task analysis research study identifying specific therapist behaviors that facilitate softening events in emotionally focused therapy (EFT) for couples. Therapy sessions conducted by an expert EFT therapist were examined. Six therapist content theme shifts were identified and specific interventions were delineated within each using an EFT coding scheme (EFT-CS) created for this study. This study extends the theoretical understanding of the softening process--a key change event in an empirically validated couples therapy approach--and provides a detailed clinical map for the training of therapists.     

EFFECTS OF A COMMUNICATION TRAINING COMPONENT ADDED TO AN EMOTIONALLY FOCUSED COUPLES THERAPY

In this study a 4-session communication skills training component was added to an 8-session Emotionally Focused couples therapy package. This treatment (EFT + CT) was compared to 12 sessions of Emotionally Focused therapy (EFT) to investigate whether the communication training component enhanced the effectiveness of EFT, and both treatments were compared to a wait-list control. Both treatments achieved superior gains at posttest compared to the control group on measures of marital adjustment and target complaint improvement (but not on intimacy and passionate love), with EFT + CT being superior on communication. The only differential treatment effect was EFT's superiority on target complaints at follow-up.