Emotionally Focused Couple Therapy

Who are the key people associated with EFT?

The key founders are Susan Johnson and Les Greenberg. The question is complicated because it depends on which version of EFT you are talking about. Susan Johnson’s version of EFT is couples and family based, and was developed by both Sue and Les, but Sue has done the primary development of this approach since then. Les calls his version Emotion-focused Therapy instead of EFT. He uses this Emotion-Focused Therapy to describe an umbrella of approaches that he talks about as being both experiential and systemic in nature and that use emotion as an agent of change. In recent years, he has piloted the individual version of Emotion-Focused Therapy. He had been developing symbolic-experiential therapy for years and has taken that, built on it, and done some marvelous work with his colleagues, just has Sue as done marvelous work with her colleagues. One of the big differences tends to be that Sue’s version is much more attachment focused and is really primarily a couple and family approach.

How is your approach to EFT similar or different from Dr. Johnson’s?

We both use the same theory. I think that my therapy is different because I am a different person and that is true for all therapists. We, as therapists, bring one of the important parts of EFT, which is lived experience and the presence of the therapist in the therapy room and use that as an agent of healing. The differences relate to who we are as people. For example, I am a man and she’s a woman. She is a Canadian who emigrated from England. She grew up in a pub in England and I grew up in the United States; therefore, culturally, we have different cultural backgrounds.

What are the similarities?

We both use a lot of evocative questions and empathic conjectures. I would say in some ways she is the master at being able to stay with emotion and walk around in it and I still aspire to be able to do it as well as she does. I have learned a lot of things about how to do EFT from her; she is my primary teacher. There are some things that I do differently though.

Such as?

Simply, I use my gender. I use my background. I use those kinds of things to relate to people. Sue will often use her personal experiences as do I. For instance, I have a background in business and to some degree, in electronics, mechanics, and construction. That allows me to join with people and connect with people, particularly engineering types. I grew up with lots of engineers around me. My first planned major in college was electrical engineering. I tend to use those kinds of things as bridges to people in addition to my experiences of living in southern California and my training in diversity and multicultural issues.

In session you mean?

In sessions and I would certainly do it in trainings as well. Even though we use the same model, we are different people. The differences in the way we use the model come from the fact that we are different people and you make the model your own. By the way, I would say that Dr. Johnson is definitely more charismatic than I am and she uses that very well in therapy. In some ways I may go a little slower than she does in therapy. I slow down as a way of walking people into their emotions. She does as well, but I think I may do it more consistently. Let me expand a little. I think theory is like a map because it guides our interventions. Interventions are like the car that we drive and we drive different cars based on our taste, on what we have access to, and those kinds of elements. You can get to the same places driving a Volkswagen as you can driving a Lexus. It may take you longer in one car oppose to another but you get there nonetheless. That’s the technique.

What are a few things that everyone should know in order to understand EFT?

You have to be able to understand systemic thinking and how couples cocreate their relationship. You have to be able to understand the power of experiential, emotional change and the power of having new experiences. It is important to understand people’s emotional landscape, their emotional world and how powerful that is in shaping the way that they experience the world, their partner and themselves. Understanding the power of attachment in relationships and our attachment needs to have safety and safe connection is critical. These needs are universal. They exist in all people regardless of culture, age, context, race, sexual orientation and other areas of diversity. The way these attachment needs are met are culturally specific, such as whether they are asked for directly or indirectly, and what is considered respectful or disrespectful. How emotional meanings occur tends to be very culturally and family-specific such as how one is raised, one’s race and ethnicity versus the surrounding context, one’s resources, and one’s lived experiences.

I know you focus a lot on context, is that what you are talking about, context?

Yes. Behavior always makes sense in its context. In fact emotion always makes sense in its context. Sue says from time to time, “I have met many irrational cognitions in my life, but I am not sure I have ever met any irrational emotion.” At first I didn’t understand because I bought into the cultural idea of cognition being rational and emotion being irrational. As I thought about it, I realized she is absolutely right because emotion understood in its context is rational. There is always a reason for emotions and there’s logic to emotions. In fact, for some of my clients who utilize left brain processing more often, explicitly talking about the logic of emotions can be very helpful. Emotions make sense if you can understand that the context includes both the past and the present, particularly in relationships. How you grew up, what you went through growing up, your previous attachment relationships and your current attachment relationships, including violations, hurts or betrayals, plays an important role in a person’s context. For example, a couple comes into your office and one person looks crazy. The emotions seem to be out of control, but when you really start trying to understand the context you find that there is a rational reason for what he or she is feeling and doing. It may not fit the current circumstances very well, but there is logic to it. Finally, to do EFT I think you have to have a basic philosophy that people have the ability to get better and grow. I’ve seen so many therapists give up on difficult couples because they don’t believe people can grow and change. I have seen really distressed couples get better. You have to believe they can change because if you don’t they will not get better, at least not on your watch.

You mentioned some great things, but they aren’t necessarily easy to learn or do. Do you think EFT is a hard model to learn?

Honestly?

Yeah.

Yes.

I love EFT, but I agree. Tell me why you think so.

