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Humanistic approaches to working with couples and families

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Catalina Woldarsky Meneses

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http://dx.doi.org/10.1037/14775-012

Humanistic Psychotherapies: Handbook of Research and Practice, Second Edition, D. J. Cain, K. Keenan, and

S. Rubin (Editors)

Humanistic psychology and psychotherapy are characterized by a posi-

tive view of human functioning, a commitment to phenomenology, a belief in

the capacity for self-determination, the promotion of in-therapy experiencing,

and a commitment to a person-centered therapeutic relationship (Greenberg,

Elliott, & Lietaer, 2003). In working with couples and families, the therapist

aims to understand empathically people’s experience within the system in a

nonjudgmental and nonpathologizing manner. According to Gurman (2008),

the therapist does so with the intention of helping individuals enhance their

relationships.

Although there are a variety of humanistic approaches to working with

couples and families, this chapter outlines the new developments in theory

and research relevant to those that are empirically supported. Currently, this

includes relationship enhancement (RE) therapy, emotion-focused couples

therapy (EFT-C), Gottman’s method for couple therapy, ﬁlial family therapy

EMPIRICALLY SUPPORTED

HUMANISTIC APPROACHES

TO WORKING WITH COUPLES

AND FAMILIES

CATALINA WOLDARSKY MENESES AND ROBERT F. SCUKA

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(FFT), emotion-focused family therapy (EFFT), and dyadic developmental

psychotherapy (DDP).

HISTORICAL AND THEORETICAL OVERVIEW

OF HUMANISTIC COUPLE AND FAMILY THERAPY

In the attempt to understand difﬁculties in living within families, the

ﬁeld of family therapy moved from focusing on the behavioral input–output

of the system and its feedback loops to targeting the family’s underlying struc-

ture (hierarchies, triangles, boundaries, etc.) and all of its associated beliefs

(i.e., rules, myths, and secrets) while attending to the context within which

the family is embedded (Rasheed, Rasheed, & Marley, 2010). The emphasis

on understanding interactional patterns generally disregarded the experience

of the individual until Virginia Satir advanced her method of therapy.

Like her contemporaries from Palo Alto, California, Satir believed that

symptoms are functional within a system and that communication is central

in family process. Satir (1972, 1988) proposed that people long to feel good

about themselves and to get close to others, noting that one of the most

important family functions is the enhancement of self-esteem. She further

proposed that self-esteem and communication are intricately connected. As

family members drop their “protective masks” and express their underlying

feelings, honest communication ﬂows, and the system can attend to the needs

of individuals and nurture their personal growth. This promotes self-esteem

(Satir, 1972, 1988). Satir’s approach integrated core humanistic principles

inspired by Rogers and Maslow, along with experiential interventions, for the

purpose of exploring and understanding the in-session emotional experience

of each individual within the system.

Current empirically supported humanistic approaches are guided by an

understanding of the mechanisms of change in therapy and a constant attun-

ement to the system. This has resulted in a process-oriented manner of conduct-

ing therapy, in which speciﬁc interventions are introduced at speciﬁc moments

based on a client’s particular presentation (rather than on intuition or strict

formulas dictated by a treatment manual) and are offered in the spirit of prizing

each individual’s growth potential (Greenberg, Rice, & Elliott, 1993).

Relationship Enhancement Therapy

Bernard G. Gurney Jr. developed one of the ﬁrst humanistic therapies

for working with couples: RE therapy (B. G. Guerney, 1977; Scuka, 2005).

The core conviction behind the RE model was that the primary source of

working with couples and families 355

family distress was a deﬁcit of good relationship skills. Hence, RE extended

Rogers’s emphasis on the use of empathy in therapy by incorporating basic

tenets of learning theory to develop a systematic methodology to teach couples

and families good communication and other relationship skills. Although the

psycho educational skills teaching component of RE therapy has been stan-

dardized (and is not typical of humanistic approaches), this condition simply

lays the groundwork for the core of the therapeutic work, which allows for

a broadly experiential dialogue process aiming to plumb the depths of the

clients’ emotions and concerns. The dual goal of this experiential process

is to promote self-acceptance and self-understanding as well as a deeper

connection and healing between partners and family members, resulting

in symptom change, personal growth, and new deﬁnitions of self and rela-

tionship (B. G. Guerney, 1994).

The skills taught in RE include the following: (a) expressive skills, such

as stating one’s desires assertively, subjectively, and respectfully; (b) empathic

skills that facilitate listening to and understanding others more deeply;

cess; (d) coaching skills to help partners keep their dialogues on track when

mistakes get made; (e) problem-solving skills to devise creative, win–win

solutions; (f) changing self skills to reduce unwanted behaviors; (g) helping

others change skills to support others in implementing their agreements;

(h) conﬂict management skills to help partners exit from cycles of hostility

and blame; (i) generalization and maintenance skills; and (j) forgiveness

skills to overcome alienation and foster healing (B. G. Guerney & Scuka,

2005, 2010).

The goal of the skills training in RE is to decrease interactions that cre-

ate anxiety and emotional insecurity while increasing participants’ capacity to

show and receive love (B. G. Guerney, 1994). RE fosters the systematic recon-

ﬁguration of interactional patterns, moving away from dysfunctional, alienat-

ing patterns toward nurturing ones. RE also aims to foster problem prevention

by equipping couples and families with the skills to solve future challenges

successfully on their own (Scuka, 2005). There is ﬂexibility in the application

of this approach, as it can be offered in a structured or experiential format,

within the context of a group or with a couple or family. Home assignments

are used to promote integration of RE skills in daily life.

Emotion-Focused Therapy for Couples

In 1988, Greenberg and Johnson developed a therapeutic model that

assimilated the systemic perspectives into an experiential approach that

resulted in a promising way of working with couples. Over time, the authors

began to diverge on their theoretical conceptualization of interpersonal

356 meneses and scuka

dynamics, giving rise to two related but slightly different “versions” of the

same approach. Inspired by the work of Bowlby, Johnson’s (1996, 2004)

emotion-focused therapy (EFT) emphasizes attachment as the central force

that organizes couples’ behavior, whereas Greenberg and Goldman’s (2008)

EFT-C emphasizes the role of affect regulation in couples’ dynamics, pro-

viding a framework that integrates the motivational forces of attachment,

identity, and liking/attraction.

According to Johnson (2004), individuals have an innate need to main-

tain closeness to a signiﬁcant other. When both partners are able to express

their emotions and needs, and simultaneously respond to their partners’ emo-

tions and needs, a secure attachment bond is established. Disruptions to this

bond typically lead to partners engaging in rigid interactional cycles in an

effort to meet attachment needs.

Greenberg and Goldman (2008), on the other hand, consider emo-

tional regulation to be at the core of interpersonal dynamics. In line with

Frijda’s (1986) view of emotions, Greenberg and Goldman considered behav-

ior, motivation, thoughts, and needs to be intimately linked to our emotional

state. They argued that without affect there would be no attachment, as they

considered affect regulation to be a primary human motivation, suggesting

that people bond because of the feelings relationships give them. That is,

partners seek the closeness of a safe-other because it generates an array of pos-

itive feelings. In contrast, they retreat when they feel afraid, or they respond

in anger when they feel attacked or threatened.

Greenberg and Goldman (2008) further proposed that the primary moti-

vating force of affect regulation operates through three primary subsystems:

attachment, identity, and attraction/liking. From this perspective, couples’

conﬂict is said to result from the painful feelings emanating from unmet adult

needs for attachment (proximity, availability, and responsiveness) and iden-

tity (feeling accepted and validated), and it is ameliorated by positive feelings

of attraction and liking. Whereas Johnson (2004) suggested that a secure

attachment bond provides the necessary conditions to help the partners regu-

late their emotions, Greenberg and Goldman proposed that couples’ conﬂict

is fueled by emotions related to both attachment and identity needs. As such,

there may be times when a partner’s maladaptive emotion schemes relate

more clearly to unmet childhood needs and/or emotions linked to the dimen-

sion of identity (e.g., shame) that cannot solely be regulated or transformed

through a secure attachment bond or a partner’s soothing but instead require

self-focused work including developing the capacity to self-soothe. Thus, for

Greenberg and Goldman, couples’ conﬂict is understood as stemming from

rigid, interactional cycles that are activated when there is a breakdown in

self- and other-regulation of affect. The application of self-soothing tech-

niques to address fears and unmet needs that generally stem from experiences

working with couples and families 357

within the family of origin is central for Greenberg and Goldman, in addition

to assisting couples to develop proﬁciency in meeting each other’s needs and

engaging in other-soothing. Therapy involves exploring and understanding

the functions of primary, secondary, and instrumental emotions, which are

outlined later. The aim is to help each partner become aware of and symbolize

the underlying attachment and identity-oriented emotions (e.g., fear under-

neath the anger/hostility or shame/inadequacy underneath contempt) and to

realize that expressing secondary or instrumental emotions is what keeps him

or her engaged in his or her interactional cycle.

