Review of Susan Johnson and Leslie Greenberg’s
Approach to Couples Therapy

Notes from my Couples Therapy Class

To hear you say my name, to see you search my eyes…
To feel you touch my hand, it more than satisfies.
If I was not the first, just say I’ll be the last.
It’s too much to expect, but it’s not to much to ask.

Now I can only dream of being all you need, And I can only try to be the reason why.
You think about today, and forget about the past. It’s too much to expect, but it’s not to much to ask.
— Mary-Chapin Carpenter and Don Schlitz

Some love is just a lie of the heart, the cold remains of what began with a passionate start.
And they may not want it to end, but it will, it’s just a question of when….

Some love is just a lie of the mind. It’s make believe until its only a matter of time.
And some might have learned to adjust, but then it never was a matter of trust….

Some love is just a lie of the soul. A constant battle for the ultimate state of control.
After you’ve heard lie upon lie, there can hardly be a question of why.
— Billy Joel

Johnson and Denton describe EFT as developing from an imaginary tea party where Rogers, Bertanlaffy, and Bowlby all sit down to chat. It’s a cute metaphor for how disparate theories were tied into one, worked over, and eventually published in 1985.

Of note, the therapy was all practice driven at first – it was not born in a laboratory, but rather in private practice and clinic offices, and refined through reflection and consideration before publication.

Basic Concepts of Emotion Focused Therapy for Couples

• Emotion and attachment have received little recognition in previous treatment models compared to rational cognitions and logical behaviors. EFT therapists validate the partners’ emotions and attachment needs, respond genuinely to the partners individually, and try to stir the two partners’ own ability to heal themselves and their relationship (the relationship is the client). This fits well with Gottman’s research that it is not negative emotional engagement that predicts divorce, but rather a lack of emotional engagement.
• The process of uncovering emotions is not the same as catharsis, but is an effort to reveal and integrate marginalized and denied emotions by identifying and engaging them in the moment.
• The therapy session is seen as a healing place where a corrective emotional experience between partners happens, and it is that process that is the method of therapeutic change. The therapist is egalitarian, and empowers the partners.
• The therapist avoids over-pathologization by remembering that current negative emotional responses were adaptive at some place and time; what seems irrational now actually was a logical response somewhere and somewhen. However, previously adaptive behaviors are now mismatched to the situation, or are rigidly practiced, and so are now maladaptive.
• Systems theory combines two individuals and creates a whole relationship that is more than the sum of the part(ner)s. For Partner 1, inner emotional experiences influence external experiences, which in turn prime the person for the same inner emotional experiences, re-influencing external experiences…. This cycle for Partner 1 feeds itself and the same cycle for Partner 2, whose cycle feeds itself and that of Partner 1…. The whole thing takes on a life of its own and becomes “a self-maintaining positive feedback loop”. This means positive encounters can have a compounding effect, while experiences in which one partner failed to respond to the other’s needs (attachment injuries) can warp perceptions of future experiences.

As for the quotes at the beginning…

The first comes from a Mary Chapin Carpenter song, and highlights that some of the things we want from our partners (to be completely satisfied in life by them, and to be everything they need in return) are too much to expect… but these are absolutely normal to want and wish for.

The other is from a Billy Joel song, and tells the story of loves that soured. They became only habits, or lies people tell themselves, or lies they tell each other. These loves lost their attachment and connection… which was always based on trust, and truly risking intimacy.

Thus, I think both songs really capture some of the basic ideas of EFT.

