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Full Chapter The Practice of Emotionally Focused Couple Therapy Creating Connection 3Rd Edition Johnson PDF
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“Susan M. Johnson’s 15-year update of emotionally focused couple therapy
shows how powerful systematic research can be in developing a great theory.
This book is a must read for all therapists.”
—John Gottman, author of 8 Dates: Essential Conversations for a
Lifetime of Love
“In this remarkable book, Susan M. Johnson provides the definitive summary
of state-of-the-art practice in what is surely now the most widely disseminated
form of couple therapy. The Practice of Emotionally Focused Couple Therapy
not only comprehensively describes how to do emotionally focused couple
therapy, but also concisely summarizes the substantial evidence about
emotion and attachment upon which this approach is based and the extensive
research demonstrating its impact. This significantly revised and expanded
new edition of a classic book highlights the many significant advances in this
evidence-based approach since its second edition. Speaking in a voice that is
accessible and clinically meaningful to couple therapists, beautifully written,
and filled with compelling clinical examples, this book should be an essential
part of every couple therapist’s library.”
—Jay L. Lebow, Ph.D., ABPP, senior scholar and clinical professor,
Family Institute at Northwestern, Evanston, IL
The Practice of Emotionally
Focused Couple Therapy
Since its original publication in 1996, The Practice of Emotionally Focused Couple
Therapy has been the definitive guide for couple therapists, supervisors, and
students wishing to practice emotionally focused therapy.
This cutting-edge third edition addresses recent changes in the field
of couple therapy, including updated research results relating to clinical
interventions, expanded understandings of emotion regulation, adult
attachment and neuroscience, and dynamic EFT applications for a range of
issues such as depression, anxiety, sexual disorders, and PTSD. Chapters
introduce micro-interventions for use in EFT couple sessions, as well as a
systematic presentation of a macro set of interventions called the EFT Tango.
Clinical examples are included throughout, bringing the in-session process of
change alive, and two case chapters offer in-depth commentaries of Stage 1
and Stage 2 EFT sessions.
Written by the leading authority on emotionally focused therapy, this
third edition is an essential reference on all aspects of EFT and its uses for
mental health professionals in the field of couple and marital therapy.
Susan M. Johnson
Third edition published 2020
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2020 Susan M. Johnson
The right of Susan M. Johnson to be identified as author of this work has been asserted by her in
accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by
any electronic, mechanical, or other means, now known or hereafter invented, including photocopying
and recording, or in any information storage or retrieval system, without permission in writing from the
publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used
only for identification and explanation without intent to infringe.
First edition published by Routledge 1996
Second edition published by Routledge 2004
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested
ISBN: 978-0-8153-4800-9 (hbk)
ISBN: 978-0-8153-4801-6 (pbk)
ISBN: 978-1-351-16836-6 (ebk)
Typeset in Palatino
by Apex CoVantage, LLC
This book is dedicated, as in previous editions, to my generous and
loving partner, John Palmer Douglas—the love of my life.
And to all of my amazing colleagues in the International Center for
Excellence in Emotionally Focused Therapy (ICEEFT), who are taking
EFT all over the world with such passion and grace.
Contents
Introduction�������������������������������������������������������������������������������������������������������������1
Individual Sessions���������������������������������������������������������������������������������������120
Therapeutic Processes�����������������������������������������������������������������������������������121
Therapeutic Markers ���������������������������������������������������������������������������121
Intrapsychic Markers���������������������������������������������������������������������������122
Interpersonal Markers�������������������������������������������������������������������������123
Interventions �������������������������������������������������������������������������������������������������124
The EFT Tango in Early Sessions�����������������������������������������������������������������124
Move 1: Mirror and Reflect Present Process�������������������������������������124
Move 2: Affect Assembly and Deepening�����������������������������������������125
Micro-Interventions in Early Sessions�������������������������������������������������������127
1. Reflection�������������������������������������������������������������������������������������������127
2. Validation �����������������������������������������������������������������������������������������127
3. Evocative Reflections and Questions �������������������������������������������127
4. Tracking and Reflecting Interactions �������������������������������������������128
5. Reframing�����������������������������������������������������������������������������������������129
Couple Process and End State of Early Sessions���������������������������������������129
Epilogue���������������������������������������������������������������������������������������������������������289
It is now 15 years since the 2004 edition of this book came out. So much has
happened in this decade and a half that, indeed, it is time for a substantial
revision. The model, EFT, for which this book provides the basic manual for
clinical practice, has grown enormously.