Both Johnson’s (2004) and Greenberg and Goldman’s (2008) versions

of emotion-focused couple work are highly similar in clinical practice, as both

assert that distress occurs when couples relate to each other with constricted

emotional patterns that lock them in rigid interactional dynamics. Therapy

aims to transform problematic dynamics by helping partners explore and

express their underlying primary emotions to create new corrective emotional

experiences of mutual openness, responsiveness, and validation (Greenberg

& Johnson, 1988). Primary emotions refer to an individual’s initial feelings

about a situation (e.g., fear when one feels attacked), whereas secondary emo-

tions refer to reactions or even a defense against primary internal responses or

emotions (e.g., anger in response to feeling hurt). Instrumental emotions are

used to fulﬁll a wish or need in an indirect way (e.g., crying in an attempt to

seek closeness; Greenberg, Rice, & Elliott, 1993).

Following Greenberg and Johnson’s (1988) original joint research ini-

tiatives, Johnson went on to disseminate and develop the couple therapy

approach, demonstrating its effectiveness for a variety of types of marital dis-

tress. Greenberg, however, focused on advancing the model for individuals,

conducting extensive process research that in many ways inspired the reﬁne-

ments made to the 1988 couple’s model developed with Johnson. Greenberg

returned to conducting process research with couples approximately 10 years

ago, as outlined in the next section. For his commitment to research in psycho-

therapy and his founding role in establishing EFT as an evidenced-based

psychological intervention, Greenberg was awarded the Lifetime Distinguished

Researcher Award in 2012 by the American Psychological Association.

Gottman’s Method for Couple Therapy

Gottman’s research has been highly inﬂuential in highlighting the power

of emotional expression in couple dynamics. Observations of couple inter-

actions, in conjunction with physiological data gathered, informed Gottman’s

(1994) ﬁndings regarding the trajectory to marital dissolution (i.e., via criti-

cism, contempt, defensiveness, and stonewalling).

358 meneses and scuka

Positive affect is also central to the well-being of couples. Healthy couples

have been observed to display a 5:1 ratio of positive behaviors to negative ones,

even during conﬂict (Gottman, 1994; Gottman & Levenson, 2002). Positive

affect plays an important role in marital stability among newlyweds (Buehlman,

Gottman, & Katz, 1992) and in long-term couples. Using mathematical mod-

eling, Gottman and Levenson (2002) predicted the timing of divorce with 93%

accuracy: Negativity expressed during conﬂict early in married life predicted

early divorce, whereas a lack of positive emotions in daily events and during

times of conﬂict predicted later divorce.

Over time, Gottman’s focus shifted to developing and testing methods

aimed at reversing the cycle of marital distress and enhancing marital satisfac-

tion, which culminated in the sound relationship house theory (Gottman,

1999; Gottman & Gottman, 2008). This approach incorporates an array of

empirically supported interventions, including psychoeducation, systemic-

based interventions, experiential exercises, and behavioral strategies designed

to help couples deepen their friendship, strengthen their conﬂict management

skills, and develop a shared meaning and purpose in their relationship.

Gottman and Gottman’s (2008) therapy method involves set protocols

and structured exercises to aid couples to develop a deeper perspective into

their relational conﬂict as well as to enhance skills such as empathic listening,

compassionate validation, self-soothing, acceptance of inﬂuence and com-

promise, and repair of emotional wounds. According to Gottman (1999), the

therapist’s role involves empowering, encouraging, supporting, and guiding

the couple. This is in line with the humanistic spirit; however, because the

approach relies heavily on behavioral strategies, further review of Gottman’s

contribution is beyond the scope of this chapter.

Filial Family Therapy

This approach is an adaptation of Rogerian-based child-centered play

therapy (CCPT), ﬁrst developed by Axline (1947) in her seminal book Play

Therapy. Bernard and Louise Guerney developed FFT by adding a psycho-

educational skills training component to CCPT that would (a) teach parents

the basic CCPT skills—so that they could conduct therapeutically oriented,

nondirective play sessions with their own children—and (b) provide ongoing

supervision to parents to improve their ability to offer empathy and accep-

tance to their children while also learning how to set limits effectively. One

of the original motivations behind the creation of FFT was the conviction

of the value of harnessing natural family relationships in order to promote

family healing (B. Guerney, 1964). FFT enables parents to help their children

with emotional and behavioral problems through understanding and accep-

tance. This allows children to be more understanding and accepting of their

working with couples and families 359

own emotions, which promotes better emotional regulation and, therefore,

improved behavioral self-regulation.

FFT was originally conducted in a group format (B. Guerney, 1964;

L. Guerney & Ryan, 2013) to maximize interpersonal modeling and group

support. It has also been successfully adapted into an individual family

therapy format (VanFleet, 2005). In either format, the therapist–parent

relationship is crucial, as the therapist teaches, models, coaches, and rein-

forces desired parent skills and behaviors. An essential part of the parent’s

learning process is observing the therapist model good relational skills and

later putting these same skills into practice. By experiencing the therapist’s

acceptance of the parent’s emotions, it is believed that the parent will

develop acceptance of the child’s emotions. FFT aims eventually to have

the parent conduct play sessions at home, independent of the therapist,

and to maintain one-on-one “special time” with his or her child once the

sessions are discontinued to continue nurturing the relationship.

The sequence of FFT sessions involves the following: (a) determination

of FFT appropriateness and introduction of the FFT method, including how

to prepare the child for play sessions; (b) parental skills training, including the

therapist role-playing the child to help parents practice the FFT skills; (c) one

or more demonstration play sessions by the therapist with the parents’ child;

(d) parents conducting play sessions with their child, with supervisory feed-

back provided by the therapist; (e) preparing the parents for home sessions;

(f) home sessions (ideally videotaped), with supervisory feedback; (g) general-

ization of the FFT skills to daily home life; and (h) termination.

Emotion-Focused Family Therapy

This approach centers on having family members explore the emotions

that underlie their interactions and express vulnerable, primary emotions and

their associated needs (Johnson & Lee, 2005). EFFT is usually conducted over

10 to 12 sessions with triads or dyads, although the family is seen together

both at the beginning and end of therapy.

The use of EFFT has been particularly fruitful in the ﬁeld of eating dis-

orders, where it has been integrated with traditional family-based therapy.

EFFT aims to address emotional regulation skills while simultaneously introduc-

ing adaptive eating behaviors (Robinson, Dolhanty, & Greenberg, 2015). On

the basis of Greenberg’s (2010) views that emotion is central to the construc-

tion of the self (and its internal organization), and that healthy emotional

processing arises from accurate mirroring and validation from caregivers, the

objective is to have parents become “emotion coaches.” The EFFT thera-

pist views family dynamics in terms of how emotions are experienced and

expressed. Parents learn the skills to teach their child with an eating disorder

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to turn to them rather than the symptomatic behavior when emotionally

dysregulated.

Over the three stages of treatment that integrate psychoeducational,

experiential, and systemic strategies, parents learn the basic skills to support

their child in terms of his or her emotional functioning and eating habits.

