Chapter 18

EMOTIONALLY FOCUSED
THERAPY FOR COUPLES:
AT THE HEART OF SCIENCE
AND PRACTICE
Paul S. Greenman, Susan M. Johnson, and Stephanie Wiebe
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Emotionally focused therapy (EFT) for couples underpinnings of the approach, including attachment
(Johnson, 2004) is an experiential and systemic theory and some recent findings from the field of
therapy for couple distress. Grounded in attachment social neuroscience. Next, we present the therapeutic
theory and social neuroscience, EFT provides objectives, steps, and stages of EFT. This will lead
practitioners and clients with a clear map for into a discussion of research on the efficacy and
navigating the potential challenges of adult love process (i.e., evidence for specific interventions and
relationships. It is a humanistic approach with a client responses at key points in therapy) of EFT. We
decidedly nonpathologizing stance on interpersonal conclude with suggestions for future research.
dependency and the fundamental human need for
emotional connection. EFT is empirically supported
ATTACHMENT THEORY:
(Lewandowski, Ozog, & Higgins, 2015; Snyder,
THE EMOTIONALLY FOCUSED
Castellani, & Whisman, 2006), with extensive
THERAPIST’S COMPASS
process research (Greenman & Johnson, 2013) to
guide clinical interventions at specific moments Romantic bonds in EFT are understood through the
over the course of therapy. EFT has been applied lens of attachment theory (Johnson, 2004; Johnson,
with positive results to partners with an array of 2013; Johnson & Greenman, 2006). The basic
problems ranging from major depression (Denton, tenet of attachment theory as it applies to couple
Wittenborn, & Golden, 2012; Dessaulles, Johnson, therapy is that all human beings, without exception,
& Denton, 2003), to posttraumatic stress disorder have an innate need to feel loved and emotionally
(PTSD; Dalton, Greenman, Classen, & Johnson, supported by significant others “from the cradle
2013; MacIntosh & Johnson, 2008), to end-stage to the grave” (Bowlby, 1979, p. 129; see Volume 1,
cancer (McLean, Walton, Rodin, Esplen, & Jones, Chapter 7, this handbook). Romantic partners tend
2013). EFT therapists thus draw on the current state to become primary attachment figures in adulthood
of knowledge about the nature of romantic love (Castellano, Velotti, & Zavattini, 2014; Zeifman &
and distress in couple relationships and on clinical Hazan, 2008), which means that they are the ones to
empirical research that helps them know what to do, whom people usually turn in times of stress, threat,
when to do it, and how. and fear, as well as the ones with whom they long to
The goal of this chapter is to provide an overview share experiences of joy, happiness, and excitement.
of EFT and the research upon which it is based. The results of more than 500 empirical studies
We begin with a presentation of the theoretical conducted since the publication of Hazan and

http://dx.doi.org/10.1037/0000101-018
APA Handbook of Contemporary Family Psychology: Vol. 3. Family Therapy and Training, B. H. Fiese (Editor-in-Chief)
Copyright © 2019 by the American Psychological Association. All rights reserved.

291
APA Handbook of Contemporary Family Psychology: Family Therapy and Training,
edited by B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, and M. A.
Whisman
Copyright © 2019 American Psychological Association. All rights reserved.
 Greenman, Johnson, and Wiebe

Shaver’s (1987) seminal paper on adult love as expression of negative emotions such as anger, fear,
an attachment process analogous in numerous and disgust. On the other hand, close relationships
ways to the one that unfolds between young in which partners feel safe and perceive each other
children and their primary caregivers consistently to be emotionally accessible tend to last longer, to be
demonstrate that (a) adults develop extremely more satisfying and calming, and to trigger positive
strong emotional bonds to their intimate relation­ emotions such as joy (Johnson, 2013).
ship partners; (b) these bonds, when they offer The blame and criticism or the tendency to
a safe haven and a secure base during times of become defensive and pull away that Gottman
vulnerability and stress, encourage independence, and associates have revealed to be toxic to couple
autonomy, and emotional closeness in couple relationships over time are construed in EFT as
relationships; (c) the perception of threat to and the ineffective protests at disconnection and attempts to
breaking of attachment bonds create psychological reestablish emotional connection to one’s partner, or
distress; and (d) people will go to great lengths as chronic attempts to regulate the strong negative
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to feel emotionally close to others and to avoid affect that accompanies the lack of connection.
loneliness (Baumeister & Leary, 1995; Cacioppo The central role of emotions in these experiences is
& Patrick, 2008; Guerriero & Zavattini, 2015; noteworthy: Emotions are the music of a couple’s
Johnson, 2013; Zeifman & Hazan, 2008). The dance; that is, they organize partners’ behavior in key
quality and stability of one’s emotional connections relationship-defining interactions. Negative emotions
to significant others is related to physical health, maintain the despair that goes hand in hand with
mental health, cognitive development, and general disconnection and loneliness, and positive emotions
well-being (Aizer et al., 2013; Greenman, Tassé, are essential components of the sense of well-being
& Tulloch, 2015; House, Landis, & Umberson, and calm that is typical of loving bonds. Emotions
1988; Pietromonaco, Uchino, & Dunkel Schetter, are shaped and regulated in new ways in EFT and are
2013). These findings are considered robust in the viewed as the principal catalyst of changes in how
social psychological and developmental literatures, partners behave in their relationships and in how they
and attachment theory provides a cogent explanation perceive themselves as individuals. Therapists work
for all of them: Human beings are wired for strong to reflect, provoke, and deepen emotional responses
emotional connections to significant others and between partners because of their conviction that
perceived isolation contributes to stress and disease. new emotional experiences engender new behaviors,
which in turn lead to new relationship dynamics
Relationship Dynamics From an (Johnson, 2004).
Emotionally Focused Perspective Scientific evidence in support of this therapeutic
Findings from research on relationship dynamics stance abounds. First, the finding that separation
are also consistent with attachment theory and are from attachment figures triggers considerable anxiety
taken into consideration when conducting EFT. is basic in all bonding research across the lifespan
For example, John Gottman and colleagues have (Johnson, 2013). Second, process research on EFT
discovered that the presence of certain repetitive has consistently linked the depth of clients’ emotional
interaction patterns in couples predicts divorce and experiencing to positive therapeutic outcomes (see
increases levels of physiological arousal and subjective Greenman & Johnson, 2013, for a review). This refers
experiences of stress in both partners. During these to clients’ ability to move past secondary coping
problematic interactions, which occur with great responses such as numbing or reactive anger into
frequency in distressed couples, partners tend to regulated sadness and vulnerability that evoke caring.
criticize, complain (behaviors that are more typical Next, on a physiological level, there has also been
of female partners), defend, and stonewall (behaviors a great deal of research into the neural substrates of
that are more typical of male partners; Gottman, 1994, emotion, and particularly the role of the amygdala in
2011; Kiecolt-Glaser & Newton, 2001). These couple the experience of fear and the effects of fear on social
interactions are characterized by the experience and behavior (e.g., Adolphs, 2010; Feinstein, Adolphs,