It has grown in conceptual depth, expanding along with adult attachment
theory, as an integrated way of understanding our basic vulnerabilities and
needs and how they play out in our most intimate relationships. Books for the
public, Hold Me Tight (2008) and Love Sense (2013), based on this model have
also taken attachment science into the popular conversation about love and
loving. EFT has expanded significantly in terms of its research base. In terms
of the number of positive outcome studies, investigations into the process of
change, and positive follow-up studies, this model now represents the gold
standard for empirical interventions in the couple therapy field.
The model has also grown in terms of its generalizability, that is the differ-
ent populations and problems to which it is applied. It is now used routinely
to address relationship distress compounded by clinical depression, anxiety,
and post-traumatic stress disorder, and has been used as a bridge between
couple and sex therapy modalities. It is used across cultures and different
racial groups, for both gay and straight, secular and faith oriented couples,
and for very educated and blue collar couples. Recently the educational pro-
gram based on this model, Hold Me Tight: Seven Conversations for a Lifetime of
Love, has been tested and formulated especially for couples facing cardiac
problems, and this program is also being applied to other physical health
issues. An educational program based on the creation of secure attachment
also has obvious relevance for, and is routinely used with, military couples
facing the stressors of separation and deployment. The training programs
teaching this approach have become systematic and highly successful, result-
ing in a large number of professionals not only taking externships and other
trainings but, becoming certified therapists with the International Center for
Excellence in Emotionally Focused Therapy (www.iceeft.com) with more
than 65 affiliated centers supporting learning and research worldwide.
It is also worth noting that in a recent study, EFT was shown to impact
not only relationship distress but the attachment orientation of individual
partners, supporting the attachment concept that love relationships provide
fertile ground for the development of a more secure and integrated sense
of self and a sense of connection to and trust in others. This orientation to
2 ◆ Introduction
attachment science has facilitated the extension of EFT, as laid out in my most
recent book (Johnson, 2019a), to both individual and family therapy modal-
ities. EFT has always treated both self and system, the individual who con-
structs his or her emotional reality and the relational drama that shapes and
reflects this reality. It appears that this model with its focus on attachment as
a developmental model of the social self and on the compelling and transfor-
mational nature of emotion can contribute not just to the growth of the field
of couple intervention but also to psychotherapy in general.
In this volume, you will find micro-interventions that can be used in EFT
couple sessions, as well as a systematic presentation of a more macro set of
interventions titled “the EFT Tango.” The conceptual platform of attachment
theory and recent understandings of emotion and emotion regulation have
also been significantly expanded. You will find many clinical examples to
bring the in-session process of change alive.
As always, however, the essence of EFT and the reason it inspires such
passion in its practitioners remains the same. It offers a compelling way of
seeing our stuck places and a vibrant model of health for which to aim, a clear
set of interventions, and a way of being with our clients that is enlivening for
both therapist and client. In a world of quick fixes, it follows the dictum of Sir
William Osler (1849–1919), who suggests that “the good physician treats the
disease; the great physician treats the patient who has the disease.” It allows
therapists to, as Rogers states, revel in finding the “order in experience,” and
to grow with their clients.
The last years have been an intoxicating journey of discovery for the EFT
community of dedicated clinicians, supervisors, researchers, and trainers. My
own trust in the power of deliberately crafted emotional experience and the
map to human functioning offered by attachment theory grows with every
client, workshop, and research study. Therapy is so much easier when we can
tap into the innate power of emotion and potent motivations, like the longing
for connection, to fire up the change process. My hope is that this book will
inform and inspire you and open the door to confidence in our joint ability
to understand ourselves as relational beings and to finally bring each other
home.
