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Acknowledge attachment field

Hi, this is Dr. Dianne Gehart and this is my lecture on Emotionally Focused Couple and Family Therapy. This lecture goes with my textbook series, Mastering Competency, specifically the text Mastering Competency in Family Therapy as well as Theory and Treatment Planning in Family Therapy. EFT is an evidence based treatment, and before I go on to describe the actual treatment I thought I would begin by addressing some myths and concerns people frequently have about evidence based treatments. Evidence based treatments are manualized treatments that have been designed to treat a specific population or problem. In the case of EFT it's designed to treat couple and family problems basically and specific forms of those problems. We'll talk about that in depth. They're manualizes and sometimes people have this vision that a manualized treatment has certain qualities. I wanted to go over and address those in case you have some of those myths in your head. The first is in this age of evidence based treatments, we don't need traditional theories anymore. You'll see as we go through this lecture on EFT that EFT is a theory and it actually integrates three other commonly known theories and put those theories together in a way that the evidence shows is particularly effective in treating couple and family distress. Yes, you still need theory, in fact you probably need to be trained in more theories in this age of evidence based treatments and to be comfortable with moving between approaches depending on the population you're working with. As we develop more of an evidence base in the area of family therapy and psychotherapy more generally, it'll probably be required that all of us not just pick our favorite theory or theory of choice, but that we learn to get good at a range of theories. The other myth is that MFT theories and myth are separable, the two inform each other. There's no researcher out there developing a research approach, an evidence based treatment that's not grounded in theory. MFT theories all began from observational research. Those theories and research in the world, especially in the 21st century are going to be two sides of the same coin as we move forward. Practitioners are going to have to get better at understanding and using research, and researchers are going to need to focus their research on applicable treatments for populations in the real world. There's also a myth out there that evidence based treatments are rigid, and robotic, and you have no freed, and they're extremely limiting. This is simply not true. I had that myth in my head when I went to my first four day, in-depth training, the externship for EFT. I quickly learned that that is simply not the case. In fact there are areas for the EFT that are more flexible than other systemic approaches in terms of how they track the interactional sequence. They're like any other approach, there are certain places where it's more prescriptive, that you need to have some prescription for it to be a valid theory, and there are other places where there is more flexibility. It's different than other approaches. It's not necessarily more rigid or robotic than any other recognized treatment out there. Another theory is that you have to give up your theory of choice to use an evidence based treatment. I just simply don't think that's possible in the sense that as you train to be a therapist you're normally trained in one or two models that you closely identify with. You learn to see people and problems through those lenses. The evidence based treatment simply get added and integrated into this and you learn to have a more sophisticated, multi-layered, multi-faceted practice and that the evidence based treatments inform that. Another common myth is that researchers agree on what constitutes the research or the evidence base for the field. There are actually multiple strands of research and I describe these in some of my chapters in the books associated with this series. Suffice it to say not all the researchers agree on what constitutes valid research and meaning for research in the field. There's a myth that cognitive behavioral therapy is the only evidence based treatment and conversely if you're doing cognitive behavioral as evidence base for everything, again that is simply not true. Cognitive behavioral therapies have the most recognized evidence based treatments associated with them but they certainly don't have it for everything. For example, with teenage conduct and substance abuse disorders, there are systemic structural approaches are really what the research shows are the primary approach for those. EFT is another wonderful example where it's not a CBT, it is more humanistic approach and it's a very strong evidence base associated with it. So no, not every evidence based treatment is cognitive behavioral and cognitive behavioral therapy is not evidence based treatment for every possible presenting problem. Finally the last myth is that standard practices up to date, you'll hear some therapists say, well we've been doing it this way for years, it's been good enough until now. Both in physical medicine and in psychotherapy what constitutes standard practice has historically been about 17 years to 20 years, depending on what study you're looking at, behind the current evidence base. Standard practice is typically about 20 years behind. You can imagine how when people hear this, maybe people outside the field, stakeholders or people who are paying for this or receiving services, would like to narrow that gap. That's a majority priority in the