Parents work through their own emotional vulnerabilities and blocks in indi-

vidual and family sessions to serve as their child’s emotion coach. As parental

empathy skills are enhanced, the focus shifts to having the parents work

through losses and failures that occurred in the family and to take responsi-

bility for their behavior (e.g., “I’m so sorry you had to go through that. That

must have been awful for you. I should have found another way to deal with

my depression”). This invites the child to work through the pain related to

these injuries and his/her sense of blame for the onset and development of

the eating disorder. The ﬁnal stage of treatment involves supporting the child

with separation and identity formation.

Dyadic Developmental Psychotherapy

Developed by Hughes and colleagues in the 1990s to address the impact

of abuse and neglect in children who had been in foster care or adoptive

homes, DDP has evolved into a comprehensive model of family therapy also

known as attachment focused family therapy (Hughes, 2007). This model

focuses on strengthening the attachment bond between parent and child by

attending to coregulation of emotion and creation of shared meaning, as well

as by the therapist’s use of self in-session and his/her ability to both follow and

guide the family. The child’s behavioral difﬁculties are understood in the light

of past emotional injuries (EIs) that need to be healed. Research indicates

that DDP can foster more secure attachment bonds and reduce problematic

behaviors (Becker-Weidman & Hughes, 2008).

RESEARCH IN HUMANISTIC COUPLE AND

FAMILY THERAPY PRIOR TO 2000

Early Research in Relationship Enhancement and Filial Family Therapy

The RE model has a strong empirical research base that encompasses

both RE therapy and the RE Educational Program. In a meta-analytic study,

Giblin, Sprenkle, and Sheehan (1985) demonstrated its superiority to 13

other models, including other communication skills training approaches,

behavioral approaches, and religion-based approaches. This study found an

average effect size for RE of 0.96, in comparison with 0.44 across all other

approaches. Superior outcomes were noted for approaches with more structure,

working with couples and families 361

emphasizing skills training and behavioral practice. A second meta-analysis

conducted by Hahlweg and Markman (1988) conﬁrmed the effectiveness of

RE, with an even stronger effect size of 1.14.

RE has been used with various populations and across a range of problem

severity, from primary prevention programs aimed at helping couples change

parenting practices associated with psychopathology to relapse prevention

programs for psychosis (Vogelsong, Guerney, & Guerney, 1983). RE has also

shown superior results compared with a Gestalt approach (Jessee & Guerney,

1981) and strategic marital therapy (Steinweg, 1990). RE has further demon-

strated positive 1-year follow-up results with an increase in gains compared

with a posttest for both mother–daughter dyads (B. G. Guerney, Vogelsong,

& Coufal, 1983) and couples (Grifﬁn & Apostal, 1993). These unexpected

outcomes provide powerful testimony as to the long-term effectiveness of RE

even after therapy has ended.

FFT was developed on the basis of CCPT. A meta-analysis of 93 empiri-

cal research studies on play therapy found FFT to be the most effective form

(Bratton, Ray, Rhine, & Jones, 2005). The group of 26 FFT studies had an

average effect size of 1.05, whereas the subgroup of 22 FFT studies that focused

exclusively on training parents had an average effect size of 1.15. FFT is a pow-

erful family therapy intervention that uses play to enhance child functioning

and parent–child relationships.

Early Phase of Research in Emotion-Focused Therapy for Couples

EFT has a strong research tradition that includes investigation of its

efﬁcacy (e.g., A. Goldman & Greenberg, 1992; Johnson & Greenberg, 1985)

and exploration of the process of change in therapy (Greenberg, Ford, Alden,

& Johnson, 1993; Johnson & Greenberg, 1988). The preliminary efﬁcacy

studies on EFT, which were led by Greenberg and his doctoral students, typically

involved comparisons between EFT and other approaches or between EFT and

a wait-list control. For example, Johnson and Greenberg (1985) found a large

treatment effect when EFT for couples was compared with a wait-list control,

along with superior outcomes on marital adjustment and intimacy when EFT

was compared with standard behavioral couple therapy. For more severely dis-

tressed couples, EFT yielded similar results to a systemic interactional approach

(A. Goldman & Greenberg, 1992), yet had lower rates of relapse.

In the mid-1980s, the ﬁrst intensive task analyses of couples’ conﬂict

resolution were conducted (Greenberg & Johnson, 1986; Plysiuk, 1985),

revealing that accessing underlying self-experience and the softening of the

critic—processes central to intrapsychic conﬂict resolution (Greenberg,

1979)—were also important in interactional conﬂict resolution. Subsequent

research by Johnson and Greenberg (1988) examined the unique elements of

362 meneses and scuka

conﬂict resolution in couples, revealing that good sessions were characterized

by (a) deeper levels of experiencing, as measured on the Experiencing Scale

(Klein, Mathieu, Gendlin, & Keisler, 1969), and (b) interactions character-

ized as “afﬁliative” (e.g., disclosing, supporting, and understanding), as coded

by the Structural Analysis of Social Behavior system (Benjamin, 1974).

Indeed, these in-session processes successfully predicted outcome. One study

by Greenberg, Ford, et al. (1993) also found that the behavior of partners was

signiﬁcantly more supportive, afﬁrming, and understanding in the late phase

of therapy (Session 7) than it was during the beginning phase (Session 2).

Another study (Greenberg, James, & Conry, 1988) found that spouses were

more likely to respond afﬁliatively to their partners after having witnessed

them engage in vulnerable self-disclosures.

These research ﬁndings lend empirical support to the importance of reveal-

ing underlying feelings in couples conﬂict resolution, which is at the heart of

EFT for couples. A meta-analysis of the four most rigorous EFT studies revealed

a 70%–73% recovery rate for relationship distress (86% signiﬁcant improve-

ment over controls) and an effect size of 1.3 (Johnson, Hunsley, Greenberg,

& Schindler, 1999). In addition, the long-term beneﬁts of this approach have

been documented (Cloutier, Manion, Walker, & Johnson, 2002). Thus, EFT-C

is considered to be an empirically supported approach (Snyder, Castellani, &

Whisman, 2006).

RECENT DEVELOPMENTS IN EMPIRICALLY SUPPORTED

HUMANISTIC APPROACHES

Relationship Enhancement Since 2000

Accordino and Guerney (2002) conducted the most comprehensive sum-

mary of RE research to date, reviewing 25 studies, each demonstrating the effec-

tiveness of RE in terms of one or more outcome measures. (For a more detailed

analysis of the more important RE research studies, see Scuka, 2005.) Five of

the studies involved a direct comparison of RE with another model, includ-

ing reciprocal reinforcement (Wieman, 1973), traditional treatment groups

(B. G. Guerney, Coufal, & Vogelsong, 1981), and couples communication

(Brock & Joanning, 1983). In each case, RE was shown to be superior on a

majority of outcome measures and at least as effective as the comparison model

on the other outcome measures.

Over the past decade, conﬂict management skills have been intro-

duced in an effort to reduce negative patterns of interaction. These skills are

designed to help couples diffuse emotionally charged, negative patterns of inter-

action by shifting into structured dialogue mode or, if necessary, a structured

working with couples and families 363

time-out (B. G. Guerney & Scuka, 2005, 2010; Scuka, 2005). In addition,

Scuka (2005) provided a systematic delineation of the theory and practice of

RE therapy that includes an analysis of “deep empathy” as the foundation of

RE and a detailed guide outlining how to conduct RE therapy. This includes

the clinical intake process, the teaching of the core RE skills, and the coaching

of couples in their use of the RE dialogue process. There also is a section dedi-

cated to the treatment of inﬁdelity as well as six clinical vignettes illustrating

the RE therapy process through extended couples’ dialogues.

Primary prevention has always been a major focus of RE. The Mastering

the Mysteries of Love version of RE has been used extensively in the context

of marriage preparation and/or relationship enrichment programs, and it has

added a new forgiveness skill (B. G. Guerney & Ortwein, 2011). A recent

on the Mastering the Mysteries of Love version assessed the impact of three

program components on outcome for 2,940 participants, ﬁnding that skills

practice time was most inﬂuential, followed by leaders’ presentation time,

whereas group discussion time did not inﬂuence outcome (Larsen-Rife &

Early, 2011). Practice time was associated with improved problem solving at

posttest; improved communication at 30-day follow-up; and improved rela-

tionship satisfaction at posttest, 30-day, and 6-month follow-up. Research on

another adaptation of RE called Love’s Cradle (B. G. Guerney & Ortwein,

2008), which supports couples transitioning into parenthood, demonstrated

statistically signiﬁcant improvements in communication and conﬂict resolu-

tion, with an average effect size of 0.65 (Wimmer & Gibbs, 2011). Finally,

RE has been translated and reformulated into eight different languages to

attend to the special needs of refugee and immigrant groups (B. G. Guerney,

Ortwein, & Amin, 2009).

