1. Introduction to Couples Therapy & EFT
Carmen R. Jimenez, Psy.D.
Florida International University

2. Relationships need routine maintenance and work!
Why Couples Therapy?
When do you put gas in your car? Change engine oil?
Relationships need routine maintenance and work!

3. Relationship myths
A good relationship means that you don’t have to work at it.
If partners really love each other, they know each other’s needs and feelings.
If you’re truly in love, passion will never fade.
Jealousy is a sign of true love and caring.
Fights/disagreements ruin relationships.
Couples therapy means your relationship is really in trouble.

4. Why Couples Therapy? When do clients typically seek couples therapy?
Relationship crisis
“Last resort”
Unrealistic sense of how
easy relationships “should” be
Why don’t couples seek counseling?
Perceived failure in seeking help; failure of the relationship
Stigma or shame
Unrealistic sense of how easy relationships “should” be

5. Why Couples Therapy?
For most couples, marriage/the committed relationship is expected to be the primary source of adult intimacy, support, and companionship and a facilitative context for personal growth.
Divorce and marital/couple problems are among the most stressful conditions people face.
Partners in troubled relationships are more likely to suffer from acute and chronic medical problems and psychological health concerns.

6. Why Couples Therapy? Consider the following:
* Only about 25% of divorcing couples report seeking professional help of any kind to improve their relationship (Albrecht, Bahr, & Goodman, 1983; C. A. Johnson et al., 2001).
* Those who do, wait an average of 6 years after serious
problems develop to seek marital therapy (Notarius & Buongiorno, 1992, as cited in Gottman & Gottman, 1999); (Doss, Simpson, & Christensen, 2004, p. 608).

7. Why Couples Therapy? Most common reasons couples seek counseling:
Emotional affection: disengagement, “lack of love”, affection/intimacy
Communication: “lack of understanding”, difficulty with problem-solving, not discussing problems , frequent conflict and arguments
Infidelity, Mistrust, jealousy, extra-marital involvement
Sexual dissatisfaction
Value and role conflicts
Control / Power Struggles/ Difficulty with negotiating
Blended families / changes in family dynamics
General relationship improvement
Doss, B. D., Simpson, L. E., & Christensen, A. (2004). Why do couples seek marital therapy? Professional Psychology, 35, 608–614.   

8. Couples Therapy…What is it?
Effective couples therapy
Changes the views of the relationship -  attempts to help both partners see the relationship in a more objective manner and see their part in the relationship dynamics. 
Modifies ineffective behavior – assesses for safety, and also teaches new skills, including communication, conflict resolution, emotional expression, etc.
Improves communication – active and empathic listening, turn taking, attunement.
Decreases emotional avoidance - creates an atmosphere of safety and trust, encourages and models vulnerability rather than defensiveness and anger.
Promotes strengths - highlights and draws on the strengths in each partner and the relationship and builds resilience.

9. Couples Therapy…What is it?
The couples therapy process requires therapists to do the following:
• provide the couple with an understanding of the structure and goals of therapy
• develop trust with each client without alienating the other
• set the boundaries of therapy so each will feel safe to express his or her point of view in a way the other can hear and understand, even though he or she may not agree
• set the stage for the couple to have a conscious relationship, where each partner begins to understand how he or she is contributing to the conflicts and how using a different interactional style can lead to the harmonious relationship they both seek and deserve.

10. Important things to consider…
Couple’s common understandings of couples therapy
Misguided Expectations
Therapist will provide answer/verdict to our problem
Therapist will finally make you understand you’re wrong!
I’m only here because he/she made me come.
Finally, I’ll have help to change you!

12. Important things to consider…
(Mis)understanding of therapist’s role as my ally, advocate, judge for one or both individually
Misunderstanding of Confidentiality – therapist will keep my secrets from my partner

13. Important things to consider…
The couples therapist is not a judge, will not rule over who is right/wrong.

14. Important things to consider…
The couples therapist thinks of the couple as his or her client rather than either of the partners considered separately. Work is in improving the connection between partners.
Treating the couple as the client keeps the focus of therapeutic discussion more firmly fixed on healing the couple's troubles, and helps the therapist resist siding with one of the partners at the expense of the other.
Couples therapy works best when both partners are physically and emotionally present.
Generally, couples therapists will not keep secrets for one/from the other.