fields of physical health as well as mental health and behavioral health. That is an overall goal and some of what these evidence based treatments are trying to do is make the current evidence base more readily available to the everyday practitioner. To close the gap so that standard practice is closer to the current state of knowledge in the field. For the rest of this lecture I'm going to focus on introducing you to emotionally focused couple and family therapy, in a nutshell, the least you need to know. So EFT originally began with the work of Sue Johnson and Les Greenburg. Each has focused on their own variation with Les Greenburg working more at an individual with individuals, and Sue Johnson working more with couples and families. This workshop is going to focus on the later work of Sue Johnson, although certainly Les Greenburg and Sue Johnson started out with these ideas together. EFT is an integrative approach that combines attachment theory, experiential therapy theory, and systems theory. You'll see all three of these in action together. The focus really is on conceptualizing couples and families as emotional systems that have both interpersonal and intrapsychic processes, systemic processes, that interrelate and interact. If you listen to the systemic lectures in this series you'll recognize the interactional sequence. Sue Johnson focus on the interactional sequence between couples and families, has found very easy ways to assess these, or relatively easy compared to some of the traditional approaches, and conceptualizes it using attachment theory as well as experiential. You will see many of the traditional elements of the systemic approach, adding in attachment theory with some humanistic elements particularly in how she intervenes. Most of the research with EFT has been conducted with couples, this has been extensively researched with couples for over three decades. Many of these principles can be used in family therapy and has definitely been studies with families, but most of the research has been with couples. It's one of the two readily identified evidence based treatments for distressed couples, this along with integrative behavioral couples theory. Those are the two primary evidence based treatments for couples. Next we're going to talk about the juice which is one of the most significant contributions of this theory to the field of mental health in general. The one thing that Sue Johnson does in this EFT theory that is truly unique is that she has applied attachment theory, which has primarily been used with infants and young children from 1-3, 1-5, and applied that theory to adult love. She is really a leader in this area of applying attachment theory to adults and developing an intervention based on this. As you may recall from introductory psych classes, attachment research and attachment theories, both physiological, emotional, and survival needs that we've always known, or we've known for a very long time in psychology, let's say, that an infant needs to literally physically survive in this world. Sue Johnson is a leader in identifying adult attachment theory. Adults have the same need for secure relationships to feel emotionally safe, to help them regulate their emotions, and for adult health. There's a lot of evidence shows that adults need to have secure attachments. It enhances their quality and length of life. This has been an exciting both in physical and mental health research, looking at adult attachment. The whole heart of her theory is based on this conceptualization, this understanding that adult attachment is necessary in couple relationships. It's the primary driving factor in understanding couple relationships. It helps to make sense of what is often very confusing when we look at couple relationships. Next let's talk about the big picture, an overview of what treatment looks like in EFT. As you may remember EFT is an evidence based treatment. It is manualized. Yes, there are very concrete stages and steps that go with EFT that help the therapist navigate treatment, monitor progress, and structure the treatment as efficiently as possible. It's this outline that's used in the evidence based studies. The first step is the de-escalation of the cycle. This involves four different steps. The first step is for the therapist to create an alliance and identify the attachment struggle with the couple. This is developing a very important therapeutic alliance that will be relied on quite heavily because it is an emotionally intense approach. The therapist has to create an extremely safe therapeutic environment for the couple and all members of the family. That's a very important process. The next step is to identify the negative cycle. This is basically tracking the interactional sequence, which we do in the more traditional forms in the systemic approaches. Very similar, tracking that systemic interactional cycle. Step three is accessing unacknowledged emotions and positions. We'll be talking about secondary emotion and primary emotion. The secondary emotions are the ones we most readily recognize, we're angry, we're frustrated, we feel attacked, we feel defensive. Those are the secondary emotions. Those are the first ones that are readily identified by the couple or family when they're presenting the problem. There is a period where you track the primary emotions, those are the attachment based emotions. That's the longing for connection, the wanting to feel safe, those emotions then get tracked. First you identify the negative interaction cycle both in terms of behaviors as well as secondary emotion, then you go back through and track the primary