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.     

Predicting Change in Marital Satisfaction Throughout Emotionally Focused Couple Therapy

Emotionally focused couple therapy (EFT) is an empirically validated approach to couple therapy that uses attachment theory to understand the needs and emotions of romantic partners. EFT is recognized as one of the most effective approaches to couple therapy, but to guide therapists in their use of EFT, a theoretically based model to predict change is needed. This study tested such a model by recruiting 32 couples, and 14 therapists who provided approximately 21 sessions of EFT. Couples completed self‐report measures of marital satisfaction, attachment security, relationship trust, and emotional control at pre‐ and posttherapy and after each therapy session. Results of hierarchical linear modeling suggested that individuals higher on self‐report attachment anxiety and higher levels of emotional control had greater change in marital satisfaction across EFT sessions. Assessing attachment security at the start of therapy will inform therapists of the emotion regulating strategies used by couples and may help couples achieve positive outcomes from EFT.     

Therapist presence in emotionally focused couple therapy blamer softening events: promoting change through emotional experience

The blamer softening event has been associated with successful treatment outcomes in emotionally focused couple therapy. Previous research has highlighted the critical role of softening events and heightened emotional experience in best sessions of emotionally focused couple therapy (EFT). This study examined the effects of a therapist's emotional presence in predicting heightened levels of client emotional experience in blamer softening events. Findings from a detailed analysis of successful and unsuccessful EFT softening attempts demonstrated that a therapist's emotional presence and corresponding evocative vocal quality were more likely to predict heightened levels of client emotional experience in successful softening attempts. Implications of these findings are reviewed in light of EFT research and practice.     

An Attachment Primer for Couple Therapists: Research and Clinical Implications

According to attachment theory, humans are relational beings and even a child's earliest experiences with caregivers have a profound effect on emotional development and an overall approach to relationships. With increasing regularity, couple therapy has utilized attachment language as a conceptual tool, but more work is needed to understand the full clinical implications of attachment theory. These include understanding the intergenerational nature of attachment and adapting the delivery, timing, and pace of interventions to client attachment strategies. In this article, we summarize the origins of attachment theory, its measurement, the role of attachment in couple relationships, attachment stability and change, and ways that attachment informs therapy process and intervention. We hope that this article will provide an impetus for couple therapists to expand their conceptualization and use of attachment in their clinical work and for couple researchers to conduct more clinically relevant, attachment‐oriented process research.     

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.     

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.     

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.     

Short-term and long-term effects of training in emotionally focused couple therapy: professional and personal aspects

This study investigated the immediate and long-term personal and professional effects of a 4-day externship training in emotionally focused couple therapy (EFT). EFT externship training uses lecture, discussion, video vignettes, live demonstrations, and role-plays to convey an attachment-based approach to working with couples. The two samples included clinicians (N = 76) who completed surveys immediately before and after training, and a subset of these clinicians (N = 29) who completed measures an average of 8 months later. Results indicate that following training, participants increased in their EFT knowledge and competence, became more open to their feelings, were more self-compassionate, were less likely to use avoidant attachment behaviors, and improved their own personal relationships.     

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.     

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.     

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     

Establishing Safety in Emotionally Focused Couple Therapy: A Single‐Case Process Study

Emotionally Focused Couple Therapy (EFT) is an effective approach to working with distressed couples. It is not only effective in reducing relationship distress, but also in successfully maintaining gains over time. In the current study, we sought to understand the therapy processes that result in the creation of safety during stage one of EFT. Safety is a key ingredient in stage one, setting the stage for deeper interpersonal and intrapsychic work in later stages of treatment. In order to achieve the study aim, we analyzed video recordings of the first six sessions of a single couple case from an EFT randomized controlled trial. Using a theory building case study approach, results reveal that all expected components related to the creation of safety were achieved. Additional findings from our analyses indicate that the therapist was highly active, especially in seizing key moments in the therapy provided by this particular case, which shifted the couple in the direction of safety and deescalated their interactional cycle. Implications of key findings are discussed.     

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).     

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     

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.     

The Mindful Couple

Couples who request conjoint treatment often demonstrate relationship problems that are exacerbated by emotional reactivity. Neurobiology research has clarified the process of emotional dysregulation, and the benefit of mindful interventions in managing and preventing hyperarousal. This paper examines the mechanics of emotional dysregulation and presents a case example that demonstrates how breathing and staying in the moment were used to help de-escalate an agitated couple. Mindful interventions can be used to help couples tolerate, understand, and manage emotional states that can otherwise become destructive. These techniques are particularly useful with volatile couples, and can be used in conjunction with other therapeutic interventions.     

Couples therapy for women survivors of child sexual abuse who are in addictions recovery: a comparative case study of treatment process and outcome

Treatment for women who are survivors of child sexual abuse and who have a history of substance abuse has largely involved gender-specific interventions. This study examines the use of conjoint couple therapy with a cohort of women who were survivors of child sexual abuse and who are in addiction recovery and with their partners. A comparative case study analysis incorporated standardized clinical measures with client and therapist interviews. Brief conjoint therapy was found to assist couples in the specific relationship skill areas of communication and mutual problem solving. Further, substantive gains were found in the realm of affective relations. The women reported an increase in support from their male partners, and the men reported a decrease in negative emotional atmosphere in the relationship.     

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.     

A Dyadic Analysis of Attachment Insecurities and Romantic Disengagement among Couples Seeking Relationship Therapy

This study sought to assess the role of attachment insecurities on romantic disengagement among couples seeking relationship therapy. Dyadic associations were examined between attachment insecurities and romantic disengagement, accounting for depression, relationship satisfaction, and commitment, using a sample of 171 couples. Partners completed the Experiences in Close Relationships Scale and the Romantic Disengagement Scale. Path analysis revealed that attachment-related avoidance, but not anxiety, was associated with romantic disengagement. Men's attachment-related anxiety was related to greater disengagement in their partner. The combination of men's attachment-related avoidance and women's attachment-related anxiety was also significantly associated with women's romantic disengagement. Although attachment insecurities were associated with romantic disengagement, contextual and intrapersonal factors also contributed to our understanding of disengagement. Findings are discussed in light of clinical interventions for couple therapy.