Strengths of Emotion Focused Therapy

• EFT is considered one of the most well-substantiated therapies (even Baucom, the heavy-duty behaviorist agrees) with well designed studies backing it up as having isolated necessary and unique factors of change in therapy.
  • It’s been shown to be an effective treatment for couples and families facing sexual abuse histories, depression, grief, management of chronic illness, eating disorders, and PTSD. The only caution I’ll offer though is that it’s hard to tell from the studies I’ve read whether the bulk of the research has been based on married or cohabitating couples.
  • Meta-analysis of the best EFT studies (with randomized assignment and control groups) shows a Fail Safe n of 30-50, so the effect sizes obtained are pretty strong.
  • EFT is brief work (8-12 sessions) and leads to as good or better rates of improvement (less distress after therapy) and recovery (adjustment and satisfaction scores in the non-distressed range) as other therapies.
  • Several studies show slight increases in adjustment and functioning after therapy has ended. Cloutier et al. (2002) found 62% improved at termination, but 77% improved at the two year follow-up (an increase of 15%). She found 15% were recovered at termination, while 64% were recovered at the two year follow-up (an increase of 49%). The longer terms studies show about the same rate of improvement; some show over a 30% increase in recovery, but the follow-up for these studies is generally a few months.
  • In Cloutier’s study, in the EFT group 7% had divorced two years after the treatment, compared to 38% of the controls.
  • In fairness though, Johnson and Greenberg acknowledge that they have been involved in the majority of the research for EFT. Even though it’s been methodologically sound, other researchers need to get involved 1) to avoid allegiance bias, and 2) to make sure that conclusions from studies of EFT with expert therapists really do relate to how it’s done with real world therapists and cases.
  • Christensen reports that there have been nine solid studies of the effectiveness of EFT, prompting Baucom and colleagues (1998) and Gurman and Fraenkel (2002) to both rate EFT as one of the most research supported therapies for couples.
• Clients report that five things happened in therapy that made things better for them:
  • One partner expressed underlying feelings, and the other changing their perceptions of the partner after hearing this
  • Learning to understand underlying emotions
  • Learning to productively express emotional needs
  • Taking responsibility for emotional needs
  • Receiving validation for one’s needs
• Indicators for EFT are high negative emotional engagement, low sexual affection, older couples (especially for men over 35), and lower sense of emotional engagement or time together in the couple; interestingly, these are also predictors of failure in TBMT.
• EFT is culturally sensitive as universal emotions are examined, but placed in a personal cultural context. For example, shame is universal, but shame takes on an additional role in the Japanese culture. Anger is universal, but often takes different forms when men and women express it. Responsibility is universal, but what’s “a man’s responsibility” and “a woman’s responsibility” is determined but the culture’s views of marriage.
• EFT is humanistic based, and believes the couple can heal itself. Feminists appreciate that the therapy model:
  • Does not shows a patriarchal pathologization of connection and attachment (women’s ways of relating), and idealization of separation and individuation (men’s ways of relating).
  • Requires that the does not assume the position of power over the couple, but empowers the partners.
  • Views both partners as lacking in some skills; men need to expand their emotional repertoire and women need to feel powerful enough to express their needs.
  • Allows for the analysis of changing gender expectations that create a new kind of stress for couples to manage. Examples include dual careers, the freedom not to marry, and expectations of both parents to raise the children.
• EFT offers a theory of how to understand adult love, which has been lacking in the field of couples therapy:
  • EFT offers a way (based on attachment theory) to integrate disparate practices like gottman’s therapy, ibmt, and narrative approaches.
  • Counter-productive behaviors can also be seen as an insecurely attached partner’s efforts to provoke some kind of response, rather than as stable pathology.
  • Attachment theory also explains healthy development, as securely attached partners are open to reframes and different points of view, and able to tolerate ambiguity, to meta-communicate, to handle learning unflattering things about themselves, to feel and express regret for their past failures recognizing and meeting their partner’s needs, and to see their understanding of the world and others as working models.
  • Attachment theory also explains unhealthy development, as insecurely attached mourn lost attachments (think about someone who is legally married but has been emotionally divorced for a long time), engage in inconsistent attachment behaviors (think attack and defend, or pursue and distance patterns), suffer ongoing attachment injury (ongoing negative sentiment override), may experience attachment panic (maintain physical and emotional control over their partners), or maintain multiple attachments for fear of losing or being swallowed by one (who have affairs).
  • Attachment theory also makes building love maps and rituals of connection, halting the four horsemen and flooding, and engaging in behavioral exchanges all behaviors that can improve attachment. However, as johnson says, simple skill building and behavioral scripting is not sufficient for marital improvement; rather, the ability to “unlatch” from negative emotional and behavioral cycles is required.