attachment emotions underneath that. Finally in stage four you reframe the presenting problem with the couple in terms of attachment and the negative cycle. To a certain extent this externalizes the problem instead of that, the problem is my wife nags or the problem is my husband withdraws. Now in step four we get the couple to see, and I'll use couples as the primary example, that the problem is not his or her behavior but the couple has a negative interactional cycle that they get into. When they get into this it triggers their attachment fears so they get into these survival positions in order to manage the threat to what feels that their partner is no longer a safe attachment figure essentially. Basically this negative interaction cycle happens when one or both partners begins to perceive the other as no longer being safe. In stage two is where you begin to change this negative interactional pattern and begin to create emotional engagement and emotional safety. You repair the attachment or strengthen the attachment for the couple and family. Typically you go through step five, six, and seven, you start with the partner who tends to withdraw. I think this is one of Sue Johnson's most brilliant contributions that came out through the research because I don't think it's intuitive. The pursuer is the one usually complaining, who wants connection, and the withdrawer is pulling away and wanting distance. Because the pursuer is the one complaining, most of us naturally start with the one who is complaining because the withdrawer will often not have too many complaints. What Sue Johnson has found is that if you begin with the person who is withdrawing from connection and you re-engage that person, you make them feel safe again, you make them feel present, then the pursuer doesn't need to pursue because the other person's open and available emotionally. She generally will begin this process with the person who tends to withdraw more in the interactional sequence, get them re-engaged, and then work with the pursuer. Step five is you promote the identification of disowned attachment need. That's working first with the withdrawer then with the pursuer, in identifying their attachment needs and expressing those to their partner in an open, direct, and congruent way. In step six you promote the acceptance of that partner's experience. For example, if the withdrawer is expressing his needs then his partner would need to acknowledge and accept that, step seven is having direct expression of the needs while strengthening attachment. You would do this with both partners as often as necessary to get them reconnected and out of that negative interactional pattern. In stage three you're facilitating new solutions to those old problems. The step nine you consolidate the new positions and attachments. This does that not happen in a perfectly linear way. Most clients move back and forth. It's more fluid than nine steps, it's not literally a checkbook thing. This is generally the basic progression in how therapists conceptualize and move through and track progress. Because of this clear outline of the therapy process it's clear when therapy is not progressing or isn't working. You can see you're stuck in stage three or four and you're not moving into the next step or stage. In EFT there are three primary therapeutic tasks. The first is creating and maintaining the therapeutic alliance with both partners or all members of the family, which is extremely challenging when working with couples and families in such an intense way. The second task is assessing and formulating emotions, so understanding that primary and secondary level of emotion and how they're interacting. The third task is restructuring the problem interaction cycles the couple or family is stuck in. Those are the three critical tasks that are the focus of EFT treatment. Now we're going to move on to making connection and developing the therapeutic relationship in EFT. Overall you'll notice the relationship in this approach is very much grounded in humanistic principles. It requires a lot of the therapist. It's a very intense therapeutic relationship. If you get a chance to watch Sue Johnson in action, or any EFT therapist in action, you'll notice there's a very particular therapeutic relationship. The therapist is exceptional in terms of empathic atunement with the client and expression of empathy. Often you'll notice the therapist speaking and engage in the clients in a very particular way. EFT is not an approach where the therapist remains aloof, emotionally attached, the therapist is right there with the client feeling and tuning in not to just the surface level emotions but the very primary attachment needs, and putting into words these very primary attachment needs, often the client almost experiences without language sometimes. The therapist is sometimes putting this into words for the client for the first time. The approach very much relies on the principles that Carl Rogers introduced such as genuineness and acceptance of the client, the therapist will often use self-disclosure like other humanistic therapists, as a way to talk about emotion, share about emotion, help clients explore emotion. Because it is an extremely intimate and emotionally intense relationship, there is a constant monitoring of the alliance, making sure that the therapist is both aligned with all members of the therapeutic system, so each of the partners and all members of the family system. There is still the concept of joining the system, learning to talk and interact in ways that are comfortable for them. The therapist's role is very much that of not just being