1
The Field of Couple Therapy and EFT
From the beginning I had known that the pure forcefulness of my argument would
not penetrate deep enough to affect change. It almost never does. . . . Only when
one feels an insight in one’s bones can one own it. Only then can one act on it and
change. . . . [I]t is extraordinarily hard, even terrifying to own the insight that you and
only you can construct your own life design. . . . [I]t is only when therapy enlists deep
emotions that it becomes a powerful force for change.
Irvin Yalom, Love’s Executioner (1989)
can truly talk about couple therapy as an art and a science, based on descrip-
tion, prediction, and explanation. EFT has emerged from and contributed to
this revolution, and, as a model, it continues to evolve and grow.
The beginning couple therapist no longer has to accept the idea that, to
quote the songwriter Lynn Miles, “Love is a warm wind—you can’t hold it in
your hand,” and that the process of the repair of love relationships is therefore
a nebulous and random affair. There are now empirically validated patterns
of marital distress and road maps of adult bonding to help the therapist jour-
ney with a distressed couple toward a more stable and satisfying relationship.
This text offers the EFT clinical road map in a format updated from the 2004
edition and revised in light of the recent book, Attachment in Practice: Emo-
tionally Focused Therapy With Individuals, Couples and Families (Johnson, 2019a).
The goals of this new edition are to:
The study of emotion has continued to advance (Plutchik, 2000; Gross, 1998;
Gross, Richards, & John, 2006; Lewis & Haviland-Jones, 2000; Sbarra & Coan,
2018). The key role of emotional regulation and engagement in marital hap-
piness and distress (Johnson & Bradbury, 1999), and the emotional nature of
human attachments (Bowlby, 1980, 1988; Johnson, 2003c), have become more
elaborated. Other approaches besides EFT have also begun to incorporate a
focus on emotion (Cordova, Jacobson, & Christensen, 1998; Gottman, 1999),
although many others do not address this issue at all. In general, in the last
decade, the necessity of addressing emotion in the process of relationship
repair has been clarified, and specific methods and interventions to address it
effectively have become more available.
As a model of intervention, EFT arose from systematic observation of
couples in therapy and the process by which they succeeded in repairing
their relationships. Recent models of marital distress, such as Gottman’s
model, also have a grounding in the observation and the coding of specific
interactions between intimates, as do models of adult close relationships
such as attachment theory. It is perhaps not surprising, then, that there is
consonance among EFT as a model of intervention, researched descriptive
models of distress, and relational theories such as attachment. Distressed
couples taught this author and the original research team how to describe the
process of change outlined in EFT and the interventions that promoted this
change process. The first EFT manual was written as part of the first outcome
study, which was this author’s doctoral dissertation, and compared EFT to
untreated couples and couples who completed a behavioral communication
and skills training intervention (Johnson & Greenberg, 1985). The results of
EFT in this first study were impressive enough to spark another three decades
of research on EFT.
At this point, there are 21 studies from North American researchers show-
ing consistently positive outcomes for EFT in terms of the power of this model
to reduce marital distress and shape relationship satisfaction (see the website
www.iceeft.com for a list of these and all other studies and Wiebe & Johnson,
2016, for a summary article focused on this research). Outcome studies also
suggest that EFT can be effective in reducing traumatic stress symptoms and
depression when these issues co-occur with marital distress. The most rig-
orous of these studies have also been integrated into four meta-analyses. It
is worth noting that in the last large study of outcome (Burgess-Moser et al.,
2015) unique results were found in that EFT couple therapy interventions
were shown to increase attachment security, reducing attachment anxiety and
attachment avoidance on self-report measures and on the coding of interac-
tional behaviors focused on attachment. An fMRI brain scan study found that
female partners’ brains’ response to threat changed when holding the hand
8 ◆ The Field of Couple Therapy and EFT
ensure that therapists were, in fact, following the EFT protocol. Two studies
also exist examining the impact of the core training—the EFT externship—on
therapist’s sense of competence, confidence, and on their personal lives (Sand-
berg, Knestel, & Schade, 2013; Montagno, Svatovic, & Levenson, 2011).