I think it is hard because the nature of the problem is hard. Actually, I think most models are hard to learn fully in-depth. People can grasp a few of the concepts of EFT and incorporate them into their work and that can be helpful. That’s one of the things that helps therapists keep working to learn the model. However, to really become a good EFT therapist takes a lot of work because we are working at lots of different levels. We are working intrapsychically, we are working interpersonally, we are working in the present primarily but we also tend to honor the way the past lives in the present and we work with it. The past is important to us as it lives in the present and some theories just focus on mainly the past. Some theories ignore the past and only do the present. Some theories only do the intrapsychic. Some theories only do interpersonal and EFT is doing all those kinds of things which is one of the reasons it is a rich approach. There is a lot to learn. There’s been a lot of research and the model is growing and it has a great deal of depth. I also just think in general learning to understand emotion can be difficult. It’s not something that is privileged in many cultures. In EFT, we have to be able to understand people’s inner emotional worlds, and we have to understanding things systemically and contextually. Neither of these are traditionally western ways of viewing the world, which makes it challenging for many people.

You talked a lot about context, which seems like it’s a part of understanding diversity. How do you see the issue of diversity from an EFT lens?

How do I see diversity from an EFT lens? I really think people’s lived experiences have a big impact on their internal emotional maps of the world, their working models of self and other, and their action tendencies. Can I trust people? Who do I trust? When or under what circumstances can I trust them? When is it safe? How do I get my needs for safety, love and belonging met? Each of these are impacted by diversity issues and each has a big impact on how we get our basic emotional needs met and what is experienced as honoring, respecting, and loving behavior. What communicates safety, honor, respect, loyalty, and love can be very vary a great deal in different cultures. For example in some cultures you don’t tell your spouse or your partner that you love them. This is a very western kind of thing. You show them through various behaviors, such as being physically present, or visually tuned in that you love them.

So, how do EFT therapists adjust what they do based on cultural context?

Couples are in our offices, most of the time, because something in their relationship is not working. You, as a therapist, know that could be many things. EFT sees safe attachment as being primary but that looks different between cultures and, consequently, if we impose our own cultural lens we may cause more harm than good. A good EFT therapist tries hard to understand the internal world of their clients, how they experience their partners, and how they experience us as therapists particularly in the context of cultural differences that inevitably exist. Culture and diversity issues are really broad. They are important and they exist at a lot of different levels. There are aspects of ethnicity, race, culture, gender, kinship, socioeconomic background, sexual orientation, ability, spiritual and religious experiences, beliefs, and identities that the therapist and clients bring into the therapy room. These impact the way we understand the world. It is incredibly important for an EFT therapist to be able to understand their own cultural context and where their clients are, and be open to the idea that their clients are going to experience relational experiences differently. These days, most therapists get at least some diversity training and we learn we are supposed to pay attention to these areas. However, it is what we are not aware of or do not pay attention to that typically leads to difficulties. The more subtle assumptions about life such as whether there is a God or not, the purpose of life, or the privileges and oppressions of socioeconomic backgrounds is an example. People who are grow up in the majority culture in their community, as opposed to the minority, often struggle to understand some of the biases and oppression that people who are in the minority experience as a daily part of their life. I think understanding is particularly tough for people who grow up the majority but I have seen this difficulty with minority students or therapists as well. They don’t always understand the experiences of other minorities or majority people and there may be an assumption that because this person is the same skin color or came from the same socioeconomic background or have the same religion, they are going to have the same value system. This isn’t necessarily the case. It is complicated, but I think a good EFT therapist is able to be very open, curious, and thoughtful about how these kinds of differences impact people’s attachment experiences, their internal map, and their attachment strategies.

Talk a little bit about your contributions to the field of marriage and family therapy and especially EFT.

I am not sure I have made that many contributions to either field. I have done a lot of training of EFT therapists around the world and I have introduced EFT to a lot of different countries. It’s really been a privilege for me to be able to help bring EFT to new countries and cultures. I have tried hard to contribute to the cultural sensitivity within the field of EFT. EFT therapists are trained to understand context and culture so they tend to focus on it more. However, we don’t always talk about various aspects of diversity and I am trying to place an emphasis on it. Furthermore, the way I have conceptualized the cycle is what I think is a valuable contribution.

Is that where you talk about the unmet needs?

The five levels of the cycle essentially came when we were working on writing the workbook for EFT and I talked about how I had conceptualized this cycle and Sue said, “Oh, you are exactly right, that is exactly right and this is wonderful.” I have gone on and used that cycle sheet in a lot of contexts. It has been translated into many different languages. I have not formally published it yet other than in a newsletter, but I will. Nonetheless, I think my biggest contribution has been simply doing trainings. Particularly, back in the earlier days when very few people knew who Sue Johnson was, it was a real privilege for me to work with her and to be able to use the university resources to start larger trainings in southern California, northern California, and other states.

Where does pathology fit or not fit in EFT?