Extensive research on FFT, the family version of RE, validates that it is

an effective approach for working with families. VanFleet, Ryan, and Smith

(2005) summarized the foundational research on FFT and reviewed the posi-

tive results of 12 of the most rigorous FFT outcome studies that were included

in the meta-analysis of play therapy research previously referenced (Bratton

et al., 2005). More recently, process research by Topham, Wampler, Titus,

and Rolling (2011) demonstrated that FFT helps parents improve their own

emotional regulation skills, which, in turn, was shown to be signiﬁcantly

related to parents’ acceptance of their child’s emotion. Moreover, the study

demonstrated improvement in children’s ability to regulate their own emotion

and manage their own behavior better. The authors hypothesized (a) that

parents’ improved capacity to regulate their own emotion is the mediating

factor that helps children better regulate their emotion and (b) that children’s

improved emotional self-regulation mediates their improved behavior self-

management. These hypothesized mechanisms of change in FFT are conso-

nant with its theoretical framework.

364 meneses and scuka

Emotion-Focused Therapy for Couples Outcome Research

Since 2000: Working With Diverse Populations

Research on EFT for couples has proliferated over the past 15 years.

A multitude of studies focusing on the efﬁcacy of using this approach with

diverse populations has been conducted by Johnson and her colleagues. Case

studies have also been published demonstrating the application of the model

for speciﬁc needs (e.g., sexuality; Johnson & Zuccarini, 2010).

Dalton, Greenman, Classen, and Johnson (2013) conducted the ﬁrst

controlled trial for couples in which the female partner had experienced child-

hood abuse. Couples were randomly assigned to 22 sessions of EFT (n = 12)

or to a wait-list (n = 10). Couples in the treatment group experienced a sig-

niﬁcant reduction in relationship distress, whereas couples on the wait-list

did not. However, no signiﬁcant reductions in trauma symptoms were found

for either group.

Couples experiencing ongoing stress related to having a child with a

chronic illness have also beneﬁtted from EFT, as evidenced by Cloutier et al.’s

(2002) ﬁndings. These authors examined changes in marital satisfaction for

13 couples who had received 10 sessions of EFT, ﬁnding statistically signiﬁ-

cant improvements on the Dyadic Adjustment Scale (Spanier, 1976) scores

between pre- and posttherapy. An examination of clinical change from pre-

treatment to 2 years following the end of therapy revealed that ﬁve couples

moved from the “distressed” to the “nondistressed” range on the Dyadic

Adjustment Scale, three couples maintained their gains, four couples showed

no change, and one couple deteriorated.

EFT for couples is also considered an appropriate treatment interven-

tion for depressed women and their partners. An early pilot study compared

the outcome of 12 couples randomly assigned to 16 sessions of EFT or to anti-

depressants (Dessaulles, Johnson, & Denton, 2003). The female partners with

depression in both groups demonstrated signiﬁcant reductions in depressive

symptoms over the course of treatment; however, only the women who received

EFT continued to improve 6 months following the end of treatment. Denton,

Wittenborn, and Golden (2012) compared EFT in combination with anti-

depressants to medication use only. Both groups showed an improvement in

depressive symptoms; however, only the women receiving EFT reported signif-

icant improvement in relationship quality. These ﬁndings were echoed in the

analysis by Denton and colleagues (2012), in which 24 couples were randomly

assigned to either 15 sessions of EFT, in combination with antidepressants, or

6 months of antidepressants alone. Signiﬁcant changes were observed under

both conditions; however, signiﬁcant improvements in relationship sat-

isfaction were reported only by couples who received both EFT-C and

antidepressants.

working with couples and families 365

Couples from diverse cultural backgrounds have also been shown to ben-

eﬁt from EFT (Greenman, Young, & Johnson, 2009). True to its humanistic

foundation, EFT is inherently culturally sensitive in that couples determine

their concerns and needs, and the meaning-making process that unfolds in

therapy is understood to be a constructive and collaborative one, stemming

from each partner’s lived experience. Working with culturally diverse couples

follows the same EFT protocol, although special consideration is given to

understanding the personal and socially constructed meanings associated with

particular emotional expressions and behaviors (Liu & Wittenborn, 2011).

The use of neuroimaging techniques was at the heart of recent innova-

tive research designed to assess the effects of EFT on the neural processing of

fear (Johnson et al., 2013). The impact of holding hands with another person

under threat of electric shock was examined, using self-reports and functional

magnetic resonance imaging pictures, with 23 couples that had received 13

to 35 sessions of EFT. Spousal handholding (vs. stranger handholding or no

handholding) following EFT had the most profound effects on neural threat

responding. That is, before commencing therapy, holding a spouse’s hand had

no impact on encoding this threat. Holding a partner’s hand posttherapy, how-

ever, was signiﬁcantly associated with nonactivation of the threatened partner’s

neural stress response and a decrease in rating the pain from the shock. Findings

also revealed that the capacity to self-regulate was enhanced following EFT, as

brain activity indicating anxiety or threat decreased even when the partner

expecting an electric shock was alone. This study provides a rich perspective

into the regulatory mechanisms of close relationships, suggesting that EFT for

couples alters their sense of safety as well as their ability to self-soothe.

Forgiveness

Resolving EIs—understood as betrayals related to issues of attachment

(e.g., inﬁdelity, abandonment during a time of need) and identity (e.g., per-

ceived humiliation)—has been the focus of extensive clinical research since

2000. For example, Greenberg, Warwar, and Malcolm (2010) developed an

effective EFT intervention for resolving EIs. Twenty couples acting as their

own wait-list controls in a 10- to 12-session treatment fared signiﬁcantly better

compared with the wait-list period on measures of relational satisfaction, trust,

and forgiveness, as well as on global symptoms and target complaints. These

changes were maintained for up to 3 months following therapy, with the excep-

tion of trust, which declined over time. At the end of treatment, 11 couples

were identiﬁed as having completely forgiven their partners, and six couples

had made progress toward forgiveness. No one on the wait-list reported hav-

ing completely forgiven, and only three injured partners indicated partial

forgiveness.

366 meneses and scuka

Similarly, Makinen and Johnson (2006) developed the attachment

injury resolution model (AIRM) and tested its validity on 24 couples who

had received an average of 13 EFT sessions. At the end of treatment, 15 cou-

ples were considered to have resolved their injuries, reporting signiﬁcantly

higher levels of relational satisfaction and forgiveness. Gains were maintained

3 years following the end of therapy (Halchuk, Makinen, & Johnson, 2010).

Process Research on EFT for Couples Since 2000

The desire to understand how in-session processes are related to out-

come is one of the hallmarks of EFT research. Ongoing emphasis on studying

vulnerable emotions in-session and exploring the softening event conﬁrms

key postulates of the EFT couples model. Interest has also expanded to study-

ing the resolution of anger and EIs.

McKinnon and Greenberg (2013) assessed the impact of exposing emo-

tional wounds to one’s partner. They studied 25 couples who had received 10

to 12 sessions of EFT, ﬁnding that couples rated sessions in which there had

been an expression of vulnerable emotions as being signiﬁcantly more posi-

tive than other sessions. Moreover, the 12 couples that displayed a vulnerable

emotional expression at least once during the ﬁve sessions examined showed

greater improvement at termination, particularly on their ratings of trust

compared to couples in which vulnerability was not observed. Expressions

of vulnerability seem to be associated with short (postsession) and long-term

(posttherapy) gains (McKinnon, 2014).

In an effort to understand the therapist’s role in facilitating the expres-

sion of vulnerability, Bradley and Furrow (2004) conducted a task analysis

on the softening event—a therapeutic event characterized by an expression of

vulnerability typically initiated by the blaming partner that leads to a mutual

sharing of needs (Greenberg & Johnson, 1988). They found that the thera-

pists used evocative responding, heightening, validation, empathic conjec-

ture, and reframing, and they focused on restructuring interactions.