16. Other misunderstandings of couples therapy

17. Important things to consider…before we begin…the couples consultation
Each partner’s understanding of the problem
Is each able to take some responsibility for how they are contributing to the “problem?”
Safety / IPV
What is the level of commitment of each partner to the relationship?
What is the level of readiness for change in each partner?
Accurate understanding of the structure of couples therapy and role of therapist?
Limits of confidentiality

18. Couples therapy intake
In addition to information gathered during an individual counseling intake:
Story of how they met / history of their relationship
Relationship histories of each, including FOO & attachment histories in prior significant adult relationships
Some understanding of each partner’s parents’ marriage/relationship
Loss/abuse history – including infidelity
Cycle of interactions
Sex life

19. Why Couples Therapy?
Generally, couples seek therapy because of threats to the security and stability of their relationships with the most significant attachment figure of adult life. (Johnson & Denton, 2002)

20. Attachment Theory and Adult Relationships
Attachment theory assumes that we are biologically wired to connect with others and attachment patterns established in early childhood tend to persist throughout life. (John Bowlby)
Early bonds with parent/caregiver set the tone and pattern for how we pursue relationships with others and how we see the world and our place in it. (Mary Ainsworth)

21. An attachment bond…

22. Important Concepts in Attachment Theory that also relate to EFT
Secure Base: The attachment figure acts as a base of security from which we can explore the surrounding environment
Proximity Maintenance: The desire to be near the people we are attached to
Safe Haven: returning to the attachment figure for comfort and safety in the face of a fear or threat
Separation Distress: anxiety that occurs in the absence of the attachment figure
EFT assumes that emotional bonding and connection is basic to human existence. It supposes that we want to matter to other people and that we need safe emotional connections.

23. Important Concepts in Attachment Theory that also relate to EFT
1. Seeking and maintaining contact is a prime motivation.
Isolation is traumatizing
2. A secure connection offers a safe haven to go to and a
secure base from which to go out into the world.
Needs for connection, comfort and caring are key. The more
connected you are, the more separate, autonomous you can be.
3. Accessibility and Responsiveness builds bonds.

24. Important Concepts in Attachment Theory that also relate to EFT
4. Disconnection cues Separation Distress – A predictable process.
Protest
Cling and Seek
Depression and Despair
Detachment
5. Emotion is the music of attachment dance.
Gives salience
Colors events
Cues organizes the dance

25. Key Features of Secure Attachment in Ainsworth’s Strange Situation
1. Child can regulate distress – trusts relationship with mother.
2. When attachment figure returns, child gives clear unambiguous cues regarding needs and asks without defensiveness
3. When attachment figure responds child trusts and takes in comfort, reassurance , and is calmed and soothed.
4. Child then turns attention to environment, (climbs down from
mother’s lap, plays with toys) takes risks, engages in tasks/activities with confidence.
According to EFT, the same process occurs in adult couples.

26. Couples Therapy (EFT) Based on Attachment Theory
1. Focuses on attachment needs and forms of
engagement and disengagement.
2. Privileges emotion – The music of the attachment
dance.
3. Creates the therapy session as a secure base.
4. Shapes new bonding responses – events.
5. Addresses impasses – attachment injuries.

27. Emotionally Focused Therapy for couples... What is it?
Emotionally Focused Therapy (EFT-C) is usually a short term (8-20 sessions), structured approach to couple therapy.
Originally formulated in the early 80’s by Drs. Sue Johnson and Les Greenberg. EFT is also used with families and individuals.
Includes elements of Experiential, Systems, and Attachment theory.

28. Emotionally Focused Therapy for couples... What is it?
EFT-C is one of the most empirically validated types of couples therapy – over 20 years.
Research studies find that 70-75% of couples who complete EFT-C move from distress to recovery and approximately 90% show significant improvements.
EFT Model outlines 3 stages (9 steps) in treatment.
(Ruzgyte & Spinks 2011)

29. Emotionally Focused Therapy for couples... What is it?
EFT views emotions as centrally important in the experience of self and others, in both adaptive and maladaptive functioning, and in therapeutic change.
From the EFT perspective, change occurs by means of emotional awareness and arousal, regulation of emotion, reflection on emotion, and transformation of emotion taking place within the context of an empathically attuned relationship.

30. Emotionally Focused Therapy for couples... What is it?
Emotion-focused therapy (EFT) focuses on the emotional bond between a couple and on each partner's emotional experience, attachment longings, needs, and fears as well their needs for validation of their identities.
EFT strives to uncover how each partner reacts emotionally to events that cause negative interactional patterns.

31. Emotionally Focused Therapy for couples... What is it?
These patterns are seen as being created when partners express secondary emotions, often anger, rather than openly expressing their primary emotions and needs, such as their basic attachment fears and needs and needs for validation of their identity.
The fractured emotional bond is healed by identifying negative interactional cycles that dominate the couple's interaction and transforming these by means of the expression of primary attachment and identity related emotions.
The essential goal of EFT is the creation of new, healthy patterns of interaction by using emotion to restructure interactions.

