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 T he Emotionally
Focused Casebook
 T he Emotionally
Focused Casebook
New Directions in Treating Couples

Edited by James L. Furrow,

Susan M. Johnson, and Brent A. Bradley

New York London

Routledge Routledge
Taylor & Francis Group Taylor & Francis Group
270 Madison Avenue 27 Church Road
New York, NY 10016 Hove, East Sussex BN3 2FA
© 2011 by Taylor and Francis Group, LLC
Routledge is an imprint of Taylor & Francis Group, an Informa business
This edition published in the Taylor & Francis e-Library, 2011.

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International Standard Book Number: 978-0-415-99875-8 (Paperback)

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Library of Congress Cataloging‑in‑Publication Data

The emotionally focused casebook : new directions in treating couples / Edited

by James L. Furrow, Susan M. Johnson, and Brent A. Bradley.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-415-99875-8 (pbk. : alk. paper)
1. Couples therapy--Case studies. 2. Emotion-focused therapy--Case studies.
I. Furrow, James L., editor. II. Johnson, Susan M., editor. III. Bradley, Brent A.,
editor.
[DNLM: 1. Couples Therapy--methods--Case Reports. 2. Marital
Therapy--methods--Case Reports. WM 430.5.M3]

RC488.5.E475 2011
616.89’1562--dc22 2010049068

Visit the Taylor & Francis Web site at

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and the Routledge Web site at
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ISBN 0-203-81804-0 Master e-book ISBN

 Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Section I Foundations for Innovation

Chapter 1 Emotionally Focused Couple Therapy:

Making the Case for Effective Couple Therapy . . . 3
James L. Furrow and Brent Bradley

Chapter 2 The Attachment Perspective on the Bonds of

Love: A Prototype for Relationship Change . . . . 31
Susan M. Johnson

Chapter 3 New Insights Into Change in Emotionally

Focused Couple Therapy . . . . . . . . . . . . . . . . . . . 59
Brent Bradley

Section II  pplication of Emotionally Focused

A
Couple Therapy

Chapter 4 Depression: Enemy of the Attachment Bond . . . 87

Wayne H. Denton and Adam D. Coffey

Chapter 5 Emotionally Focused Therapy for Couples

Living With Aphasia . . . . . . . . . . . . . . . . . . . . . 113
Kathryn Stiell and Gillian Gailey

v
vi Contents

Chapter 6 Emotionally Focused Couple Therapy in

Chronic Medical Illness: Working With the
Aftermath of Breast Cancer . . . . . . . . . . . . . . . . 141
Sandra Naaman, Karam Radwan, and
Susan M. Johnson

Chapter 7 Dancing With the Dragon of Trauma: EFT

With Couples Who Stand in Harm’s Way . . . . . 165
Susan M. Johnson and George Faller

Chapter 8 Emotionally Focused Couple Therapy and

Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Martin Landau-North, Susan M. Johnson,
and Tracy L. Dalgleish

Chapter 9 EFT for Sexual Issues: An Integrated Model

of Couple and Sex Therapy . . . . . . . . . . . . . . . . 219
Susan M. Johnson and Dino Zuccarini

Chapter 10 Rebuilding Bonds After the Traumatic

Impact of Infidelity . . . . . . . . . . . . . . . . . . . . . . . 247
Judy A. Makinen and Lorie Ediger

Section III  pecific Treatment Populations and

S
Emotionally Focused Couple Therapy

Chapter 11 Emotionally Focused Therapy for Remarried

Couples: Making New Connections and
Facing Competing Attachments . . . . . . . . . . . . 271
James L. Furrow and Gail Palmer

Chapter 12 Emotionally Focused Therapy With

Culturally Diverse Couples . . . . . . . . . . . . . . . . 295
Ting Liu and Andrea Wittenborn
Contents vii

Chapter 13 Emotionally Focused Therapy for Gay

and Lesbian Couples: Strong Identities,
Strong Bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Dino Zuccarini and Leigh Karos

Chapter 14 Spirituality and Emotionally Focused Couple

Therapy: Exploring Common Ground . . . . . . . . 343
James L. Furrow, Susan M. Johnson,
Brent Bradley, and John Amodeo

Chapter 15 Lessons Learned: Expanding the Practice of

Emotionally Focused Therapy for Couples . . . . 373
James L. Furrow, Brent Bradley, and
Susan M. Johnson