New developments have also been made in the understanding of a

nonvulnerable emotion common to couple therapy—namely, anger. A task

analysis of 15 couples attempting to resolve an EI (Fisher, 2012) revealed that

anger must ﬁrst be differentiated into attachment-oriented anger (over viola-

tion of trust; loss of security due to betrayal) or identity-oriented anger (over

mistreatment, harsh criticism, or violation of boundaries), although in some

cases both types of anger emerge. Therapist validation of the difﬁculties that

the listening partner may be experiencing is important (e.g., “You’re sensitive

to hearing her anger. . . . I suspect there is something going on underneath

there for you”) as well as an exploration of the blocks to tolerating the part-

ner’s anger (e.g., “I do have trouble with her anger. It makes me feel bad. You

working with couples and families 367

know, like a piece of shit”). Resolution of anger requires empathic acceptance

and validation of the expressing partner’s anger. This typically leads to the

offending partner taking responsibility for the injury, including expressing

shame, which makes forgiveness more likely to occur.

The investigation of EIs and forgiveness has been a central research

focus for both Johnson and Greenberg and their respective colleagues. The

AIRM (Makinen & Johnson, 2006) evolved from the observation of three

couples who successfully resolved their injuries (Millikin, 2000). Resolution

involves identifying the marker of an injury, its origins, and the negative

interactional cycle that has developed. The injured partner then discloses the

impact of the EI and differentiates the emotions associated with it, whereas

the offending partner attempts to hear this fully, shifting to expressing empa-

thy, remorse, and regret when the injured partner expresses pain over the loss

of the attachment bond. Finally, as the injured partner expresses a need for

comfort, the offending partner’s afﬁliative response restores the attachment

bond, making way for forgiveness and reconciliation.

The AIRM has been validated through a series of studies based on a

methodology derived from task analysis. Speciﬁcally, Makinen and Johnson

(2006) analyzed 24 couples’ self-identiﬁed best session on the Experiencing

Scale as well as on the Structural Analysis of Social Behavior system, and they

found that resolved couples displayed signiﬁcantly more afﬁliative behavior

and attained higher levels of experiencing than couples who did not resolve

their injuries. In an effort to determine the steps of the AIRM essential to

resolution, Zuccarini, Johnson, Dalgleish, and Makinen (2013) compared

the processes of nine resolved couples with those of nine unresolved couples,

ﬁnding that therapy followed the EFT couples model leading up to an injury-

related softening event. For resolved couples, an expression of vulnerabil-

ity by the injured partner was met with empathy, remorse, and an apology,

and it was followed by the injured partner’s expression of attachment needs.

Resolved couples discussed the EI in an emotionally differentiated, integra-

tive, and afﬁliative manner—a pattern linked to positive outcome (Johnson

& Greenberg, 1988).

Similarly, Meneses and Greenberg (2011) explored via a task analysis

the subtleties of the processes that give way to forgiveness in EFT-C. They

closely studied four couples who reached forgiveness, comparing them to two

couples who did not. This was an exploratory study, representing the discov-

ery phase of a task analysis (Greenberg, 2007); it resulted in the construc-

tion of an empirically based model of interpersonal forgiveness, along with

a rating system of the observed “steps” leading to forgiveness. The valida-

tion phase examined the relationship between selected components from the

task-analytic model and outcome for 33 couples who received 10 to 12 ses-

sions of EFT (Meneses & Greenberg, 2014). Hierarchical regression models

368 meneses and scuka

were used to assess the link among the injurer’s expression of shame, the

injured partner’s accepting response to the shame, and the injured partner’s

in-session expression of forgiveness and therapy outcome. An expression of

shame was found to contribute to 33% of the outcome variance in the model

(i.e., forgiveness posttherapy). Adding into the model the injured partner’s

accepting response to the shame explained an additional 9% of the variance,

and in-session forgiveness explained another 8%. The ﬁnal regression model

accounted for 50% of the variance in forgiveness.

Unlike the AIRM, which emphasizes the injured partner’s expression of

vulnerability as central in moving the forgiveness process forward, Meneses

and Greenberg’s (2014) ﬁndings indicate that the offender’s expression of

vulnerability (shame about the injury) is key to interpersonal forgiveness, as

illustrated in this excerpt of therapy with Peter, Johanna, and the therapist:

Peter: I feel bad . . . [looking down]. I’m really, truly, so sorry. I wish

I could change the past.

Therapist: And what happens for you, Johanna, as he says this?

Johanna: [sigh] I’m a bit annoyed, actually. He’s said this before—but

you know, there’s something about how he says it . . . it just

feels empty or without meaning.

Therapist: Peter, can you try speaking to Johanna directly? Look at her

and then speak to her from the heart, so she can feel what

you are saying. She needs to know how this affected you.

Peter: I . . . I . . . um [looking at Johanna] . . . [voice cracks] I can’t even

look at myself in the mirror some days knowing how much I

hurt you. I wish I could have told you about what was going

on for me, instead of sneaking around . . . and damaging what

was most important to me. [crying] I know I really damaged

us . . . It hurts to know I did that.

Johanna: [tearful] Um, I have never heard him say it like this. . . .

[whispering] Thank you.

Therapist: Tell him how it touches you when you see him like this.

Johanna: Uh, it’s actually hard for me to see you, like in your own way

suffering. I always felt alone in my sadness, but now I see he’s

sad too about what happened to us.

Recent Research in Emotion-Focused Family Therapy

Although still in its infancy, existing research in EFFT suggests that this

model is appropriate for working with families experiencing severe clinical

issues. For example, Efron (2004) applied the EFFT model to working with

working with couples and families 369

children struggling with long-term behavioral (e.g., oppositional deﬁant dis-

order) and emotional problems. In outlining three clinical cases involving

complex family dynamics in which there had been severe attachment inju-

ries (e.g., recovering from a mother’s absence due to incarceration), Efron

described the positive effects on parenting and provided clinical evidence for

EFFT’s efﬁcacy. In one family, the parents became less hostile and punitive

toward their “angry child” once they realized that his anger was secondary to

his feelings of anxiety/discomfort about being part of a blended family and

sadness/hurt at no longer feeling special to his father. When they began to

model interactional patterns that did not emphasize anger, they observed that

their children seemed calmer, less angry, and more pleasant to each other.

Preliminary support for the efﬁcacy of the EFFT model for treatment of

eating disorders is promising. Five parents who participated in eight 2-hour

sessions of an EFFT group (including psychoeducation and experiential EFT

interventions) reported signiﬁcant improvements in their sense of compe-

tency related to helping their child recover, beliefs about the value of their

child’s negative emotions, and their own emotional regulation abilities

(Kosmerly et al., 2013).

Recent Research on Dyadic Developmental Psychotherapy

Becker-Weidman’s (2006) pilot outcome study assessed the efﬁcacy of

DDP by randomly assigning children who had experienced chronic abuse in

early childhood and met the criteria for reactive attachment disorder to the

DDP group or treatment as usual. The results indicated that, at the end of

therapy and for up to 4 years posttherapy, children in the DDP group showed

a signiﬁcant decrease in their symptoms, whereas symptoms became more

pronounced for children who received treatment as usual.

FROM RESEARCH TO PRACTICE

A Transcript From an Experiential Relationship Enhancement

Family Therapy Session

The following is a slightly modiﬁed transcript from an experiential RE

family session (B. G. Guerney, 1991)1; it involves the mother, the father, their

15-year-old son, and the therapist discussing the son’s behavioral problems

1From Relationship Enhancement® Family Therapy: Experiential Format (P-Family) [DVD], by B. G. Guerney, Jr.

permission.

370 meneses and scuka

and violent behavior. Various RE skills are demonstrated, in particular the

advanced skill of Becoming, intended to facilitate exploration of blocked

emotion, self-disclosure, and insight. After the son declines the therapist’s

invitation to share his feelings, the therapist takes on the son’s identity so as

to empathically represent his experience.