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 Emotionally Focused Therapy for Couples

Damasio, & Tranel, 2011; LeDoux, 2007; Panksepp, to changes in the dorsolateral anterior cingulate
1998). The perception of threat to the bond with one’s cortex and the prefrontal cortex of the brain in a study
primary attachment figure is especially prominent using fMRI techniques. This reflects decreases in the
in troubled couple relationships (Johnson, 2013). subjective experience of fear in threatening situations
Any attempt at creating safe, meaningful emotional following therapy (Johnson et al., 2013).
connection will therefore most likely involve soothing
the fear response, framed as a sense of rejection or Therapy Fosters a Secure
abandonment, that is activated by the amygdala when Attachment Bond
loved ones appear to be aggressive or unavailable. In light of the empirical findings outlined above,
In a study of stroke patients, for example, Farinelli the primary goal of EFT is the creation or the
and colleagues (2015) discovered that those who reestablishment of a secure attachment bond in
had suffered lesions to the anterior regions of the the couple relationship. Chronic relationship
brain after their stroke reported significantly more distress is considered in EFT to be the result of a
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intense experiences of fear and sadness than did lack of emotional security; one or both partners
patients with other types of lesions or participants perceive the other to be either inaccessible or
in a control group who had not suffered strokes. unresponsive, that is, to be a source of criticism
Interestingly, those lesions, which appeared to and stress rather than safety (Johnson, 2004).
generate the experience of fear and sadness, also This lack of safe connection breeds strong emotions
predicted insecure attachment as indicated by such as anger and fear that drive individuals’
constant seeking behaviors, such as the solicitation behavior in their relationship, as predicted by
of presence, comfort, and reassurance from family attachment theory (Johnson, 2013).
members and hospital staff, as well as heightened Throughout the EFT process, therapists therefore
expressions of fear and anger if those responses were help relationship partners identify the emotions that
not immediately forthcoming (Farinelli et al., 2015). typically accompany their problematic interactions,
This is evidence that in the face of perceived threat, especially emotions that are not immediately apparent
attachment needs become activated and that the but that have an impact on how they interact with
perceived lack of responsiveness can lead to intense each other. These primary emotions include sadness,
negative emotions. fear, and shame, and tend to be masked by secondary
On the other hand, it is possible to mitigate emotions such as anger or frustration (Greenberg,
the activity of the amygdala by inducing a sense 2012). Primary emotions are linked to unsatisfied
of attachment security, as Norman and colleagues needs for emotional closeness with a partner (Feeney,
found in a fascinating functional magnetic resonance 2005; Mikulincer & Shaver, 2005; Simpson, Collins,
imaging (fMRI) study of healthy adults who were Tran, & Haydon, 2007).
exposed to pictures depicting secure attachment Couples in EFT learn to identify the behaviors
behaviors (i.e., hugging, holding hands) before in which they typically engage (e.g., aggressively
engaging in a series of threat-inducing tasks (Norman, demanding or withdrawing) during conflicts or
Lawrence, Iles, Benattayallah, & Karl, 2015). They disagreements while they are struggling to regulate
discovered that the priming of secure attachment the previously described emotions (Johnson, 2004).
decreased amygdala firings in experimental threat Therapists then direct partners’ attention to the
conditions, irrespective of participants’ attachment impact that these behaviors have on the other;
styles (secure, anxious, or avoidant). In other words, aggression tends to push partners away and with­
exposure to new attachment-related information drawal tends to threaten partners and trigger anger.
helped participants feel safer. EFT therapists Both responses tend to maintain distance and distress.
strive to expose clients to and help them take in After couples develop an awareness of the spectrum of
new attachment-related information of this kind, emotions that underlie their problematic relationship
particularly in Stage II of therapy (discussed later in behaviors and link them to specific unmet needs for
the chapter). In fact, EFT interventions were related closeness and comfort, EFT clinicians guide them