empathetically attuned, but helping the clients learn how to work with these very difficult emotions that we all have in our most intimate relationships. Anyone who is human and paying attention, our relationships with family and partners are both some of the most wonderful and some of the most deep and painful emotions one can experience. The EFT therapist is right there with clients in all of that in a very intense and intimate way. Next we're going to talk about the viewing, case conceptualization and assessment in EFT. Here you're going to see a lot of the attachment theory as well as systemic case conceptualization that they use to understand the dynamics and where couples and families get stuck. In EFT, they are conscience about assessing how intrapsychic, how individuals are processing their experiences, particularly focusing on key attachment oriented emotional responses, so their attachment patterns, as well as looking at the interpersonal, interactional patterns about how two partners or family organize into both negative and positive interaction cycles. The therapist is constantly monitoring what is going on with the individuals emotionally as well as how they are interacting to create the broader systemic dynamics. Primary and secondary emotions, as I mentioned earlier, play a significant role in the conceptualization in EFT. As I mentioned earlier, primary emotions typically represent attachment fears and needs. These are usually more softer, venerable emotions. You fear abandonment from somebody else, you want to be attached, you're afraid to show your true self to somebody else. These are generally venerable fears of being rejected and also the fear of needing someone, for a lot of people that's scary to acknowledge, that you need someone else to be okay or to have a sense of being okay you want someone else. You need them at that emotional attachment level especially for those who come from cultures where there's a sense of independence. I can take care of myself, I don't need someone else. Men tend to have more of that, at least in western American society, than women. There is this idea that I can be totally independent, I don't need anyone else. These emotions can be particularly to recognize because of social cultural norms. The secondary emotions are our emotions about the primary emotions. They often take the form of anger, frustration, withdrawal. These secondary emotions allow you to not feel the sense of vulnerability associated with those primary emotions. If you can get angry and frustrated, you don't feel the scarier emotions of being vulnerable, of being abandoned, that often feels worse. We tend to be more conscious of these secondary emotions. Early on in therapy we track, like I mentioned, the secondary emotions because that's what the clients initially present. Once that becomes clear and those patterns are clear then you can go back in and try to identify and have clients identify with, those more primary emotions, which are much more difficult to access for most people. If you've been following along in the text you'll remember earlier on in the traditional systemic approaches like MRI, Milan, and strategic, they assessed a negative interaction cycle. Sue Johnson does this also in EFT. The way she does it is quite frankly a bit easier. She focus on, ultimately if you can conceptualize around adult attachment needs there is one partner pursuing for attachment and another who is withdrawing. That's the basic dynamics at least at how relationships start. This still fits with traditional systemic theory, the pursue/withdraw has always been viewed as, there is only a certain amount of intimacy a given couple can tolerate. Even when we were looking at first and second order change, you can flip who is pursuing and withdrawing but the same level of intimacy is generally tolerated. It takes a major second order intervention to shift how much intimacy can be tolerated within the couple. Typically the pursuer protests any type of separation or distancing type of relationship. This tends to be associated with a more anxious attachment style. The emotions this person typically feels is hurt, alone, and feeling unwanted by their partner. Their withdrawer tends to be distance, protect himself, and whatever perceived lack of safety that they're seeing in the relationship. This is typical of the avoidant attachment style. This person typically feels rejected, inadequate, or judged by the pursuer. You get that pattern. It is possible, particularly when one of the partners has been traumatized, they can flip roles in the cycle so you get a figure 8. One pursues, the other distances, then as part of their cycle, that actually changes and they flip roles within the same argument or cycle that they go through. It tends to be indicative of trauma according to Sue Johnson's research. If you just track this pattern, this is the basic pattern, who is pursuing for closeness and who is withdrawing. I always like to joke that typically you asses this quickly because it's the pursuer who is calling to set up the therapy appointment, unless the pursuer threatened divorce in which case the withdrawer would be picking up the phone to call you. I joke about that, I say it jokingly but I encourage you if you use this approach to consider that as you take your intake phone calls and tell me if that seems to match up with your experience because that's been my experience. Early on in the therapeutic relationship the EFT therapist will do an attachment history if they're working with a couple or family. Often this is done in individual sessions, usually there's a single individual