Mother: [empathizing] So, you know I care and that I really appreciate

you. [Places hand on chest, the sign used to indicate a shift into

Expresser mode.] Is there anything I can do to help you?

Son: [depressed, helpless tone] I doubt it.

Therapist: [coaching] First give your mother an empathic response.

[modeling] You really would like to help me with this.

Son: [quiet, uncomfortable laugh] You would like to help me in this.

Therapist: [additional modeling] And you’d like to do it in a way that I

would feel okay about.

Son: And you’d like to do it in a way that I feel would be okay.

[Places hand on chest, shifting into Expresser mode.] But I think

I am the only one who can change myself. No one else can

help me because it’s me, it’s in my head. And you don’t know

what’s in there. And it’s only me. And I’m the one who is

going to have to change it.

Mother: [empathizing] You feel that you are all alone, and you’re the

only one who knows what’s in your head and who can deal

with what’s in your head and can change yourself. [pause]

But you’ve expressed a desire to change. You want to change.

Therapist: [prompting to Son] I think it would be helpful if you would

share some of the things that you struggle with. [shifts to

troubleshooting/empathizing] You say you’ve got things in

your head related to this that get in the way. And . . . you’re

not sure. Your thoughts are that the family can’t help; you

have to do it yourself.

Son: Um . . . hmm.

Therapist: [additional prompting] But I think I can help, if we learn more

about what those things are. . . . I might have some ideas or

ways that I can suggest. . . . But it’s true, we have to know

some of the things that you struggle about, some of the fears,

some of what you want, what gets in the way of what you

want to do.

Son: [halting speech, essentially hopeless] I don’t really want to talk

about it. It’s already . . . That’s just forgotten . . . Pretty much

of it.

working with couples and families 371

Therapist: Between you and your brother, is that what you’re talking

about?

Son: [withdrawn, quiet] My older brothers, what they did to me. I

don’t know why . . .

Therapist: [proposes becoming the son] Okay. That gives me some ideas.

[pause] I’d like to speak for [Son] then, and see if at least

you could perhaps tell me if I am on the right track or the

wrong track about that. I can see it’s difﬁcult for you to talk

about it.

Son: [correcting therapist’s empathy] [quiet, hopeless] No, it’s not.

Therapist: [troubleshooting/empathizing] It’s not that difﬁcult. It’s just that

you’re kind of hopeless about it doing any good.

Son: [discouraged] It’s just . . . It’s already happened. I can’t change it.

Therapist: [troubleshooting/empathizing] So it’s this kind of feeling: It’s

futile to talk about it. It’s not so hard to talk about, but it

won’t do much good because it’s . . .

Son: [interrupting] It won’t do much good.

Therapist: Well, I feel it might. And I think your parents would like

to know very much what these things are. [Son winces and

shakes his head.] Maybe they have some ideas.

Son: [suddenly animated, emphatic, and angry] They know! They

should know. The times [my older brothers] beat me up. [Brian]

picked me up by my neck and threw me against the wall.

Therapist: [addressing the parents] Do you feel that you know what he’s

talking about? Could you identify with what he’s saying?

[invites one of the parents to become the son]

Father: I might know some of it. I don’t think I know all of it.

Therapist: [addressing the father] Could you put yourself in his place?

Help him express it?

Father: [looks helpless, doesn’t explicitly answer, implying he doesn’t feel

he can]

Therapist: [addressing the mother] Could you talk? I think there would

be a lot of anger, a lot of rage at being treated that way.

And maybe even . . . [The therapist picks up on the mother’s

reluctance as well, and shifts gears.] Do you want me to do

it? To try it?

Father: Yes. I’m feeling a lot of mixed emotions.

Therapist: [to the Son] Let me try it. I think your parents may know what

happened, but they may not know how much it means to

372 meneses and scuka

you or how it relates to your anger. [pause] If I’m going off

track, could you just give me a tap? [Son nods afﬁrmatively.]

[It is important that the client be given permission to correct

the therapist if necessary.]

Therapist: [initiates Becoming, speaking to the parents as Son] I think you

know what happened, but I’m not sure you know how much

anger I have inside of me because of the way I was beaten

up by my brothers. I felt I was terribly abused, and even felt

scared to death at times. I felt my life was in danger. I felt

tremendous fear and anger and frustration, and a desire to

strike back. A lot of rage about not being able to defend

myself, or to hurt those who were hurting me like I wanted

to do. [seeks conﬁrmation from the son] Is that all true? [Son

nods afﬁrmatively.]

Therapist: [continuing Becoming mode] And I carry that around with me.

I have a lot of anger, rage, and resentment toward my older

brothers. It’s always within me. And sometimes it jumps out.

[seeks conﬁrmation from Son] Does that feel right? [Son gives

afﬁrmative nod.]

Therapist: [continuing Becoming mode] And I do struggle with it, because

I do appreciate what you are trying to do for all of us. I appre-

ciate that enormously, and your sharing and your telling us

that you care for us, and your willingness to help us. But I

still carry all of those feelings around. And that’s my struggle,

because the way you’re acting now is so different. So I’m

struggling to do that better, to control [my anger], and be a

constructive person in the family, but [my anger] just pops

out of me sometimes. [seeks conﬁrmation from Son] Is that

correct? [Son gives afﬁrmative nod.]

Son: [now expressing for himself] [more animated, with angry but con-

trolled tone] Well, sometimes I feel like I just want to kill

someone. If they’re bugging me, I can feel my hands [clenches

his right ﬁst several times], they start to contract and I just get

mad. It seems like there’s smoke coming out of my ears. And

I can feel it swelling up inside me, and I just . . . I just punch

the wall or something.

Therapist: [continuing Becoming mode] So I want you to understand how

hard it is for me to struggle against that. I’m willing to hurt

myself to keep from doing that. But it’s a constant battle

because of what was done to me and the rage I felt about it.

When someone makes me angry it all comes up . . . It’s hard

to stop it, as much as I want to.

working with couples and families 373

Son: [again expressing for himself ] Part of the way I acted at school

is probably part of how they treated me. When I threw that

kid over the desk, it was probably part of how what they did

affected me.

Therapist: [prompt to Mother] Could you empathize?

Mother: [empathizing with Son] [tentatively, but with genuine caring in her

voice] So you feel very angry. You have a lot of anger, a lot

of hate, a lot of rage inside of you as a result of the way your

older brothers treated you. And, because of that, it’s very

difﬁcult for you, even though we love and appreciate you,

and we’ve changed the way the family runs now, it’s very dif-

ﬁcult for you to control that anger. It’s so much a part of you.

It’s even spilled over into other parts of your life, not just

with your family, but in the way you treat people at school,

and the way you behave. You have felt so much anger there

was smoke coming out of your ears. You would hit a wall

to avoid hurting someone else. That’s how much anger you

carry inside of you.

Therapist: [resuming Becoming mode] I’m even afraid sometimes that I’m

capable of killing somebody if that gets out of hand. [turns

toward Son] Is that going too far?

Son: [quietly] A little too far.

Therapist: [empathically reinforcing Son’s disclaimer] A little too far. But

almost.

Mother: [empathizing] You’re angry almost to the point of wanting to

hurt somebody.

Son: [uncertain, and a little afraid] I mean, like if I start beating up

[my younger brother], I laugh and I think it’s funny. [pause]

Tell me if I’m crazy. [quiet laugh]

Mother: [empathizing] You’re saying that you feel that the kind of

anger you have is not normal, and it scares you, the way

you feel when you start hitting your brother. It scares you,

because you’re getting some enjoyment out of that and that’s

what scares you, the enjoyment you get in hurting someone

else. [Son nods afﬁrmatively.]

Mother: [switching to Expresser mode] I’d like to respond. [surprised

tone] I wasn’t aware of the depth of your anger, so I’m feel-

ing now that, when I ask you to control your anger, it’s

really asking an awful lot of you. [Mother shakes her head.]

374 meneses and scuka

I’m just amazed at the effect, amazed at what you’re feeling.

[big sigh] . . . though I think part of me has known that

somehow this was serious, very serious . . . [frightened tone]

and it scares me.

Son: I just want to stop. I don’t want to talk about that anymore.