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 Greenman, Johnson, and Wiebe

through the process of communicating these needs to your partner turns away and goes still and silent?”),
each other directly in qualitatively new ways. Thus, empathic conjectures (e.g., “That sounds like it might
a person with a tendency to make accusations and to hurt”), reframes (e.g., “The problem is the dance of
criticize his or her partner learns to identify the needs disconnection you are caught in, not that you are bad
and fears beneath the criticism. Instead of expressing partners”), and the shaping of guided enactments,
secondary anger, the person develops an ability to which are structured interactions in which partners
speak of his or her loneliness and desire for emotional speak directly to each other at the therapist’s request
connection; this then evokes new responses from (Johnson, 2004). EFT is a short-term approach to
the partner. Someone with a tendency to rationalize couple therapy lasting between eight and 20 sessions
or to become defensive in problematic interactions in most cases (Johnson, Hunsley, Greenberg, &
learns instead to share his or her apprehension about Schindler, 1999).
not living up to a partner’s expectations and losing Most likely due to the strong emphasis in Stages I
the partner, evoking compassion in the partner. The and II on the relationship dance and the music of
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repetition of “enactments,” in which one partner this dance (i.e., on the formulation and sending
accesses and expresses interpersonal vulnerability of emotional signals rather than on the content of
followed by a comforting response from his or her a couple’s interactions), a potential misperception
significant other, serves to strengthen the couple’s of EFT might be that practitioners do not directly
sense of safety and security and is related to increases address relationship problems such as sexuality,
in relationship satisfaction (Bradley & Furrow, 2004, finances, child rearing, division of household
2007; Dalgleish, Johnson, Burgess Moser, Wiebe, & chores, and the myriad practical problems that
Tasca, 2015b). In this way, EFT appears to encourage couples are likely to discuss with their therapist. In
secure attachment between partners (Johnson & fact, these practical concerns are indeed targets of
Greenman, 2006). intervention in EFT, but mainly in Stage III, once
a secure attachment bond has been established
EMOTIONALLY FOCUSED THERAPY: in the relationship, which is the work of Stage II
AN OVERVIEW (Johnson, 2004). There are two reasons for this.
There are three stages in EFT: de-escalation of negative First, when couples become extremely emotionally
cycles of disconnection (Stage I), restructuring of aroused during conflicts and the intensity of their
attachment—the shaping of positive cycles of reaching emotional reactions prevents them from listening to
and responsiveness (Stage II), and consolidation and communicating effectively with each other—for
(Stage III). The two main tasks of the EFT therapist example, when a simple discussion about household
are to help couples access and reprocess the key tasks escalates into a fight so bitter that partners
emotions that organize their responses to each other barely speak to each other for days afterward—the
and to guide them into new patterns of interaction main issue that needs to be addressed is not, from
characterized by accessibility, responsiveness, and an EFT perspective, the practical problem at hand.
engagement, the prime indicators of a secure bond. It is the lack of safe connection that pushes both
Significant change occurs not through skill coaching partners off balance and undermines any attempt
or cognitive explanation or correction, but from at collaborative problem-solving. The problems
alive, bottom-up, corrective emotional experiences of of daily living trigger a couple’s negative cycle
emotional balance and safe connection. Interventions because the partners do not feel seen, heard, safe,
are a mix of experiential and systemic techniques and respected, and important in the relationship. Each
may vary in pace and intensity across stages. They person in the couple becomes caught in attachment
include empathic reflections of partners’ primary and anxiety, when the answers to the key questions
secondary emotions and their relationship positions “Do I matter to you and do you care about my needs?”
(e.g., pursue–withdraw), the heightening of affect or “Do you love me the way I am?” are uncertain or
in session by repetition and imagery, evocative negative (Johnson, 2013). The intensity of partners’
questioning (e.g., “What happens to you when emotional reactions is explained by attachment

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theory, which stipulates that the perceived lack responsive emotionally or has a tendency to point out
of a secure emotional connection will trigger faults and to criticize (Johnson, 2004).
overwhelming attachment fears, loss, and shame at Stage I is about helping couples realize the pain
failing as a partner, and lead to critical protests or and the vulnerability that accompany isolation
defensive withdrawal (Mikulincer & Shaver, 2005, and distance. At the end of Stage I, couples reach
2007; Zeifman & Hazan, 2008). Once partners de-escalation, which means that they have less of
acquire an emotional balance and see each other as a tendency to perceive their partner as the main
a source of safety and support, therapists return to source of problems in the relationship and a greater
the question of helping couples solve these practical understanding of and feel for their interaction dance,
problems in Stage III (Johnson, 2004; Johnson & which involves an array of feelings and behaviors
Greenman, 2006). We turn now to a more detailed on both sides. They understand that each person’s
overview of the stages of EFT. position in the cycle stems from a desire to feel
emotionally connected to the other and the strong
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Stage I: De-escalation feelings that are triggered when this connection is