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
 Contributors

John Amodeo James L. Furrow

Department of Psychology Department of Marriage and
Meridian University Family, Graduate School of
Petaluma, California Psychology
Fuller Theological Seminary
Brent Bradley Pasadena, California
MFT Program, Department of
Psychology Gillian Gailey
University of Houston, Clear Aphasia Centre of Ottawa
Lake Ottawa, Ontario, Canada
Houston, Texas
Susan M. Johnson
Adam D. Coffey Department of Psychology
Private Practice University of Ottawa
Dallas, Texas Ottawa, Ontario, Canada
Department of Marital and
Tracy L. Dalgleish Family Therapy
School of Psychology Alliant International
University of Ottawa University
Ottawa, Ontario, Canada San Diego, California

Wayne H. Denton Leigh Karos

Department of Family and Centre for Interpersonal
Child Sciences Relationships
Florida State University Ottawa, Ontario, Canada
Tallahassee, Florida
Martin Landau-North
Lorie Ediger Department of Marital and
Briercrest Seminary Family Therapy
Caronport, Saskatchewan, Alliant International
Canada University
San Diego, California
George Faller
New York City Fire Ting Liu
Department Counseling Department of Psychology
Services Kean University
New York, New York Union, New Jersey

ix
x Contributors

Judy A. Makinen Karam Radwan

Royal Ottawa Mental Health Department of Psychiatry and
Centre Behavioral Neurosciences
Ottawa Couple and Family University of Chicago
Institute Chicago, Illinois
Ottawa, Ontario, Canada
Kathryn Stiell
Ottawa Couple and Family
Sandra Naaman Institute
Faculty of Medicine Aphasia Centre of Ottawa
University of Ottawa Ottawa, Ontario, Canada
Ottawa, Ontario, Canada
Andrea Wittenborn
Department of Human
Gail Palmer Development
Ottawa Couple and Family Virginia Polytechnic
Institute University
Ottawa, Ontario, Canada Falls Church, Virginia

Dino Zuccarini
Centre for Interpersonal
Relationships
Ottawa, Ontario, Canada
 Introduction

The development of emotionally focused therapy (EFT) for

couples began with listening and learning from couples. Over
25 years later, EFT practitioners and researchers have devel-
oped a compelling model for effective and lasting change in
couple therapy. EFT fosters new, secure bonding interactions
and unleashes powerful new positive emotions as partners
experience each other in new ways that promote support and
growth. The process of EFT focuses on the creation of interac-
tions that address deep, primary human needs and promote
a felt sense of being safe, held, comforted, and loved. These
bonding events can reverse the destructive effects of long-
standing and destructive couple distress (Johnson, 1996, 2004;
Lebow, Chambers, Christensen, & Johnson, in press).
EFT integrates experiential and systemic theories under the
umbrella of attachment theory (Bowlby, 1988; Mikulincer &
Shaver, 2007). It offers a unique combination of empirically
supported change processes and techniques informed by an
explicit theory of adult love. In just over 20 years, EFT has
become one of only two empirically supported treatment
approaches to couples therapy (Lebow et al., in press; Snyder,
Castellani, & Whisman, 2006). It continues to grow in popular-
ity because of its ever expanding research base, its application
to new and diverse clinical populations, and its strength-based
and unapologetic humanness that innately appeals to so many.
We believe that EFT is the most scientifically and clinically
compelling model of contemporary couples therapy.
Recent developments in couple therapy point to the impor-
tance of specializing treatment approaches to a variety of pre-
senting conditions. Research studies continue to illustrate
the important adjunctive role of couple therapy in the treat-
ment of individually based disorders (e.g., substance abuse,
trauma exposure, and depression) (Snyder & Whisman, 2003).
A review of the EFT literature details its application with
couples where issues of chronic illness, infidelity, trauma
and posttraumatic stress disorder, and depression are prevail-
ing treatment concerns (Dalton, Johnson, & Classen, in press;
Denton, Wittenborn, & Golden, in press; Dessaulles, Johnson,

