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.     

Relationship Education and Therapy for Same‐Sex Couples

The gay and lesbian community suffers higher rates of discrimination, mental health problems, and relationship break‐up than their heterosexual counterparts. In this paper we analyse the challenges confronting same‐sex couples, and the implications for couple education and therapy with same‐sex couples. We describe some similarities in the challenges confronting heterosexual and same‐sex couples (e.g., negotiation of shared realistic relationship expectations, effective communication). These similarities suggest existing evidence‐based approaches to couple therapy and relationship education are likely to assist same sex couple relationships. We also describe distinctive challenges for same‐sex couples (e.g., homophobic discrimination, internalised homophobia, and low support from many families for same sex relationships). These distinctive challenges suggest some adaptation of existing approaches to couple education and therapy could enhance their relevance and effectiveness to same sex couples.     

Exploring Social Class: Voices of Inter‐Class Couples

Social class is not often discussed or examined in‐depth in couple and family therapy research and literature even though social class shapes familial relationships and is considered an important variable in marital satisfaction. In this qualitative study, we explored the perceptions of eight couples who made lasting commitments across class lines by asking them about the impact of their social class backgrounds on their relationships. Three categories of themes emerged including: (a) differences and similarities in values and attitudes toward education, work, money, and class awareness/classism, (b) relationship issues involving families of origin, friends, and class‐based couple conflict, and (c) differences in economic resources, social capital and privileges/opportunities. Implications for assessment and treatment of couples are included.     

Therapy with Lesbian Couples

Speaking as a therapist and a heterosexual, the author discusses her work with lesbian couples. She suggests that necessary components of good therapy are the therapist's awareness of his or her own views, fears and assumptions about homosexuality, and an understanding of the ways that society, including the world of therapy, still subjugates same sex relationships. Working with lesbian couples raises challenges that are pertinent to the wider issue of the redefinition of couple therapy in a society where the couple relationship itself is being redefined.     

Spirituality and Relationship: A Holistic Analysis of How Couples Cope With Diabetes

This study explores how couples' spirituality and relationship processes holistically interact to inform diabetes management. Qualitative analysis of interviews with 20 heterosexual couples identified five spiritual coping styles based on the spiritual meaning they ascribed to the situation and the nature of their relationships with God and each other: (a) opportunists approach the illness as an opportunity for growth; (b) mutual problem solvers collaborate with their partners to respond to their disease; (c) individualistic problem solvers take personal responsibility for managing their disease; (d) accepters endure their disease; and (e) victims take a hopeless, discouraged approach. Results suggest that spirituality and couple communication and problem-solving patterns appear intertwined and integral to the practice of family therapy.     

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.     

Factors Preventing Gridlock in Chilean Couples’ Relationships Based on the Discourse of Couples Therapists and Highly Adjusted Couples

The term gridlock describes the occurrence of rigid patterns in couples’ conflict. This study aimed to describe strategies of conflict resolution and gridlock prevention from the perspectives of couples and couple therapists. Participants were couple therapists and highly adjusted couples scored by the dyadic adjustment scale (DAS), distributed according to traditional and non‐traditional position in life and duration of relationships. Conflict gridlock scenarios were used to create video stimulus that were presented to participants. A qualitative methodology was used to analyse couples’ and therapists’ commentaries on the scenarios. Results showed differences in preventing conflict gridlock among sub‐groups of couples. Long‐term traditional couples focused on loyalty to a common project and value sacrificing to a higher good; long‐term non‐traditional couples prioritised caring and validating the bond in the relationship. Short‐term traditional couples focused on mutual love and the relief of hurt while short‐term non‐traditional couples supported the value of equity.     

Emotionally Focused Therapy for Couples and Attachment Theory

Emotionally focused therapy for couples (EFTC) is an important framework for couples therapy. It provides an integrative model, drawing upon experiential, systems and attachment theory to understand the dynamics of the couple relationship and to describe the therapeutic process. The aim of this paper is to ask how EFTC uses attachment theory, and whether it draws as fully as it can upon the richness of that theory to inform the process of therapy. This is set in the context of the evolving importance of attachment theory for therapeutic work.     

Moving Up the Continuum of Hope: Developing a Theory of Hope and Understanding its Influence in Couples Therapy

For years therapists have suggested that hope is an important catalyst in the process of change. This study takes a grounded theory approach to address the need for a clearer conceptualization of hope, and to place interventions that increase hope within a therapeutic context so that therapists know how and when to use those interventions. Fifteen active and experienced marriage and family therapists from across the United States participated in hour-long phone interviews about hope in couples therapy. Moving Up the Continuum of Hope emerged as the core category from the grounded theory analysis of the data. This category represents a process, with general and specific conditions and consequences that increase a couple’s level of hope. This study serves as a foundation for future process research on couples therapy, as well as research on hope in other contexts (e.g., individual and family therapy) and with other perspectives (e.g., clients).     