The primary aims of the first stage of therapy are to under siege. This realization that they are both victims
sensitize couples to the pervasive interaction patterns of a pervasive interaction pattern generally helps
that impede emotional connection and reinforce couples feel more united against a common enemy
a sense of insecurity, hostility, or distance in their (Johnson & Greenman, 2006). They notice both
relationship, and to unite them against these patterns inside and outside of the therapy session how they fall
or cycles (Johnson, 2004). After establishing a strong into their cycle and they usually express a desire to
therapeutic alliance with each partner and identifying learn how to change it. Once partners become aware
triggers of the couple’s problematic interaction of their cycle and can begin to help each other out
cycle, the EFT therapist utilizes evocative questions, of this cycle (as in, for example, “Hey, we are getting
reflections, reframes, and empathic conjectures to stuck in our spiral again. This is where you start to
help partners recognize how they each contribute feel like a big disappointment and I feel all alone. Let’s
to the cycle. The therapist explores each person’s calm down and have tea.”), thus establishing a secure
subjective experience of the relationship, including base of hope in their relationship, they are ready to
perceptions of self and partner, and, most importantly, proceed to Stage II of EFT.
the spectrum of his or her emotional reactions to the
other partner above and beyond the irritation that Stage II: Restructuring Attachment—
is often most readily apparent. After establishing Withdrawer Reengagement and
both secondary (anger, frustration) and primary Pursuer Softening
(sadness, fear) emotions and the effects that they The goals of Stage II of EFT are to alter the couple’s
have on each partner’s interpersonal behavior (e.g., negative interaction cycle and to replace it with a
attacking, criticizing, defending, withdrawing), EFT new one in which both partners feel safe enough to
therapists actively frame the couple’s problem as the fully feel and express their primary emotions and
result of ineffective attempts to manage the intense attachment needs and to respond in a comforting,
feelings that arise during their interactions that encouraging manner to the direct, unequivocal
leave both partners feeling inadequate, unimportant, manifestation of such needs from each other
or alone. An important component of Stage I (Dalgleish et al., 2015a; Johnson, 2004). In order
involves making the attachment framework explicit to achieve this, EFT therapists reflect and heighten
for clients. Therapists reflect the ways in which the primary emotional responses and attachment
partners’ feelings and behaviors are manifestations longings first discussed in Stage I. For example, a
of unmet attachment needs for closeness, safety, withdrawn partner might explore with the therapist
and connection. They point out and validate that in detail his sense of inadequacy, sadness, and fear
it is normal to feel afraid, alone, and angry when it of not living up to what he thinks are his wife’s
appears as though one’s partner is not available or expectations. A pursuing partner may discuss her

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 Greenman, Johnson, and Wiebe

feelings of isolation and the preoccupations that predict successful therapeutic outcomes (Bradley &
they bring about in her. In many instances, these Furrow, 2004; Burgess Moser et al., 2016). Following
primary feelings in the couple relationship trigger withdrawer reengagement and pursuer softening,
longstanding fears of loneliness and abandonment when partners are mutually accessible and responsive
that have roots in previous experiences with other and thus able to create a corrective emotional
attachment figures, including parents and previous experience of secure connection for each other, the
relationship partners. The therapist works with each couple is ready to move on to Stage III of EFT.
partner individually in the presence of the other, to
distill and deepen these emotional experiences and Stage III: Consolidation and Integration
to link them to current relationship positions (e.g., The emotional security established between partners
“I withdraw because I get so stressed out when I see through the new relational experiences of Stage II
that she’s mad at me, just like I used to do when my facilitates effective problem-solving and the
dad would become violent,” or, “I go after him to get consolidation of therapeutic gains (Johnson, 2004).
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his attention. I want him to see me and I feel so alone EFT therapists now encourage couples to engage in
when he doesn’t. That reminds me of how I always a discussion of longstanding pragmatic relationship
felt at home when I was younger.”). Once these problems, such as sexual differences, finances, or
primary emotions, attachment needs, and behaviors household chores. Problem-solving is much easier
are established, the therapist engages partners in at this point because these practical issues are no
enactments, in which they express their emerging longer imbued with the hot emotional attachment
feeling states and needs directly to each other. significance that they were at the beginning of
The key is not to simply discuss feelings and therapy. Thus, a conversation about finances, for
needs on a cognitive level, but to provoke vulnerable example, remains focused on finances. Money no
emotional responses in session. The rationale behind longer represents a way for partners to feel either
this type of intervention is the notion that comforting excluded from the relationship (e.g., “You never
responses to clear expressions of vulnerability ask me what I think about how we should manage
strengthen emotional connections between relation­ our money!”) or unduly criticized (e.g., “No matter
ship partners. This idea comes from attachment what I suggest, you don’t like it!”). If partners do
theory and has been substantiated in research with become hurt, fearful, or angry, the therapist directs
couples (Johnson, 2013). Once a person can own them to deal with these feelings directly as they
and express fears and hurt, the therapist guides the arise, which they can now do much more fluidly
partner to respond in an empathic, loving way to these and effectively.
expressions of vulnerability. Finally, partners can name Finally, the therapist engages couples in the
and own the attachment longings associated with process of consolidating their gains, pointing out
their vulnerabilities and ask each other to meet these the new positive ways in which they interact and
needs directly (e.g., “I want to be with you and I helping them shape an empowering narrative of
need you to hold and encourage me rather than to how they now understand love and have healed
criticize me,” or, “I want you to comfort me instead their relationship. The aim here is to help solidify
of running away.”). Withdrawn partners move into the couple’s new interaction cycle, which now
a stance of emotional reengagement, and pursuing features flexible responsiveness, closeness, and a
partners exhibit a softening—a key change event strong sense of connection. Therapists discuss
in EFT (Bradley & Furrow, 2004; Johnson, 2004; future challenges the couple might face, assist
Johnson & Greenman, 2006). Now, the withdrawn them in making time for “attachment rituals”
partner remains present and responsive and the (i.e., activities and behaviors that help partners
pursuing partner opens up and clearly expresses feel close and connected to each other), and address
needs from a position of vulnerability that evokes the importance of recognizing when they might
mutual soothing and connection. Process research have fallen back into their negative cycle as the first,
has confirmed that such softenings consistently most powerful tool for stepping out of it. Therapy