All of these studies give EFT the status of being the gold standard in terms
of empirical validation in the couple therapy field. Regarding the standards
for this validation laid out by the recent APA committee (Sexton et al., 2011),
EFT is the only approach that meets the criteria and so qualifies for placement
in the highest category outlined by this committee. In general, in the couple
therapy field there is a dearth of outcome data on nearly all models of inter-
vention. Indeed the behavioral models, TBCT and IBCT (Christensen et al.,
2004), are the only other models that have published data on the outcome of
couples interventions.
For the practicing clinician, the most significant facts about the research
on EFT appear to be:
◆ There is clear evidence that the alliance with the therapist is import-
ant in predicting the outcome of EFT, and a female partner’s faith
in her partner’s caring is also very predictive. Initial distress level,
usually the most important predictor of outcome in psychotherapy,
was not found to be very powerful in predicting couples’ levels of
satisfaction four months after the end of therapy. Active engagement
in the tasks of therapy seems to be more linked to outcome than
initial distress level. EFT also seems to be effective with traditional
couples and with men who have trouble with withdrawal and diffi-
culty in expressing emotion (Johnson & Talitman, 1997). These kinds
of results emphasize the model’s focus on shaping and maintaining
safe connection with both clients all through therapy and reminds
the therapist that it is the level of client engagement moment to
moment in therapy that matters, not the interventions per se. The
therapist engages each client where they are at present rather than
focusing on where they should be, and leads each client forward,
small step by small step, so that the client is fully engaged in the
process. This research also assures the therapist that with the meth-
ods of EFT, it is not difficult to help clients connect with and “assem-
ble” their emotions and then begin to use the power of emotion to
literally “move” people into new ways of seeing self and other and a
new interpersonal dance.
◆ There is considerable research on the process of change in EFT.
The question of how change occurs is particularly important to the
practitioner, especially since studies have made it clear that the key
variables set out in a model of therapy may not be the active agents
that create change at all. In a famous behavioral study on methods
of alleviating depression, confronting clients’ dysfunctional beliefs
was, contrary to theory, not associated with change. In fact, it was
associated with ongoing dysfunction. However, deepening of
emotion in session did predict positive change. Key change events
leading to positive outcomes have been studied in EFT and key
interventions identified (Bradley & Furrow, 2004; Johnson, 2003d).
New tasks and processes, such as the resolution of attachment
injuries by a forgiveness and reconciliation procedure, have been
identified and tested (Makinen & Johnson, 2006). The EFT therapist
knows specifically what is necessary and sufficient to create the
change in affect regulation—models of attachment and interactional
responses that make for significant and lasting improvements in
relationship satisfaction.
The Field of Couple Therapy and EFT ◆ 11
only approach to couple and family therapy that is based on a clear, develop-
mental theory of relationship bonds that is substantiated by many thousands
of studies on the nature of attachment focusing on infant and mother bonds,
and also hundreds of more recent studies on adult romantic attachment.
The purpose of this book is to teach clinicians how to implement EFT in as
systematic a way as possible, given the uniqueness of every couple and every
relationship, and the intricacies of the therapy process.
The strengths of EFT can be summarized as follows:
Oluidastesme señora,
mucho mas os quiero agora.
Sin ventura yo oluidado
me veo, no sé por qué,
ved a quien distes la fe,
y de quien la aueys quitado,
El no os ama, siendo amado,
yo desamado, señora,
mucho más os quiero agora.
Paresceme que estoy
uiendo
los ojos en que me ui,
y uos por no uerme assi,
el rostro estays escondiendo,
y que yo os estoy diziendo:
alça los ojos, señora,
que muy mas os quiero agora.