32. Stages and steps in EFT-C (Johnson 2008)
Stage 1. Stabilization (assessment and de-escalation phase)
Step 1: Identify the relational conflict issues between the partners
Step 2: Identify the negative interaction cycle where these issues are expressed
Step 3: Access attachment emotions underlying the position each partner takes in this cycle
Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs

33. Stages and steps in EFT-C (Johnson 2008)
The most important goal of the first stage is establishing a collaborative alliance, which allows the partners to more easily express their vulnerabilities.
While establishing this alliance, the therapist is also assessing the negative interactional cycles between the couple and the underlying emotions of each partner in creating the negative cycles.
The therapist helps the couple to reframe their problems in terms of their underlying emotions, and also to externalize the problem as the negative interactional cycle.

34. Stages and steps in EFT-C (Johnson 2008)
During this stage:
the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist.
The therapist also gets a sense of the couple's positive and negative interactions from past and present and is able to summarize and present the negative patterns for them.
Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

35. Stages and steps in EFT-C (Johnson 2008)
Phase 1 is the hard part. Therapists have to seek out vulnerable emotions, and very slowly build the awareness of them.
Johnson gives the example of moving from “uncomfortable” to “upset” to “hurt” eventually. You can explain to the couple that some emotions may be especially uncomfortable for them to uncover (because of their early experiences, or society’s gender roles, etc.) that have encouraged them to avoid doing so all their lives.
This takes some of the blame off of them, and provides another example of how the couple can be affected by something larger, but not slaves to it.

36. Stages and steps in EFT-C (Johnson 2008)
The “secondary” emotions of anger and resentment are easier to feel and show and are typically the emotions clients will reveal first.
“Primary” feelings are often covered up by more powerful secondary feelings that help a client avoid vulnerability in the presence of their partner.
Therapists create safety and security by validating each partner’s emotions and using the common goal of changing the pattern of interactions between them as “the enemy.”

37. Stages and steps in EFT-C (Johnson 2008)
Stage 2. Restructuring the bond (changing interactional positions phase)
Step 5: Access disowned or implicit needs (e.g., need for reassurance), emotions (e.g., shame), and models of self
Step 6: Promote each partner's acceptance of the other's experience
Step 7: Facilitate each partner's expression of needs and wants to restructure the interaction based on new understandings and create bonding events

38. Stages and steps in EFT-C (Johnson 2008)
In the second stage the therapist works closely with each partner to experience their underlying emotions and attempt to uncover their attachment and identity feelings and needs.
This allows each partner to express their vulnerabilities and self-doubts; ask for the comfort and validation they need; and ultimately become more approachable, emotionally expressive, and communicative with their mate.

39. Stages and steps in EFT-C (Johnson 2008)
This stage involves:
restructuring and widening the emotional experiences of the couple.
This is done through couples recognizing their attachment needs, and then changing their interactions based on those needs.
At first their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behavior from reemerging.

40. Stages and steps in EFT-C (Johnson 2008)
Stage 3. Integration and consolidation
Step 8: Facilitate the formulation of new stories and new solutions to old problems
Step 9: Consolidate new cycles of behavior
This stage focuses on reflection of new emotional experiences and self-concepts. It integrates the couple's new ways of dealing with problems within themselves and in the relationship.

41. Stages and steps in EFT-C (Johnson 2008)
The third stage involves consolidation of each partner's new position, and the positive cycles of interactions and their integration into their everyday relationship.
The consolidation and integration is achieved by having the therapist review the couple's transition from negative cycle to positive cycle, and eliciting examples of their personal and relational growth and change.
The therapist also encourages the articulation of a new narrative of the relationship.

42. In a nutshell… 3 basic stages of change in EFT
1. De-escalating the negative cycle
Critical demanding – withdrawal
Mutual withdrawal
Help couple see & understand pattern from an attachment perspective.
Frame negative pattern, insecurity & distance between them as “the problem.”
Partners in the couple become observers of the pattern they are caught in and help each other step out of it.

43. Techniques in Stage 1
Speaking slowly, calmly, and patiently, checking with the client to make sure they are remaining engaged and help clients tolerate emotional intimacy.
Reflective statements (“It seems you are feeling terribly scared by that”) helps the partner listening to understand the key points, the words to describe what they see in the other, and the power of these emotions.
Validation (“And it’s hard to even talk about this kind of fear, especially for you given your past experiences with relationships”) helps the partner listening see the link between the past and the present, and helps the partner speaking see it and accept it too.

44. Techniques in Stage 1
Evocative questions (“What’s happening now for you as I say that… What’s it like to say that out loud, here and now?”) draw attention to meta-emotion, or emotions about emotions and expressing feelings. It can help the partner speaking be mindful of the moment, attend to what they feel in their bodies as they talk, and “own” in a very concrete way their feelings.
Heightening (using images like “It feels like a noose around your throat that could strangle you at any time”) helps evoke imagery that captures their emotional experiences, or asking one person to repeat something to their partner.
The therapist tries to shift the emotional expressions from the secondary aggressive ones to the underlying primary vulnerable ones, moving the couples toward a softening or corrective experience.