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ends when the couple’s new relationship pattern received EFT, 14 received EFT plus communication
is evident both in the therapy session and in the skills training, and 14 were wait-list controls. Results
couple’s daily life outside of therapy. indicated significant improvements in relationship
satisfaction for both treatment groups but not for the
control group. However, there were no differences at
EMOTIONALLY FOCUSED
a 4-month follow-up between treatment groups.
THERAPY RESEARCH
The author of the study reported that the majority
There have been many studies of the efficacy and the of couples who received communication skills
process of EFT. The results of this body of research training indicated in poststudy interviews that
demonstrate that EFT is an effective approach for they “did not feel confident incorporating the
alleviating relationship distress and that specific communication skills into their daily marital
interventions and client reactions are related to interactions” (James, 1991, p.272) and concluded
positive therapeutic outcomes. There is also outcome that the addition of communication skills training
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research on the use of EFT for couples as a treatment did not add to the efficacy of EFT.
for major depression and PTSD. We provide in this A few years after the publication of James’s (1991)
section an overview of the body of published studies study, Dandeneau and Johnson (1994) investigated
on EFT outcomes and on the process of EFT. Please the differential effects of EFT and cognitive marital
see Wiebe and Johnson (2016) for an extensive, therapy (CMT) on intimacy, trust, empathy, and
detailed review. dyadic adjustment. There were 12 couples in the EFT
condition, 12 couples in the CMT condition, and
Emotionally Focused Therapy 12 couples in a control group in this study. Results
Outcome Research revealed improvements for both treatment groups
EFT has been the subject of 10 randomized controlled in intimacy after treatment, and superior effects for
trials (RCTs), in addition to a number of other EFT on empathy and self-disclosure. Couples who
investigations that have featured a variety of methods. participated in EFT scored significantly higher on
Couple distress.   Two early studies yielded the measures of intimacy and adjustment at 10-week
first signs of the efficacy of EFT as a therapeutic follow-up than did couples who participated in CMT.
approach to treating relationship distress in couples. These findings suggest that the effects of EFT tend to
In the first one, which was an RCT involving endure posttreatment.
15 couples per group, couples who participated in Further evidence for the lasting effects of EFT
eight sessions of EFT demonstrated significantly has come from four other outcome studies with
greater improvements in relationship satisfaction, follow-up measurements ranging from 3 months
intimacy, and the reduction of target complaints (Johnson & Talitman, 1997) to 3 years (Halchuk,
than did couples who participated in a behavioral Makinen, & Johnson, 2010) posttherapy. In one,
problem-solving intervention or who were assigned Johnson and Talitman analyzed data from 34 couples
to a wait-list control group (Johnson & Greenberg, who had received 12 1.25-hour sessions of EFT.
1985a). The findings of a second study in which The couples in this study exhibited statistically and
subjects served as their own controls were similar. clinically significant improvement in relationship
In that study, Johnson and Greenberg (1985b) found satisfaction at the end of therapy and at a 3-month
significant increases in relationship satisfaction, follow-up appointment. Specifically, half of the
intimacy, and therapeutic goal attainment and couples in the sample were no longer in distress at
significant reductions in target complaints in the end of therapy and fully 70% of them showed no
14 couples (Johnson & Greenberg, 1985b). signs of distress at 3-month follow-up. According
In another comparative outcome study, James to the reliable change index (Jacobson & Truax,
(1991) added four sessions of communication 1991), 79% of participating couples made clinically
training to what was, at the time, the standard eight- significant gains at the end of therapy and continued
session EFT protocol. Fourteen couples in this study to do so over the follow-up period. Three months