Steps of Emotion Focused Therapy

Building of an Alliance with the Therapy
This isn’t a discrete stage, as it is a process that spans the whole of therapy. But you have to start with this as your first goal for therapy. The therapist has to create a safe holding environment for the partners in order to open up intense emotions. Research supports this is a better predictor of outcome than initial emotional distress, and that if you haven’t established this by session #3, therapy is very likely to fail.

There are several keys to doing this well:

• Be genuine; you can’t fake this. Part of this is being transparent, making sure they understand what you are doing with them and why, tying the therapy activities to the goals for therapy, and being a consultant who educates and moves with them, rather than leads and expects them to follow. Transparency is actually one of the better predictors of success in EFT.
• Trust is a key (as Billy Joel said). 20% of failures in EFT can be predicted solely by asking the female partner during the assessment phase if she trusts the male partner. If she doesn’t, then therapy has a lower chance of working.
• You stress strengths, willingness to face and overcome problems, and natural ability to heal. To do this well though you have to believe this of the couple and their potential. Johnson stresses the irrational things people do were rational and logical at some time and place; you have to be willing to see that and validate it for them, but support them in believing they can find a new way to adapt now.
• Monitor the alliance–expect there will be breaks, but actively monitor the process. Avoid flooding them with emotions they can’t handle or “leaving them behind.”
• Admit when you are wrong, when you made a mistake, or when you failed to understand something (it supports corrective emotional experiences and models for the couple how to do the same).

Interestingly, level of initial distress, lack of emotional expression, age and income, and religious differences do not seem to limit benefit from EFT. If anything, lower education and income clients seem to do better in EFT compared to high SES clients.

Phase 1 Assess and De-Escalate
Step 1 Identify the Conflict
Step 2 Identify the Cycle where the Conflict is Expressed
Step 3 Access Unacknowledged Emotions
Step 4 Reframe – Victims of the Cycle and Now Allies Against It

Steps 1-3 are sometimes called the Three P’s — Present context, Process patterns, and Primary affect.

Johnson advocates an assessment phase to guide all this, seeing them together and separate. However, this kind of is Step 1, rather than being a separate assessment phase followed by an official beginning to therapy. Background is important only as it impacts the current life dynamics; this is not a Bowenian insight into the family history kind of therapy. Ask them what they hope to gain from therapy to focus them. Weave their separate complaints into one, and tie this to a plan for treatment and a contract for therapy. Sometimes you may see them together, but sometimes apart to help them be together when you do the next conjoint session.

Phase 1 is the hard part. You have to seek out vulnerable emotions, and very slowly build the awareness of them. Johnson gives the example of moving from “uncomfortable” to “upset” to “hurt” eventually. Feminists argue we are surrounded by social and cultural messages that tell men to not express emotions of dependency and fear for risk of being seen as needy and weak. These messages tell women to not express assertiveness and anger, or risk being seen as dominating and bitchy. Thus, you can explain to the couple that some emotions may be especially uncomfortable for them to uncover because society’s gender roles have encouraged them to avoid doing so all their lives. This takes some of the blame off of them, and provides another example of how they can be victims of something larger, but not slaves to it.

When uncovering the “primary” or underlying emotions, notice the language the partners use. You’ll hear partner’s say things like “I feel like I’m drowning” or “I’m dying and you can’t hear me screaming for help.” It seems dramatic, but it captures an intense, painful, and powerful emotional experience (and Narrative therapists would use these words and analogies to weave together a story that both members could accept). The “secondary” emotions of anger and resentment are far easier to show and talk about when you think about it this way.