The Implicit Realm in Couples Therapy: Improving Right Hemisphere Affect-Regulating Capabilities

Attachment theory, viewed through the lens of neurobiology, explains how infants learn, through unconscious, rapid, non-verbal interactions with caretaking adults, to successfully manage their own emotional energy. These neurological affect-regulating mechanisms formed in early childhood shape later-forming attachment relationships, including those of adult romantic dyads which depend, for intimacy and stability, on the same right brain, nonverbal, modulating capacities. Psychoanalytic researchers have identified healing, implicit, unconscious psychobiological mechanisms, other than verbal insight, explanation and interpretation that can be learned remedially in couples’ therapy. This paper examines an implicit, emotion-focused approach to couples’ work that brings unconscious affect center stage.     

The Critical Component of Cognitive Restructuring in Couples Therapy: A Case Study

This case study is offered as an example of how cognitive‐behavioral strategies, namely, cognitive restructuring of couples' schemas and the use of specific homework assignments, may be integrated into the course of couple therapy. The article suggests that all therapeutic modalities, regardless of their theoretical orientation, embrace some form of cognitive restructuring and behavioural instruction as a primary agent of change. Cognitive restructuring is highlighted in particular as a critical component of treatment. Michelle Webster, who practices Emotionally Focused Therapy, responds to Frank Dattilio, and he then replies.     

The Efficacy of Emotionally Focused Couples Therapy and Behavioral Couples Therapy: A Meta‐Analysis

Behavioral couple therapy (BCT) and emotionally focused couples therapy (EFCT) are well‐established treatments to reduce couple distress. This meta‐analysis summarizes the current state of knowledge on the efficacy of these two therapy methods by focusing on randomized controlled trials only. A literature search revealed 33 suitable primary studies (2,730 participants in total), all of them measuring relationship satisfaction. Robust‐variance random‐effects meta‐analysis revealed medium effect sizes at post‐test (overall: g = 0.60; BCT: g = 0.53; EFCT: g = 0.73) and small effect sizes of 6 months after treatment (overall: g = 0.44; BCT: g = 0.35; EFCT: g = 0.66), but these gains were not maintained after 12 months (BCT only: g = 0.06). Between the two therapy methods, no significant effect size differences could be found. Results have to be interpreted with caution due to potential publication bias.     

Couples Therapy: Unravelling the Strands

Work with couples is one of the more widely practised forms of counselling or psychotherapy, yet seems to have found it difficult to establish its own identity and theoretical base. A theoretical tradition specific to work with the couple relationship has, however, developed over the past 40 years. Recently, this tradition has become more clearly demarcated and has begun to show signs of vigorous growth. It is important for therapists whose primary identification is with individual or family therapy, but who work with couples, to be familiar with this theoretical tradition, and with its practice implications. This paper selects six aspects of theory relating to couples therapy that the author has found useful in practice, and seeks to show how, separately and together, they can illuminate the nature and dynamics of the couple relationship.     

A Model of Engagement Promotion in a Professionally Facilitated Online Intervention for Couples Affected by Breast Cancer

Professionally facilitated web‐based interventions for couples affected by an illness such as cancer are growing in popularity. Attrition rates for such online programs, however, are substantially higher than what is observed in face‐to‐face therapeutic contexts, and lower levels of participant engagement are associated with poorer outcomes. In the present investigation, a task analysis was employed to develop a model of engagement promotion in an online intervention for couples affected by breast cancer called “Couplelinks.” Results indicated that facilitators utilized a variety of meta‐processes, such as humanizing the technology, and associated “eBehaviors,” to maintain three relationships involved in promoting online engagement: (a) between the facilitator and couple; (b) between the intervention and couple; and (c) between the partners within the couple.     

Clients' relational conceptions of conjoint couple and family therapy quality: a grounded formal theory

Based upon a qualitative metasynthesis of 49 articles centered on clients' experiences of their conjoint couple and family therapy, the investigators constructed a grounded formal theory of Clients' Relational Conceptions of Conjoint Couple and Family Therapy Quality. The theory suggests from pretherapy conceptions to posttherapy reflections, clients' perceptions of conjoint couple and family therapy quality appear to consist of clients' constructed meanings regarding a series of interrelated relationships between clients and their therapists and therapy environments, between clients and themselves, between clients and other family members, and between process and outcome both inside and outside therapy. Within and across these relationships, clients appear to focus on expectations, connections, balance, and change when evaluating the quality of their clinical experiences. Based upon this theory, the investigators recommend that researchers continue to explore this clinical phenomenon and that therapists regularly seek clients' conceptions of quality in therapy.     

Principal‐agent relationships on the stewardship‐agency axis

This article provides an overview of the literature on nonprofit principal‐agent relationships. It depicts the nature of agency theory and stewardship theory, analyzes the origin of their struggle within the nonprofit structure, and marks directions for a conciliatory approach. We open with an introduction to agency theory and discuss the two main components of its mathematical branch. We thereby contrast it with stewardship theory and elaborate on the arguments that can affect the position of nonprofit principal‐agent relationships on the stewardship‐agency axis. Analysis of the existing literature points to a lack of consensus as to which theory should be applied. We argue that the division of nonprofit principalagent relationships into board‐manager and manageremployee interactions may help to clarify the balance between agency theory and stewardship theory and may lead to the establishment of a strongly founded theory on nonprofit principal‐agent relationships. We close with a discussion of how this article may prove valuable to nonprofit policymakers and other empirical researchers.     

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.