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 Greenman, Johnson, and Wiebe

after the completion of therapy, 82% of the couples after their participation in EFT (Halchuk et al., 2010).
in this sample demonstrated clinically significant These studies are discussed in more detail later
improvement in dyadic adjustment when their in the chapter.
follow-up scores were compared to their initial ones Other noteworthy studies of the efficacy of EFT
(Johnson & Talitman, 1997). include an intriguing investigation of the ability
In a different RCT that included parents of of novice therapists to implement EFT (Denton,
children with chronic illnesses (e.g., cancer, cystic Burleson, Clark, Rodriguez, & Hobbs, 2000) and
fibrosis, autoimmune diseases), Gordon Walker, a meta-analysis of randomized clinical trials of
Johnson, Manion, and Cloutier (1996) assigned EFT (Johnson, Hunsley, Greenberg, & Schindler,
couples, all of whom were in distress and struggling 1999). In the first study, Denton and colleagues
to cope with their child’s illness, to 10 sessions of EFT compared outcomes on a composite scale of marital
or to a wait-list control group. They found statistically satisfaction between 22 couples who received
significant improvements in relationship satisfaction, eight weekly sessions of EFT and 14 couples on
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communication, and intimacy posttherapy. The a waiting list. They found that the couples who
relationship satisfaction and communication scores received EFT demonstrated significantly higher
of couples who participated in EFT were also relationship satisfaction than did couples on the
significantly higher than were those of couples in the waiting list (Denton et al., 2000). Once they had the
control group at the end of therapy (Gordon Walker opportunity to participate in eight sessions of EFT,
et al., 1996). Interestingly, at a 5-month follow-up, the couples originally on the waiting list reported
the relationship satisfaction and communication significantly higher relationship satisfaction after
scores remained significantly higher in the EFT therapy than they did prior to it (Denton et al.,
group, and intimacy scores were significantly higher 2000). In the meta-analysis, Johnson et al. (1999)
for couples who participated in EFT as well (Gordon analyzed the results of the four randomized trials
Walker et al., 1996). Couples in the EFT group also of EFT available at the time. This analysis yielded
demonstrated clinically significant improvement at a weighted mean effect size (d) of 1.3 across the
the end of therapy and at follow-up. four studies, which is considered very large in
Further, the impact of the initial course of EFT psychotherapy research (Johnson et al., 1999).
appeared to last. Two years later, the researchers Stated differently, this suggests that there is an 82%
contacted all of the couples who were originally chance that a couple picked at random from the
part of the EFT group (Cloutier, Manion, Walker, & EFT treatment groups in these studies would have a
Johnson, 2002). Thirteen of them (81%) completed higher relationship satisfaction score than a person
the same battery of questionnaires as in the original picked at random from a control group. In addition,
outcome study. Results revealed the maintenance of between 70% and 73% of couples in the studies
therapeutic gains in most cases, with no statistical under investigation recovered completely from
decline on participants’ relationship satisfaction and
their relationship distress upon completion of EFT
intimacy. Analyses of clinical significance revealed
(Johnson et al., 1999). Taken together, the results
that 38.5% of couples actually continued to improve
of the studies reviewed in this section indicate
after the end of therapy (Cloutier et al., 2002).
that EFT for couples is effective at alleviating
There are two other published studies (Dessaulles
distress in couple relationships. Other outcome
et al., 2003; Halchuk et al., 2010) whose results attest
research has focused on the application of this
to the lasting effects of EFT. In one, EFT was shown
approach to problems related to, but also distinct
to have a positive effect on symptoms of depression in
from, couple distress.
a group of women in therapy, and this effect persisted
after the termination of the intervention (Dessaulles Emotionally focused therapy and the treatment
et al., 2003). In the other, couples who successfully of mental health problems and coping.  There is
resolved longstanding relationship struggles known some evidence of the usefulness of EFT for couples
as “attachment injuries” maintained their gains 3 years in the treatment of individual problems such as

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 Emotionally Focused Therapy for Couples

depression, posttraumatic stress, and coping with (Denton et al., 2012, p. 33) given well-established
chronic illness. In the first study of this kind, links between couple relationship functioning and
Dessaulles et al. (2003) examined the impact of symptoms of depression (e.g., Whisman, 2001).
EFT on symptoms of major depression in women. EFT may also be helpful for people experiencing
All participants in their study were in relationships the effects of trauma in their lives. Although more
in which at least one of the two partners scored in research on the topic is necessary, data from two
the distressed range on a measure of relationship published reports suggest that EFT can help manage
adjustment. Results were compared for seven trauma and improve the relationship functioning of
women randomized to the EFT condition in which people who have experienced trauma. For example,
they received 16 weekly couple therapy sessions MacIntosh and Johnson (2008) conducted a study
with their partner, and five women randomized of 10 couples in which one partner had experienced
into a pharmacotherapy condition in which they childhood sexual abuse and met diagnostic criteria
received desipramine, trimipramine, or trazadone. for PTSD. Couples participated in an average of
Copyright American Psychological Association. Not for further distribution.