If you watch Johnson doing this kind of therapy, it may seem she goes on and on at times about the same issues. However, it is the act of saying these things, hearing these things, and afterward finding nothing horrible happened… that helps people tolerate their emotions and feel safe when they express them. Good EFT therapists use techniques like:

• Speaking slowly, calmly, and patiently, checking with the client to make sure they are remaining engaged. Like Bowenian therapists, they know they set the tone for the session, and if they communicate by their demeanor that they can tolerate the intimacy, and are not afraid of it, they can help the clients do the same.
• Reflective statements (“It seems you are feeling terribly scared by that”). This may seem to be simple validation a la Rogers, and to some extent it is… but it is also helping the partner listening to understand the key points, the words to describe what they see in the other, and the power of these emotions.
• Validation (“And it’s hard to even talk about this kind of fear, especially for you given your past experiences with relationships”). This kind of statement helps the partner listening see the link between the past and the present, and helps the partner speaking see it and accept it too.
• Evocative questions (“What’s happening now for you as i say that… What’s it like to say that out loud, here and now?”). In some sense, this is drawing attention to meta-emotion, or emotions about emotions and expressing feelings. It can help the partner speaking be mindful of the moment, attend to what they feel in their bodies as they talk, and “own” in a very concrete way their feelings.
• Heightening (using images like “It feels like a noose around your throat that could strangle you at any time” to evoke imagery that captures their emotional experiences, or asking one person to repeat something to their partner). Sometimes students say they think that Johnson is leading the clients by talking this way. I think of her as being out in front of them, blazing a trail instead. Once she says something like this, it is safe for the partner to agree if it is true, as well as safe to say “Well, it’s not that bad” if it is not. This clears some emotional safe to explore the feelings. her extreme language though is often needed because people have sort of become lost, deadened, or cut-off from their feelings, and this kind of language “wakes them up” so to speak.

You might be thinking this contradicts Gottman’s idea of halting the Four Horsemen in their tracks. How can you validate their emotions and shut them off if they seem caustic? Johnson acknowledges trying to contain the caustics, but she also tries to shift the emotional expressions from the secondary aggressive ones to the underlying primary vulnerable ones, moving the couples toward a softening or corrective experience.

Phase 2 Change Events
Step 5 Promote Identification of Disowned Needs
Step 6 Promote Partner Acceptance
Step 7 Facilitate Expression of Needs and Wants

Phase 2 really involves creating corrective emotional experiences. Teaching the partner to use “I” statements to identify their needs for themselves, priming the mate to accept and maybe meet these needs, and coaching them both on how to effectively compromise on this is the process here. So, rather than the partner berating the mate for being so cold, the partner acknowledges their loneliness and need for companionship, and asks the mate for help in this. This is also consistent with Gottman’s ideas of having “the conversation they never had” and finding the “dreams within conflicts” that make a seemingly minor problem a battle of epic proportions.

Use techniques like

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

Part of Step 7 is getting the mate to express they want to be close to the partner, but the partner does things to push them away (such as speaking contemptuously or critically). The mate needs this to decrease before they can provide support to the partner. Help the “attacker” in this case share their fears, rather than try to drag the “distancer” back to the relationship. You have to make it safe for the “distancer” to come back. Affirm for them how hard it is to do this, how risky it feels, and make sure the partner integrates this, and the mate realizes how hard it is for the partner. Johnson gives examples of asking a wife to tell her husband how scared she is. She says she can’t. Johnson responds, “Can you tell him that you simply can’t talk to him about this, that it is so painful to talk about you just can’t do it yet.” The act of telling the mate these primary emotions is displaying vulnerability; even the act of telling the mate they aren’t strong enough yet to do it still displays vulnerability. It is also a successive approximation to confiding in the mate.

This process is in many ways like Solution Focused Therapy. In Solution Focused Therapy, we hope to expand your awareness of the problem, change the way you talk about it, and thus change the underlying way you experience the problem. In Emotion Focused Therapy, we hope to expand your awareness of your inner emotional processes, change the ways you feel about problems, and thus change the way you experience the world. Both should open up new solutions.

Feminists offer that men may have been trained to assert their needs clearly and strongly, but to expect nurturing or soothing responses from women without any awareness of the cost for the women. Getting the woman to explain what’s going on for her and the costs may be eye opening for both. There is a case discussed in a chapter on gender issues of a husband who gave his wife whatever she needed, and she became angry when he expected she would be able to set up a dinner to entertain a client. He couldn’t understand her anger, and she felt she wasn’t entitled to it. He later realized his control of money was based on his fear that she would either use him or leave him, and she was afraid to express her emotions for fear that he could replace her easily. Sometimes these gender issues can be explored by asking what partners learned from their parents about relationship roles and what makes for a successful relationship… and what they want to do or teach their own children that is different.