assessment with each partner. They get a sense of what their attachment was like with their primary caregivers and is there an adolescence an intimate relationship they had in their early dating years or whatever phase of adulthood they're in. You want to look at the various major attachment figures they've had in their life and their patterns. What has been, in particular there person's experience in terms of secure attachment, avoidant, and anxious attachments. As part of this you're looking for how accessible were the other people, how responsive, and how engaged are they used to experiencing in their intimate relationships. Another thing that EFT therapists assess for is an attachment injury. They're looking for a significant attachment event -- what this means in a moment in high need such as when a woman is pregnant or a partner lost their parent that the other partner did not offer support in this moment of particularly high need. This is a very specific type of betrayal, or abandonment, or violation in the relationship. This fundamentally redefines the relationship for the injured party as unsafe. This is something the EFT therapist assess for and this needs to be identified and addressed before moving on to the second stage of intervention. Certainly if the therapy process becomes stuck this is something they would look for to see if these missed one of these but it's also something to look for early in the relationship to get a sense. That needs to be repaired. Yes, they have a specific process for that. That's something they're assessing here and repairing this if needs to be in order to move into the intense work of the second stage. In terms of the initial assessment sessions, which I alluded to a couple slides ago, there's an initial assessment to make sure the couple is appropriate for EFT. Typically this initial assessment will include first, a joint couple session, then some individual sessions, and then a return to regular, ongoing, conjoint sessions. In the conjoint session you're assessing for both the perceptions the problems in the relationship as well as strengths. You're looking for the negative and positive interaction cycles. You're looking at the key relationship history and key events, including the attachment injuries. You're getting a brief attachment history for each partner. Then typically if all looks good there, they would move on to an individual session. You can take one session divided in half or take two full one-hour sessions with each. You're assessing for each partner's commitment to the relationship, the potential for past or current affairs, you're trying to get a trauma history, as well as a detailed attachment history screening for violence and such, overall making sure they're appropriate for the EFT process. There are contraindications to EFT, this means through the assessment if a therapist discovers some of these key elements they would not proceed with EFT. EFT is not for every couple that walks in the door. The one is if the couple has different agendas for the relationship in therapy. If one member of the couple is really ready to end the relationship or mostly out the door, this may not be an appropriate therapy for them. This takes someone who is really committed because you have to be vulnerable and that takes a high level of commitment. Couples who have different agendas for the relationship or therapy or are really in the process of committing, oh I'm not sure, maybe I'll give it one last try but I don't think there's much of a chance. They're probably not the right couple for this because this does require quite a bit of commitment from both parties. If there's any type of physical or emotional abuse then EFT is not indicated, as well as if there is an untreated addiction for one or both partners, then it also would not be an appropriate treatment for those couples. The therapist doesn't just jump right in and start with EFT but makes sure the couple is well suited and appropriate for the treatment. Once the therapist has assessed the couple then the next process is to set the goals for treatment. As an evidence based treatment, EFT has very basic, consistent, overarching goals. After all, most of the people using this approach are using it for the similar populations. The first is to create a strong, secure attachment for both partners. The second overarching goal is to develop new interaction patterns that are nurturing and supportive for each partner. The third basic goal is to increase direct expression of emotion, especially those related to attachment needs. Those are direct expression of primary emotions. Next we're going to talk about interventions in EFT, the doing. As an evidence based treatment the link between specific goals and interventions is much closer than many other approaches. There are actually certain interventions that are used in each phase. Some of them are used differently across phases. In this early phase of intervention, when you're deescalating and identifying the problem interaction cycle, there's a lot of validation that each person needs to experience in their emotions. There's a lot of reflecting of emotions and helping clients identify both the secondary and primary emotions. There is a lot of tracking of the cycle. This can be done in multiple ways, this is one of my insight, realizing there is quite a bit of flexibility. If you look at other systemic approaches many of them are more limited. In EFT they don't care if you track the interactional cycle on a single event, on a general hypothetical event, or typical event. They're just tracking the cycle, you can do it more behaviorally, you can