[The therapist closes the session by acknowledging how difﬁ-

cult this was for the son. The parents (via the therapist) express

appreciation for his efforts to control his behavior and his desire to

change. They also express a desire to help him.]

Mother: [hopeful tone] I feel very touched and I feel good because,

now that I know, I feel I can understand what you’re going

through a bit better. I feel determined to try to help . . .

with how you deal with the anger, since it seems to me that

this is something that you would like to get a grip on . . .

a burden that you would like to get rid of. I am willing to

help you in any way I can, to get rid of that burden, to do

whatever it takes.

This powerful family dialogue illustrates the emotional depth of the

RE process and how the therapist’s use of Becoming can open up a client’s

blocked emotions. The therapist’s deep empathic representation primes the

son’s “emotional pump” so that he can take ownership of his own experience

and speak for himself. Insight and personal transformation are promoted,

particularly when the therapist asks the son, “Is that going too far?” (refer-

ring to the son’s statement about feeling like he wants to kill someone), and

he responds, “A little too far.” In that pivotal moment he reclaims his life by

afﬁrming the life path he does not want for himself.

A Case Illustration of Emotion-Focused Therapy for Couples

Johnson (1996, 2004) organized the 1988 EFT model into three stages:

(a) cycle deescalation, (b) restructuring of interactions, and (c) integra-

tion and consolidation. As noted previously, Johnson focused on working

with attachment (i.e., closeness) in her approach to EFT. In contrast,

Greenberg and Goldman (2008) expanded on the original EFT framework

by proposing a ﬁve-stage treatment model that addresses the dimensions of

attachment and identity (validation; self-worth). In brief, Greenberg and

Goldman’s approach to EFT includes the following stages: (a) validating each

partner’s current position and forming an alliance, before working on (b) neg-

ative cycle deescalation. This is followed by (c) accessing underlying vulner-

able feelings, and (d) restructuring the negative interaction and the self, where

the emphasis is on acceptance of expressed vulnerability and exploration of

working with couples and families 375

difﬁculties that may arise for one or both of the partners in this process. The

therapist facilitates an in-session enactment by encouraging partners to turn

toward each other and express, as well as respond to, each other’s feelings and

needs, generating a new way of interacting for the couple. Self-soothing work

may be introduced to transform maladaptive emotional responses predating

the relationship (R. N. Goldman & Greenberg, 2013). Finally, the couple

moves to (e) integration and consolidation.

The following transcripts come from an EFT-C session conducted by

the therapist, L. S. Greenberg (personal communication, 2013) with Sophia

and Richard, focusing on their loss of intimate connection.

Stages 1 and 2: Validation and Alliance Formation; Negative Cycle Deescalation

Sophia: On the weekend I will admit that I exploded. It was so beau-

tiful on Sunday and I suggested going for a drive to the coun-

try, and you know, maybe having a picnic by the lake, and he

just looked at me and said he had to ﬁx the shower.

Therapist: So it sounds like you’re saying that you were disappointed.

Sophia: Absolutely! Sometimes I even wonder if he even wants to be

with me.

Therapist: So somehow that comes out as anger, especially when you

feel your needs are not being met.

Sophia: In the past I would yell and scream, but now I know there’s

no point. So I go do something nurturing for me, you know,

with my daughter and my friends, or by reading.

Therapist: Right, right, so you take the initiative to take care of yourself

during these moments. But my sense is that can only go so

far, until you have to have a connection with him. And what

happens for you, Richard?

Richard: Sometimes it’s like I don’t know what to do when she tells

me that she needs this or that. I didn’t grow up in a family

where we talked about emotion or needs. It’s uh . . .

Therapist: Right, right. So it’s difﬁcult for you to make sense of her

reactions, given your history. But at the same time she’s like

a plant needing water. If you are not able to nurture her, she

starts feeling deserted, and she gets really angry, but actually

she’s feeling quite alone. And it sounds like you’re saying

you’re feeling a bit unsure at those times, so you retreat and

busy yourself.

Richard: Right, I just can’t handle all the tension.

376 meneses and scuka

Therapist: And part of what keeps this cycle going is that your with-

drawing triggers her sense of loneliness, so she comes forward

more forcefully, and so we need to work on getting the two

of you unhooked from this cycle.

Stages 3 and 4: Accessing Underlying Feelings and Restructuring

the Negative Interaction

Therapist: Try to connect with that feeling of loneliness and see if you

can put some words to it.

Sophia: [sighs] I, uh, I’m not sure where to begin . . .

Therapist: Mm-mm, so take a moment and see if you can ﬁrst locate

that feeling in your body and then just try to see what’s there.

Sophia: It’s in my chest, and it just, uh, [tearful] feels really heavy—

and sad. [crying]

Therapist: Right. “I feel really alone sometimes and I need you to be

closer.” Richard, what’s it like for you when she says she is

lonely and she needs closeness?

Richard: It’s hard. It’s like she’s saying that I’ve let her down because

I didn’t meet her expectations.

Therapist: Somehow it makes you feel like you have failed her, or that

you’re inadequate

Richard: Right, that she is demanding more from me and I don’t know

if I can give her that closeness.

Therapist: Tell her what you feel right now.

Richard: When you tell me that you’re lonely, and tell me that you

want more closeness, it makes me feel bad. Like I have let

you down . . . that I failed, and then I feel inadequate.

Sophia: [sigh] It’s like I can’t express anything without him feeling

that I am criticizing him and oomph! He puts up a wall.

Therapist: So what we have is two very different people with very dif-

ferent needs, and each one is actually legitimate and valid.

Yet somehow his withdrawal invalidates you by not giving

you what you need, and he says that you overreact. You are

very sensitive when he says that, and he withdraws, feeling

inadequate inside.

Sophia: I just don’t know what to say. I’m feeling hurt, and alone, and

he’s behind his wall.

Therapist: So what happens inside? She’s saying this quite intensely. . . .

Do you tighten up?

working with couples and families 377

Richard: I don’t know. . . . I guess I tend to . . . back away a little bit.

Sophia: As soon as I say that I am angry with him, he feels unloved. I

can see it in the look on his face. All of a sudden, there is this

look of a little boy: “What? You don’t love me anymore?” He

once told me that in his house when people got angry they

never made up.

Therapist: Do you feel unloved? Is it scary for you? You say you pull

away.

Richard: It’s more the feeling that I am unable to cope with what’s

happening—with her emotions.

Therapist: I don’t know how to handle this? It is a bit overwhelming.

Richard: Yes! It’s like, how do I make it all better again? I feel I have

a need to make it all better.

[In a later session, Sophia describes the physical disconnection

in the relationship.]

Sophia: And I’m watching the movie thinking—Ha! He doesn’t

have the feeling where you want to kiss somebody. [crying]

It’s just not there.

Therapist: So it feels like this kind of passionate love is missing, and

that makes you feel unloved.

Sophia: I feel like he is my friend.

Richard: I don’t know what to say. I’m sorry I’m a disappointment

to you.

Therapist: So this activates something deep in you, like “I am no good.”

And left alone this can escalate. Sophia, you can feel quite

unloved, and you, Richard, can feel very inadequate.

Sophia: This is not a criticism.

Therapist: Yes, yes, I understand you are actually saying “I feel very

lonely. I miss the passion.” My sense is that Richard may also

miss that. What’s your sense about the kissing?

Richard: I am aware of it, but it’s tied in with my state of mind, um,

and that’s got to do with how Sophia is feeling. When I feel

that she’s not comfortable or happy, it affects me.

Therapist: So you’re sensitive to her, and if you feel she’s unhappy, there

is an implicit criticism in that for you, like “I am not meeting

her needs.” So you tend to tense up and withdraw, which is

the opposite of what she wants. Can you tell her what it’s

like behind the wall?

378 meneses and scuka

Richard: [sigh] Uh, behind the wall is very lonely and confusing . . .

because I just drown in bad thoughts. I can’t seem to . . . [looks

down] like I can’t ﬁnd my sense of self-worth.

Therapist: So behind the wall you are feeling like “I am not OK, not

good enough, or I am failing.”

Richard: Hmmm. And then I think, if I stay behind and shut everyone

out, it’s better.