That’s a good question. EFT is a strength-based approach. The problem with the idea of pathology is it typically tends not to help. It doesn’t help us change things. One of the challenges with labeling people and giving diagnoses to people is that it tends to punctuate systemic processes in ways that tend to focus on what’s wrong. Depression has become a common term, and I think a lot of times people can look beyond that label to understand some of the systemic processes. However, even with a common one like depression, one of the challenges is that people think she’s depressed, we need to get her on medication, we need to get her into an exercise routine, and she needs cognitive behavioral therapy for depression. When in fact she may very well be depressed because her relationship is in shambles and she has been deeply, deeply betrayed by her partner. The research is pretty strong in showing both EFT and other forms of couples therapy can be helpful for treating depression. The problem with any kind of label is it narrows the way we think about it such that we don’t see the power of the relationships as a healing factor. It blinds us and we get stuck. That’s particularly true of personality disorders. Sometimes I think as therapists we tend to use personality disorders as a way to excuse ourselves because we do not know how to help people. It’s not to say that there aren’t many factors that influence functioning. We are all biological beings. We all grow up in families and have environmental factors that are constantly impacting us. The real question is how to bring about change and EFT is a roadmap to change. If a diagnosis or a label gets in the way of change it’s a problem. That doesn’t mean that you can’t acknowledge people’s struggle with closeness or distance or that they struggle with emotional regulation and are stuck feeling sad and negative all the time. It doesn’t mean you can’t acknowledge that. What it means is that at times it limits our thinking in terms of how we help bring about change and our responsibility is to help people change and the power of using attachment relationships to do it.

EFT is one of the evidence-based approaches to couples therapy. What have been the most important research findings about EFT?

The most important research findings occur in two different categories. First, to put it simply, it works and works when done by therapists who are not originators of the model. Studies that have been done by people who are not closely associated with Sue Johnson and Les Greenberg show that EFT is effective (Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000). The other area is process research, which gives EFT a richness and has helped move EFT forward. For example, the research that Brent Bradley and Jim Furrow (2004) did on understanding softening in couple’s therapy and their mini-model of how to facilitate a softening is laid out very clearly, which is really valuable for EFT therapist. The other piece I would say is one of the most important studies in EFT, but is not yet published, is the functional magnetic resonance imaging (fMRI) study, which stands for functional magnetic resonance imaging. From what I am hearing, it is showing significant changes. An fMRI machine is an MRI machine that measures the way your brain is functioning over a period of time. It has really helped brain researchers map out the way the brain works because you can touch somebody on the toe and see what happens in the brain. There was some very important research done by Jim Coan and his colleagues (Coan, Schaefer, & Davidson, 2006) on hand-holding experiment that involved heterosexual women. It began with heterosexual women alone in the fMRI machine and they were given a negative stimulus on their foot, I believe it was a shock to their foot. What happened is they had a signal that would say in 15 s you will be receiving a shock and they were able to watch the brain in a relaxed state when they knew they wouldn’t be shocked, in an anticipatory fear state when they got the signal they would be shocked, and pain when they were shocked. They were able to measure how the pain response activated different parts of the brain. The test was done under three different conditions: the woman was alone, the woman was with a male lab assistant who held her hand, the woman was with her husband who held her hand. They included the husbands wondering if this would lower the fear response. What they found was very important. They found that the women who experienced the most fear and the most pain were alone in the fMRI machine. The results also showed having anybody there holding their hand did lower, the fear response and it also lowered the pain response. If it was their husband, that lowered both fear and pain even more and within that group the better the marriage, the lower the fear levels and the lower the pain levels. Sue and her group up in Ottawa have done an fMRI study now with couples basically replicating this study but utilizing pre/post EFT therapy. They had the fMRI brain test with the shocks and saw how the brain responded and then they went through EFT, so you see the differences in brain response to the pain and the fear threat after EFT. There are some pretty dramatic differences, but that is not published yet. It will probably be the most important one because it will be the first research showing that a relational therapy changes brain processes.

And how do you think it will be great for therapy, especially for EFT?

I think it will set EFT apart, and will demonstrate how a relational talk therapy impacts biological brain processes in response to fear and pain.

What do you think the future direction of EFT is or should be?

I think there are several different directions. I see more research on the biological processes, such as brain functioning, and how it relates to EFT. EFT is being used more and more with diverse populations. I see us learning a lot more on how to incorporate different diversity concepts into EFT work with different groups. Everybody in the world has attachment needs, but again, they do not always express them the same way. The more we can articulate that from an EFT perspective, the more it will help in the training processes. There needs to be more research on how, for example, attachment signals and attachment processes operate in non-North American couples. EFT is spreading a lot in Asia and Europe and starting to spread across Central and South America. EFT is being used in same gender couples and with couples throughout the life cycle. I see EFT also expanding into the treatment of things like domestic violence and I see it being developed more in the area of family. Gail Palmer has probably published the most on EFT for families but Gail and a group of EFT trainers got together recently and are working further developments of theory with families. We do have some outcome research with families but not a lot and we need more. One of the things I really like about EFT is it is an integrative approach and Sue continues to work on integrating the latest research and Les does as well for his version. Sue’s willingness to integrate new research findings and new processes, and so on is one of the things I admire and respect a great deal about Sue. The model is vibrant and growing and useful and I see that continuing to happen.

You have been a good ambassador for EFT and I hope you will continue to be for a long time. Thank you for the interview.