Phase 3 Consolidation of Change
Step 8 New Solutions
Step 9 Consolidation

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

Impasses
Johnson and Greenberg, to their credit in designing a good theory, focus on successes in treatment, but also on failures and impasses. Here are some ideas for when progress seems stalled:

• Try having some individual sessions with the partners to explore what’s not happening.
• Use disinquisitions. The Inquisition was an active, painful, abusive uncovering of “the truth.” Disinquisitions are stories, fables, metaphors… that invite introspection but don’t demand it. They are about the client, but not on the surface, and reflect client processes, but not directly and obviously. They normalize the couples’ experience by reducing it to a simple and universal struggle, and offer a new way of looking at issues without labeling things for the client. You can introduce them with, “I don’t know why this came to mind, but I was thinking of this story I heard once…” or “When I hear you say that, I get this image in my mind…”
• Millikin offers he told a story of a little boy who was walking through the woods, and was very scared of the shadows. He met a girl who carried him to keep him safe from the shadows. She became tired, but he wouldn’t let her put him down. Eventually, she fell down and dropped him, and he was hurt. He thought she deliberately threw him to the ground to hurt him, and so in anger he kicked her. He limped away in one direction and she limped away in another.
• Johnson gives an example of a wife who needed an emotional gun (her anger) in order to protect her, and without it she felt vulnerable. Metaphors like this offer solutions too, as she could understand that a person pointing a gun at her husband would not be approachable, and that she could holster her gun–not give it up and feel vulnerable, but learn to put it away for a time when she judged the situation as safe. Other examples include walking through fire, or surrounding oneself with barbed wire. I once had a client who used the expression “the smell of burning martyr” in his family to mean those times when someone was using their attachment to get something from a family member, and did it by inducing guilt and shame in the family member for the sacrifices the person had made for them.
• Look for an attachment injury that may be preventing forward movement. For these, coach:
  • the injured one to “stay with the injury” and own it
  • the mate to acknowledge it
  • the injured one to admit still being hurt, and to express a desire to move on toward healing but a need for help to do this
  • the mate to state their willingness to offer the help
  • the injured one to ask for what they need to move on
  • the couple to construct a new dynamic and story between them about what can be done to help heal the injury, and how they both are valiantly working together to overcome it and heal each other

Resources

For more information, see:

• Vatcher C. A. & Bogo, M. (2001). The feminist/emotionally focused therapy practice model: an integrated approach for couple therapy. Journal of Marital and Family Therapy, 27(1), 69-83.
• Millikin, J. W., & Johnson, S. M. (2000). Telling tales: Disquisitions in emotionally focused therapy. Journal of Family Psychology, 11(1), 75-79.
• Johnson S. M. & Greenberg L. S. (1985). Differential effects of experiential and problem-solving interventions in resolving marital conflict. Journal of Consulting and Clinical Psychology, 53(2), 175-184.
• Millikin, J. W. (2000). Resolving Attachment Injuries in Couples Using Emotionally Focused Therapy: A Process Study
• Johnson, S., Maddeux C., Blouin J. (1998). Emotionally focused family therapy for bulimia: Changing attachment patterns. Psychotherapy: Theory, Research & Practice, 35, 238-247.
• Johnson, S., Hunsley, J., Greenberg, L., & Schindler, D. (1999). Emotionally focused couples therapy: Status & challenges. Clinical Psychology: Science & Practice, 6, 67-79.
• Johnson, S. & Talitman, E. (1997). Predictors of success in emotionally focused marital therapy. Journal of Marital and Family Therapy, 23(2), 135-152.
• Cloutier, P. F., Manion, A., G., & Gordon-Walker, J. (2002). Emotionally focused intervention for couples with chronically ill children: A two-year follow-up. Journal of Marital and Family Therapy, 28(4), 391-398.
• References for EFT