Symptoms of depression abated for women in both 19 sessions of EFT (ranging from 11 to 26 sessions).
conditions after 16 weeks of treatment. However, at Half of the couples in the sample reported clinically
a 6-month follow-up, the depression of women who significant reductions in trauma symptoms, along
had received EFT continued to improve; there were with increases in relationship satisfaction. Dalton,
significant decreases in their depression scores from Greenman, Classen, and Johnson (2013) conducted
the time they completed therapy to reassessment an RCT of the effects of EFT on couples in which the
6 months later (Denton, Golden, & Walsh, 2003). female partner had experienced childhood abuse.
In contrast, the depressive symptoms of women in There were 12 couples in the EFT treatment group
the pharmacotherapy group reverted to pretreatment and 10 in the wait-list control group. There was a
levels once they ceased taking medication after significant effect for EFT on relationship satisfaction
the 16-week treatment period (Denton et al., 2003). for both men and women in this sample, which
These findings are consistent with the perspective that is a notable finding given the harmful effects of
improvements in their relationship functioning may childhood abuse on couple relationship satisfaction
have helped participants overcome their depression. in adulthood (Dalton et al., 2013).
This reflects one of the basic assumptions of EFT, In addition to this evidence of the applicability
derived from attachment theory: Improvements in of EFT to couples in which there is a history of
emotional connection in couple relationships ought trauma, a report also has been published on the
to have positive effects on overall psychological integration of EFT into cancer care. McLean and
functioning. colleagues (2013) randomized 42 participants with
In a more recent study of the application of EFT end-stage metastatic cancer into a usual care group
to women with depression, Denton, Wittenborn, that consisted of regular appointments with members
and Golden (2012) randomly assigned 12 women of a multidisciplinary team or into a group that
received usual care and eight sessions of EFT with
to a condition in which they received antidepressant
their partner. They measured a number of variables,
medication (bupropion, venlafaxine, escitalopram,
including relationship adjustment and cancer patients’
or sertraline) and 12 other women to a treatment
perceptions of their partner’s empathy and caregiving.
condition in which they received medication
People who received EFT, but not those in the usual
and 15 sessions of EFT with their partner. All
care group, demonstrated significant improvements
couples were in the distressed range on a measure
in relationship adjustment and in perceptions of
of rela­tionship adjustment. There were significant
their partner’s empathy (McLean et al., 2013). They
reductions in depressive symptoms in both treatment
maintained these gains at a 3-month follow-up.
groups. Only in the EFT group, however, did couples
report significant relationship improvement, which Emotionally focused therapy and sexuality.  A
the authors suggest is “likely to be important in common complaint of couples who come to therapy
advancing long-term management of depression” is that their sex life is unsatisfying or in some cases

299
 Greenman, Johnson, and Wiebe

nonexistent. When it comes to sexuality, EFT draws studies published recently (Burgess Moser et al.,
on empirical data which have shown that people 2016; Johnson et al., 2013) support this claim, with
who are able to recognize their emotional needs for data from a sample of 32 distressed couples who
security and closeness and who tend to actively seek received an average of 21 sessions of EFT. In the
out emotional support from their partner in times of first study, Johnson and associates examined the
stress, need, or vulnerability (i.e., who have a secure effects of EFT on the neural processing of fear,
attachment orientation) tend to have sex more one of the principal emotional experiences involved
frequently, to have more positive feelings about sex, in attachment behavior. In this study, female partners
to experience more intense sexual arousal, and to were informed of the possibility of receiving an
have more orgasms than do people with insecure electric shock while lying alone in a fMRI scanner,
attachment orientations who do not tend to reach while holding a stranger’s hand, or while holding
out to their partners in this way (e.g., Birnbaum, their partner’s hand. Before therapy, partner hand-
2007; Carrasco, 2012). When treating couples’ holding did not seem to affect the way that parti­
Copyright American Psychological Association. Not for further distribution.

sexual concerns, the focus in EFT therefore remains cipants’ brains encoded the threat of electric shocks,
on the strength of their attachment bond. as indicated by a series of fMRI scans. This changed
There have only been a few studies of the impact after therapy, when holding their partner’s hand
of EFT on sexual satisfaction and physical intimacy. during the same procedure attenuated the women’s
In one, MacPhee, Johnson, and Van der Veer (1995) neural fear response, as suggested by the near total
offered 12 sessions of EFT to 49 couples in which cessation of limbic activity and decreased activity
the female partner reported inhibited sexual desire. in the prefrontal cortex (Johnson et al., 2013).
Couples were randomly assigned to an EFT group Participants also reported significant reductions
or to a wait-list control group. At the end of therapy, in their subjective experiences of pain when the
the women in the EFT group demonstrated shocks were administered while they were holding
significant improvement in sexual desire (MacPhee their husband’s hand. Johnson and colleagues
et al., 1995). More recently, Honarparvaran, Tabrizy, also observed significant increases in relationship
Navabinejad, and Shafiabady (2010) applied EFT satisfaction.
to eight couples with low sexual satisfaction and In addition to their participation in therapy and
compared posttreatment scores with those of a fMRI scans, participants in this sample completed a
control group. They detected significant increases number of self-report and observational attachment
in sexual satisfaction. An interesting aspect of this measures prior to therapy and immediately following
study is that it was conducted in Iran. Finally, Elliott every therapy session; their interactions were also
and colleagues (2018) analyzed trajectories of coded before and after therapy. Couples who had
sexual satisfaction in the couples who participated softening events in Stage II of EFT demonstrated
in an EFT–fMRI study (Johnson et al., 2013). They significant decreases in attachment anxiety as
detected an increase in sexual satisfaction from therapy progressed. There were also significant
pretherapy to posttherapy that continued across improvements in attachment security as indicated
a 2-year follow-up phase. These studies provide by observers’ coding of their interactions, and
preliminary evidence for the efficacy of EFT to help self-reported decreases in attachment anxiety and
couples improve their sexual relationship, but more
avoidance in the context of the relationship were
work needs to be done to substantiate the claim that
related to increases in relationship satisfaction over
participation in EFT leads to increases in sexual
time (Burgess Moser et al., 2016). Couples in this
satisfaction.
sample continued to show decreases in attachment
Emotionally focused therapy and attachment anxiety and increases in relationship satisfaction at a
orientations.   One of the fundamental tenets 2-year follow-up (Wiebe et al., 2017).
of EFT is that it is possible, through therapy, to In sum, the studies reviewed herein support
alter the nature of the attachment bond in couples the efficacy of EFT. The outcome research is
(Johnson & Greenman, 2006). The results of two rigorous and consistent: Couples in distress who