Therapist: Therefore you put up the wall to hide, so there is sort of . . .

a sense of embarrassment?

Richard: Yeah, because if they knew how I was feeling or thinking

they would think . . . uh, that I am no good, and they would

leave me.

Therapist: So it’s like you’re saying to her, “I am afraid that you would

think badly of me if you knew who I am behind the wall.

And so it is hard for me to show you.”

Sophia: But it’s precisely what has always attracted me to him and

kept our bond, that he’s this frightened, needy, lonely boy. I

want to love him and make him better.

Therapist: So when he says that, you are really moved. Tell him about

this.

Sophia: [tearful] Yeah. I want to help you. I mean I love you, and I

know that part is there, and then when you push me away,

it’s really hard for me to be loving towards you.

Therapist: He smiled when you said that.

Richard: I always imagined or envisioned a different reaction . . .

never like a reaction of love. I know you’ve never reacted

any other way, but it’s like I am always expecting the worst.

Therapist: So you see the love rather than the disapproval, and when

you, Sophia, see the little ﬂag from the frightened child, you

are quite able to respond.

Sophia: I haven’t seen that frightened child for years because of the

walls. For me it’s been like the frightened child has been

pushing me away, and then I don’t feel needed.

Richard: Uh, but the frightened child has also seen the other side of

you . . . like the witch side, and that frightened child is very,

very afraid of the witch and so closes off.

Sophia: Are you calling me a witch? [laughs]

Richard: You know what I mean.

working with couples and families 379

Therapist: And this is why I also want you to see her lonely child who

drives the witch. [laughter from both] The witch is not really

the witch; the wall is not really the wall.

Sophia: I’m putting that on the fridge! The underlying parts need to

talk more to each other.

Stage 5: Consolidation and Integration

Therapist: So it sounds like things between the two of you have improved.

Sophia: Yes, it’s taken a lot of effort, but I’m feeling closer to Richard

than I have in years.

Richard: This has been really helpful in terms of having me reﬂect on

how we’ve evolved and also how it’s been for Sophia. I feel

like I’ve learned a lot about her . . . well, both of us.

Therapist: And what would it take for you two to get back into your

cycle?

Richard: I think if I reverted back to my tendency of expecting her

to reassure me, instead of remembering the way we worked

with my memories of being a little boy, um, then I would

probably start feeling really down about myself and we would

be in trouble, because I would put up my walls, as she says,

and not be able to come out to reassure her.

Sophia: Well, I also have a role in this.

Richard: Of course you do. [laughs]

Sophia: If, instead of showing him my lonely side, the witch comes

out, then I know he would retreat because I can be scary.

[laughs] So I have to be more direct, but also soft.

CONCLUSION

Humanistic approaches to couple and family work have evolved tremen-

dously over the past decades, due in large part to the contribution of research

ﬁndings. There is now a sense that different types of processes are necessary for

different types of problems, and that emotional expression and regulation are

central to transforming dysfunctional patterns within a system. The approaches

outlined in this chapter have succeeded by maintaining the integrity of their

philosophical roots, while continuing to be process-oriented even while further

systematizing and integrating the various therapeutic approaches. It is hoped

that this will continue to be the case, even as knowledge is enhanced and

theories are reﬁned.

380 meneses and scuka

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Chapter

Apr 2022

Families are systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Family systems theory places primary focus on exchanges of behavior that take place in a given moment of interaction between family members. Systemic family theory and therapies pay close attention to repeating transactions that connect the problem behavior of one person with the behavior of others within the family or other primary groups. Family system therapy is not a specific therapy with a specified theoretical orientation. Although it is efficacious for several child and adult mental problems, further efficacy studies are necessary.

In-Session Change in Emotionally Focused Therapy

Article

Full-text available

Feb 1993

This article presents 3 different studies of in-session changes in emotionally focused couples therapy (EFT). Studies of in-session conflict events demonstrate both that couples’ conflict interaction at the end of treatment is more affiliative and interdependent than at the beginning of treatment and that peak session conflict interaction is deeper in level of experience and more affiliative than the interaction in poor session conflict episodes. In addition, events beginning with intimate, affective self-disclosure by one partner were found to involve greater affiliation in spouses’ responses to the self-disclosure than in a control event not involving self-disclosure. The possible change processes in EFT are discussed in light of these results.

Perceived Change Processes in Emotionally Focused Couples Therapy

Article

Full-text available

Sep 1988

Reports from 21 couples of critical change incidents in their marital therapy experience were sorted into five categories of change processes. The couples' reports were collected 4 months after the completion of eight sessions of emotionally focused couples therapy. The couples' reports revealed five major change processes: expression of underlying feelings by one of the partners leading to change in interpersonal perception, expressing feelings and needs, acquiring understanding, taking responsibility for experience, and finally receiving validation. These empirically derived processes were compared with the theoretically derived processes and demonstrated the importance of studying what clients say about change to enrich the understanding of change processes in marital therapy.

Effectiveness of Behavioral Marital Therapy: Empirical Status of Behavioral Techniques in Preventing and Alleviating Marital Distress

Article

Full-text available

Jun 1988

This article uses meta-analyses to determine the effectiveness of behavioral marital therapy (BMT) and premarital intervention (BPI) studies. The effect size for the 17 BMT studies was .95 and for the 7 BPI studies was .79, and these gains were generally maintained over time. Cross-cultural comparisons of BMT indicated equal benefits for couples in Europe and the United States. For BMT, effect sizes were higher for comparisons with no treatment versus placebo control groups, whereas the reverse was true for BPI. For BMT, effect sizes were similar for observational and self-report measures, whereas for BPI, effect sizes were larger for observational versus self-report measures.

Differential Effects of Experiential and Problem-Solving Interventions in Resolving Marital Conflict

Article

Full-text available

Apr 1985

The present study compared the relative effectiveness of two interventions in the treatment of marital discord: a cognitive-behavioral intervention, teaching problem-solving skills, and an experiential intervention, focusing on emotional experiences underlying interaction patterns. Forty-five couples seeking therapy were randomly assigned to one of these treatments or to a wait-list control group. Each treatment was administered in eight sessions by six experienced therapists whose interventions were monitored and rated to ensure treatment fidelity. Results indicated that the perceived strength of the working alliance between couples and therapists and general therapist effectiveness were equivalent across treatment groups and that both treatment groups made significant gains over untreated controls on measures of goal attainment, marital adjustment, intimacy levels, and target complaint reduction. Furthermore, the effects of the emotionally focused treatment were superior to those of the problem-solving treatment on marital adjustment, intimacy, and target complaint level. At follow-up, marital adjustment scores in the emotionally focused group were still significantly higher than those in the problem-solving group.

The empirical validation of relationship enhancement couple and family therapy.

Chapter

Jan 2002

Relationship Enhancement Therapy: Healing Through Deep Empathy and Intimate Dialogue

Book

Jan 2013

Robert Scuka

Filial therapy: A critical review.

Chapter

Jan 2005

Research on experiential psychotherapies

Article

Jan 1994

The emotions

Book

Jan 1986

N. H. Frijda

Emotionally Focused Couple Therapy with Intercultural Couples

Chapter

Jan 2009

Emotionally focused couple therapy with intercultural couples In the past three decades, there has been an unprecedented increase in the number of intercultural marriages worldwide (Frame, 2004; Molina, Estrada, & Burnett, 2004; Waldman & Rubalcava, 2005). Intercultural relationships typically refer to a union between partners from different racial, ethnic, national, or religious backgrounds (Ho, 1990). Although all couples negotiate their individual differences to a certain extent, intercultural couples are faced with a “synergy of differences” that often taxes the relationship (Sullivan & Cottone, 2006). Despite the prevalence of intercultural marriages and the unique stresses of such relationships, including higher rates of divorce and a greater tendency to be in second marriages compared with intracultural couples (Gaines & Agnew, 2003; Gaines & Ickes, 1997; Gaines & Liu, 2000; Waite, Bachrack, Hindin, Thomson, & Thornton, 2000), the impact of cultural factors in couple therapy has largely been ignored, with a few notable ...

Humanistic approaches to working with couples and families

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