do circular questions, you can do it more solution oriented, you can use video talk questions, you can do it any way that makes you happy and makes the couple happy as long as you're tracking that full cycle just like you do in all the others from basic homeostasis, rising tension, conflict or symptom, and then how they get back to homeostasis again. You're tracking that cycle whatever it looks like. You can do it behaviorally and you'll certainly in one of your passes through the cycle look at the interaction of the secondary emotions and then ultimately the goal is to go through and track how the primary emotions are underlying this cycle. Evocative responding is responding in a way that evokes a deeper emotions, often primary emotions. Empathetic conjecture is where you might offer up in a tentative way, might you have been feeling rejected at that point when you were looking so angry? That empathetic conjecture is used to help clients identify both their primary and secondary emotions. Then in the working phase you're going to say these are interventions that used to restructure their interactions. Again, you're seeing that evocative responding, responding in a way that gets evokes emotion and helps them get in touch with their emotion. The empathetic conjecture, helping them to identify by tentatively putting out some possibilities for the emotions that might be primary and secondary emotions that might be fueling the interactions. Heightening emotions, helping when clients indicate there is something there to help heighten and help express that. Reframing their emotions. Often using primary emotions as a way to reframe and/or the interaction sequence. And then restructuring interactions. This would be using the enactments that are familiar to us from structural family therapy but specifically focusing on restructuring the interactions to keep them engaged and help them get in touch with and directly express their more primary emotions fueling these negative interaction cycles. Then finally in the closing phase there's a lot of validation, this time often validating the new interactional patterns they're developing, using evoking responding, reframing to help them understand these new patterns, and restructuring interactions to a more positive interactions between the couple or family. Finally we're going to close by talking about diversity considerations when working with EFT as well as the evidence base. EFT has been studied on a range of ethnically diverse couples. Generally the basic premise are used across diverse couples. Research does not indicate that different protocols are necessarily required for different ethnicities. In general, attachment needs have been found to be universal the theory and across the cultures in just studying attachment needs across cultures. Cultural norms generally have very specific rules for how to handle emotional expression. Therapists need to be very well aware of the expression norms for both males and females within the client's cultural group to accurately express what's going on and how to best help them reconnect. The therapist when working with diverse clients, identifying specific cultural meanings and functions of various expressions, and also for attachment behavior. Although the need for attachment is cross culturally documented, how that gets done and how attachment happens across cultures can look very different. There have been special studies working with same-sex couples. EFT has been researched for almost three decades and it's one of two empirically validated couples therapy approaches. It's very highly regarded as an evidence based treatment. In clinical trials or Sue Johnson's research they have a very impressive 70%-73% recovery rate for distressed couples in 10-12 sessions, 90% of couples showing significant improvement that is extremely impressive, especially if you've ever worked with couples. Once you've worked with your first few you'll be more impressed. To be fair, this is not typical in the sense of these are highly trained EFT therapists that the studies have been conducted on, but still with more average trained people in the field, the recovery and improvement rates just take a little bit more time, more like 20 sessions, but still that is extremely impressive in the area and realm of couples treatment. Like I said, if you haven't worked with a couple yet it's more impressive the more you do it. What's interesting is the couples' initial level of stress doesn't seem to matter as much as their engagement in the sessions, or the male partner's level of trust in general. Those are two of the indicators they have found which is surprising and counter-intuitive. You would think the more distressed couples would take longer to treat, not necessarily so. The more engaged, the more willing the couple is, especially the male partner to engage in addressing these attachment needs, the more quickly the couple responds. Nearly 2/3 of the couples resolving attachment injuries are able to do so with a brief intervention which is quite impressive and important and the results do tend to be stable. In terms of using, there is a special protocol you can read about using EFT with attachment injuries, again a very positive outcome. Again, they have a very specific treatment and it is for a specific type of population and problem. But overall EFT is a very well-respected couples approach that has very impressive outcomes considered within the world of mental health. Hopefully this was a useful and helpful introduction to EFT to you and I encourage you to do further reading and there are more details, obviously, in the chapter.