Process Research on Emotionally Focused Therapy (EFT) for Couples: Linking Theory to Practice

• Author: Paul S. Greenman,Susan M. Johnson
• DOI: http://doi.org/10.1111/famp.12015
• Published date: 01 March 2013
• Date: 01 March 2013

Process Research on Emotionally Focused Therapy

(EFT) for Couples: Linking Theory to Practice

PAUL S. GREENMAN*

,†

SUSAN M. JOHNSON

‡

The focus of this article is on the link among theory, process, and outcome in the practice

of Emotionally Focused Therapy (EFT) for couples. We describe the EFT model of chang e

and the EFT perspective on adult love as the reflection of underlying attachment processes.

We outline the manner in which theory and research inform EFT interventions. This leads

into a detailed review of the literature on the processes of change in EFT. We highlight the

client responses and therapist operations that have emerged from process research and

their relation to treatment outcomes. We discuss the implications of this body of research

for clinical practice and training.

Keywords: EFT; Couples; Process Research

Fam Proc 52:46–61, 2013

Awareness and understanding of the complex interpersonal processes germane to the

practice of psychotherapy are essential tools to help clinicians maximize the effective-

ness of their interventions. It is imperative that therapists know what to do with particu-

lar clients, when to do it, and how. Couple therapists especially are in need of a detailed

guide for their work to make meaningful differences in the lives of the people they serve,

because they have to manage the feelings and reactions of two individuals whose behav-

iors, thoughts, and emotional experiences are in constant interplay (Gottman, 2011; Gott-

man & Levenson, 2002). It is also important for couple therapists to take note of their

clients’ reactions to and confidence in the interventions that they use during the course of

treatment, because these are related to outcomes (Johnson & Talitman, 1997).

Unfortunately, knowledge of the process of psychotherapy is lacking, which can be par-

ticularly troubling to the therapist attempting to navigate the landscape of couple and fam-

ily dynamics (Bradley & Johnson, 2005; Johnson & Bradley, 2009). As Bradley and Johnson

(2005) have pointed out, “Mountains of research support and charismatic presenters matter

little when clinicians are unable to translate application into the moment-to-moment pro-

cess of a key session…the abstract ‘map’ given in clinical handbooks and described and

tested in research studies is often not detailed enough to guide a therapist through the

actual in-session terrain” (pp. 254–255). This is problematic in light of repeated findings

over the past 30 years which suggest that between 25% and 30% of couples who receive

therapy do not demonstrate significant improvement and that there are substantial rates of

relapse (close to 40%) among those who do (Halford & Snyder, 2012; Halford et al., 2012).

Despite claims of the relevance of process research for the day-to-day practice of couple

therapy (e.g., Gurman, 2011) and calls for more practice-focused research with an emphasis

on “specific mechanisms of change” (Sexton et al., 2011, p. 379), there is nonetheless scant

*Universit

eduQu



ebec en Outaouais, Gatineau, Canada.

†

Hoˆpital Montfort and Ottawa Couple and Family Institute, Ottawa, Canada.

‡

Ottawa Couple and Family Institute, University of Ottawa, Ottawa, Canada.

Correspondence concerning this article should be address to Dr. Paul S. Greenman, D

epartement de

psycho

education et de psychologie, Universit

eduQu



ebec en Outaouais, 283, boul. Alexandre-Tach

e, Gati-

neau, QC, Canada J8X 3X7. E-mail: paul.greenman@uqo.ca

46

Family Process, Vol. 52, No. 1, 2013 ©FPI, Inc.

doi: 10.1111/famp.12015

information linking the process of therapy (i.e., what therapists actually do in session and

how their clients respond to their interventions) to successful outcomes (Halford, Sanders,

& Behrens, 1993; Halford & Snyder, 2012).

One of the few exceptions to this is Emotionally Focused Therapy (EFT) (Johnson,

2004; Johnson & Greenberg, 1985), an approach to couple therapy with substantial empir-

ical support, evidence of lasting treatment effects (Cloutier, Manion, Gordon Walker, &

Johnson, 2002; Halchuk, Makinen, & Johnson, 2010), and a growing body of process

research (e.g., Bradley & Furrow, 2004; Couture-Lalande, Greenman, Naaman, & John-

son, 2007; Johnson & Greenberg, 1988) that illustrates some of the behaviors and

responses of both clients and therapists that appear to be related to positive treatment

outcomes. In light of the pressing need for a compass to help orient couple therapists, the

primary aim of this paper is to elucidate the therapeutic processes involved in the success-

ful implementation of EFT for couples. We will demonstrate the manner in which specific

theories of psychotherapeutic change, scientific research on the nature of adult love, and

attachment theory combine to provide a map for EFT practitioners. This will lead into a

review of the process research that has already been conducted on EFT and a discussion of

the implications of our current knowledge of EFT processes for therapists, researchers,

and trainees. We conclude with reflections on potential directions for future process

research into this approach, in a continuing effort to improve its efficacy and applicability

to as wide a range of populations as possible.

EMOTIONALLY FOCUSED THERAPY FOR COUPLES: A THEORETICALLY

GROUNDED, RESEARCH-BASED APPROACH

Emotionally Focused Therapy (Johnson, 2004; Johnson & Greenberg, 1985) for couples

is an experiential-humanistic, systemic intervention. It is an empirically supported treat-

ment for couple distress (Johnson, Hunsley, Greenberg, & Schindler, 1999; Snyder, Cas-

tellani, & Whisman, 2006) whose effects appear to be stable over time (Cloutier et al.,

2002; Halchuk et al., 2010). EFT consists of three stages divided into nine steps; each

stage has its own specific set of therapeutic goals. The steps and stages of EFT as it is

taught and practiced today are the result of research into the process of change in couple

therapy (e.g., Greenberg, Ford, Alden, & Johnson, 1993; Johnson & Greenberg, 1988).

This section contains a brief overview of the basic components of EFT. For a detailed

description of the therapist operations and client end states at each step and stage of EFT,

please consult the treatment manual (Johnson, 2004).

Therapists work during Stage I toward what is known as cycle de-escalation. This

involves helping partners identify problematic interaction patterns as the root cause of dif-

ficulty in their relationship. They sensitize couples to the myriad emotional experiences

that drive their negative interaction pattern, but that remain out of awareness during con-

flict. These include sadness, loneliness, and fear, all borne out of a desire to feel emotion-

ally close and connected to their partner (Johnson, 2004, 2008).

Stage II of EFT involves re-structuring the couple’s interactions to achieve a secure

attachment bond. Withdrawer re-engagement and blamer softening (Bradley & Furrow,

2004; Johnson, 2004) are the major therapeutic objectives of this stage. In general, couples

in distress often display an interactional pattern in which one partner tends to criti cize,

complain, or make numerous unsuccessful attempts to engage the other during conflict,

while the other partner tends to become defensive and to withdraw emotionally from the

problem situation (Gottman & Silver, 1994). Expressions of contempt, anger, and height-

ened physiological arousal (particularly in men) typify this “pursue-withdraw” cycle (Gott-

man, 2011; Gottman & Silver, 1994). At the end of successful Stage II work, previously

withdrawn clients are more at ease acknowledging and expressing their hurts and fears

Fam. Proc., Vol. 52, March, 2013

GREENMAN & JOHNSON

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