45. 3 basic stages of change in EFT
2. Restructuring the bond: “Hold me tight” conversations
Withdrawer / re-engagement
Blamer / softening
Talk about fears: rejection, deserted/abandoned, etc.
Discuss fears to allow partner to offer reassurance,
calming, safety for fears.
Talk about needs in a way partner can hear and respond.
Create deeper levels of emotional responsiveness between partners.

46. Techniques in Stage 2
Stage 2 involves creating corrective emotional experiences.
Teaching the partner to use “I” statements to identify their needs for themselves, preparing the other to accept and maybe meet these needs, and coaching them both on how to effectively compromise on this is the process here.
For example, rather than the partner berating the other for being so cold, the partner acknowledges their loneliness and need for companionship, and asks the mate for help in this.

47. Techniques in Stage 2
Tracking (“Is this what it’s like at home? What’s missing?) uses the calmness in the moment in the session to look at the not-so-calm or upset and hurtful moments. It also helps to be sure the intense moment in session is just as “real” as those intense moments outside of session.
Reframing and restructuring to clarify and expand experiences. This sometimes means translating experiences for the partner listening into language they can understand, and sometimes giving an attachment context to their experiences for both partners.
Helping each partner to understand and express their emotions, and helping their mate hear that and realize the partner is not the mean monster, icicle, or emotional cripple they’ve been seeing. Rather, the partner is just a hurt and scared person like them. This is called a softening.

48. 3 basic stages of change in EFT
3. Consolidation
Look at all the changes made.
Create own love story/narrative about what happened, how they got stuck, and how they fixed their relationship and made it better.
Dream about the future and where they want to go.

49. Techniques in Stage 3
Stage 3 entails resolving old problems, which are now easier and more naturally solved because the emotional “contamination” stemming from attachment conflicts is gone. Some problems are still managed, but they are not so toxic, difficult, and demanding anymore.
The therapist becomes much less directive, and lets the couple direct therapy until they are ready to leave.
Future relapses, flare ups, etc… are discussed as inevitable, but easier to handle.

50. Common techniques in EFT
Creating safety
De-escalating
Helping couple understand the pattern between them
Validating and normalizing feelings
Slowing down process in session so partners can move into deeper, more emotional places
Reflecting reality in session, as couple creates it

51. Common techniques in EFT
Reflection of secondary feelings and interpretations of primary feelings
Showing patterns and re-framing problem as pattern the dance the couple gets caught in
Setting up new enactments and interactions that lead to bonding conversations
Shifting the emotional expressions from the secondary aggressive ones to the underlying primary vulnerable ones, moving the couples toward a softening or corrective experience.

52. Common techniques in EFT
Asking reflective / process / evocative questions:
What’s that like for you?
How are you feeling right now?
What happens to you inside when you say this?
What is the trigger for this?
Where does this anger start?
What do you say to yourself when you see the expression on her/his face?
When you try to really understand what you are feeling, what emotions are underneath your anger?
When you really listen to your partner, what emotions do you feel?

53. Videos Dr. Sue Johnson speaking of EFT

54. Videos Sample story of EFT by Dr. Sue Johnson

55. The Problem: W: Do you love me? (accusing tone)
H: Of course I do. How many times have I told you?
W: Well it doesn’t feel like it (tears, looks down, turns away)
H: (Sighs-exasperated) Well, maybe you have a problem then. I can’t help it if you don’t feel loved. (Set mouth, lecturing tone.)

56. The Problem:
W: Right. So it’s my problem is it? Nothing to do with you, right? Nothing to do with your ten feet thick walls. You’re an emotional cripple. You’ve never felt a real emotion in your life.
H: I refuse to talk to you when you get like this. So irrational. There is no point.
W: Right. This is what always happens. You put up your wall. You go icy. Till I get tired and give up. Then, after a while, when you want sex you decide that I am not quite so bad after all.
H: There is no point in talking to you. This is a shooting gallery. You’re so aggressive.

57. The Problem: “Love is the kiss of porcupines.” (Fincham 2000)
Two porcupines huddle together on a winter’s night - closeness is necessary for survival and normal, but in getting close, they risk getting hurt.
Freud - “We are never so vulnerable as when we love.”

58. The Problem:
Rigid pattern- blame/withdraw and absorbing states of negative emotion form feedback loop. No safe emotional connection - escalating danger and isolation.
How would you begin??

59. Video of EFT-C session with Sue Johnson
Example of validating, reflecting, distilling feelings, processing in the moment; exploring primary emotions; expressing underlying needs
What would you do next?

62. The End!