300
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participate in EFT tend to get better. Recent evidence abandonment during a period of vulnerability learn to
suggests that therapy does indeed change the nature trust in the emotional availability of their partner
of the attachment bond between partners. But EFT once again (Halchuk et al., 2010; Makinen &
therapists do not only rely on theory and outcome Johnson, 2006). The effects of the resolution
research to guide their interventions. There is also a of attachment injuries appear to be stable, as
sizable body of process research into the approach, indicated by a 3-year follow-up investigation of
which helps clinicians develop specific therapeutic the application of the model (Halchuk et al., 2010).
goals. Whereas outcome research can help determine The research on attachment injuries, and the
whether a particular therapeutic approach works for empirical validation of the specific therapeutic
a particular population, only process research can operations that lead up to their resolution, are
offer clues as to how therapy works. particularly useful dimensions of EFT because
they provide therapists with a clear guide to
Emotionally Focused Therapy assisting couples through the kind of enduring
Copyright American Psychological Association. Not for further distribution.

Process Research emotional pain that generally precludes closeness,

Greenman and Johnson (2013) authored an extensive connection, and trust.
review of the existing EFT process research. In Four EFT process articles were published between
their article, they identified nine studies of the 2012 and 2016, bringing the total articles to 13.
process of EFT, both from the perspective of In one, Furrow, Edwards, Choi, and Bradley (2012)
the client and the perspective of the therapist. sought to identify the specific interventions that
Most EFT process research features the task lead to softening events. They applied the task analysis
analysis method of investigation, which involves procedure to recordings of sessions that involved
developing a theoretical model of what one might successful or unsuccessful softening attempts.
expect to observe in therapists and clients as they The emotional presence of the therapist in session
work toward a specific task, such as de-escalation and the quality of his or her voice predicted
or pursuer softening (Greenberg, 2007). Once success­ful softening (Furrow et al., 2012). In
the theoretical model is developed, the researcher another study, Swank and Wittenborn (2013)
then verifies it empirically through a systematic conducted a task analysis of the repair of a ruptured
analysis of actual psychotherapy sessions, using both therapeutic alliance in EFT. They found that in order
qualitative and quantitative indicators of whether to reestablish the therapeutic alliance, therapists had
the particular therapeutic task under investigation to directly raise concern about the potential rupture,
has been resolved. Process research using this encourage clients to explore their emotional reactions
method has indicated consistently that the depth to it, take responsibility for their part in creating
of clients’ emotional experiencing in session and the rupture, and express gratitude to the client for
the active restructuring of couple interactions to disclosing concerns. The results of other process
involve vulnerable self-disclosure are directly related studies published in recent years have indicated
to improvements in their satisfaction with their that clients’ typical emotion-regulation strategies
relationship (Greenman & Johnson, 2013). The (i.e., emotion self-awareness or emotion control) are
steps leading up to pursuer softening have been not related to softening events (McRae, Dalgleish,
thoroughly investigated; this change event appears Johnson, Burgess-Moser, & Killian, 2014), that
to be essential to the successful outcome of EFT clients with attachment anxiety tend to benefit more
(Bradley & Furrow, 2004; Dalgleish et al., 2015a). from EFT than do clients who tend to be avoidant
Process research has also generated a set of (Dalgleish et al., 2015b), and that blamer softening
therapist tasks, known as the attachment injury events lead to decreases in attachment anxiety over
resolution model (AIRM), that lead to the resolution time (Burgess Moser et al., 2016). These findings add
of the relationship traumas called attachment injuries. to the extensive array of EFT process studies and can
These tasks (e.g., reframes, enactments) involve help therapists hone their interventions in order to
helping clients who remain hurt after perceived reach the prescribed therapeutic milestones.

301
 Greenman, Johnson, and Wiebe

FUTURE DIRECTIONS IN EMOTIONALLY that appear to matter most to people: needs for
FOCUSED THERAPY RESEARCH emotional connection and safety.
Despite the breadth of research on EFT, there is still
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