xi
xii Introduction

& Denton, 2003; Johnson, 2005; Johnson & Williams-Keeler,

1998; Knowal, Johnson, & Lee, 2003).
That this model has been used with so many different pop-
ulations speaks to its relevance and generalizability. It is a
model that addresses the great universals—affect and attach-
ment—but it also values individual differences and varying
emotional realities. Currently, no one source brings together
the rich and diverse clinical applications of EFT into one
summary volume. The time has come to capture and clearly
illustrate the numerous and relevant ways that EFT is being
applied in clinical practice.
This casebook creates a primary clinical resource for clini-
cians, supervisors, students, and scholars seeking an under-
standing of the practical application of EFT to a variety of
populations and clinical problems. Following a hands-on
case study approach, the chapters in this edited volume pro-
vide concrete guidance and illustrate the application of EFT to
couples with specific treatment conditions. The book’s format
includes attention to the unique concerns endemic to treating
specific presenting problems. Each chapter provides a distinc-
tive conceptualization of the underlying attachment-related
issues likely to be faced in using EFT treatment in a particular
context. Throughout the various chapters, authors illustrate
how attachment processes in a couple’s relationship ultimately
provide both a resource and a point of intervention that sup-
port a couple’s resilience in the face of physical and psycho-
logical challenges.
The casebook contains three sections offering specific direc-
tion for conceptualizing EFT with couples facing a variety
of conditions and/or differences in background. In Section I,
“Foundations for Innovation,” James Furrow and Brent Bradley
provide an overview of EFT, including relevant empirical sup-
port and several common challenges faced by therapists in
mastering the approach. Sue Johnson (Chapter 2), the princi-
pal proponent of EFT with couples, explains the critical role
that attachment theory plays in the conceptualization of couple
issues and its crucial relevance as a powerful theory of adult
love. Brent Bradley’s chapter offers new insights into the EFT
change process by delineating key fundamentals utilized in
effective EFT and moment-by-moment, in-session details on
how to work powerfully and systemically with core affect
states.
In Section II, “Application of Emotionally Focused Couple
Therapy,” a number of authors present unique applications of
Introduction xiii

EFT across a variety of treatment issues based on their first-

hand experience. For example, chapters in this section illus-
trate the treatment of couples where their relationship has
been impacted by a medical disorder or disability (e.g., breast
cancer, aphasia). Additional chapters describe using EFT when
a partner suffers with a mental disorder or psychological dis-
tress (e.g., depression, posttraumatic stress disorder, addic-
tions, and sexual dysfunction). Authors illustrate their use and
refinement of EFT by describing actual treatment application
with specific case examples. Other chapters focus on unique
challenges, including infidelity and remarriage. Chapters
include transcript examples providing practical illustration
of in-session work with a specific treatment situation. Each
author’s commentary provides an innovative perspective for
the successful application of EFT to more complex presenta-
tions of couple distress.
The final section, “Specific Treatment Populations and
Emotionally Focused Couple Therapy,” comprises chapters
describing the use of EFT with particular populations. These
chapters explore applying EFT with culturally diverse cou-
ples, same-sex couples, and religious and spiritual couples.
Authors review the competencies needed to work sensitively
and effectively with unique perspectives and concerns found
among couples from diverse backgrounds. This section high-
lights the importance of therapist awareness and ability in
attending to the individual concerns of couples and cultural
contexts that inherently shape their experience of more inti-
mate relationships.
The book concludes with an overview and synthesis of EFT
innovations. The various insights and practices highlighted
throughout this book illustrate the creative pulse of therapists
finding new ways to reach new couples with the power of EFT.
In closing, we consider various future directions, recognizing
the essential contribution that EFT has made to the broaden-
ing role of couples therapy.
Our hope is to provide a substantive reference for clinicians,
students, professors, and supervisors who teach and train in
the practice of EFT. We believe this resource serves as a much-
needed and timely complement to the other major EFT train-
ing materials: The Practice of Emotionally Focused Couple
Therapy: Creating Connection, 2nd edition (Johnson, 2004),
and Becoming an Emotionally Focused Couple Therapist: The
Workbook (Johnson et al., 2005). This casebook is a practical,
hands-on resource for those searching for examples of specific
xiv Introduction

ways to think about couple issues within an EFT frame and

modify the application of this model to fit the specific needs of
their clients. To date, there is no single resource that has com-
piled the many creative applications of EFT with the myriad of
clinical populations being served by this model today.
Now there is.

References
Bowlby, J. (1988). A secure base. New York, NY: Basic Books.
Dalton, J., Johnson, S. M., & Classen, C. (in press). Treating rela-
tionship distress and the effects of childhood abuse with
emotion focused couple therapy: A randomized controlled
trial. Journal of Marital and Family Therapy.
Denton, W. H., Wittenborn, A., & Golden, R. N. (2010).
Augmenting antidepressant medication treatment of
depressed women with emotionally focused therapy for
couples: A randomized pilot study. Manuscript submitted
for publication.
Dessaulles, A., Johnson, S. M., & Denton, W. H. (2003).
Emotionally focused therapy for couples in the treatment
of depression: A pilot study. American Journal of Family
Therapy, 31, 345–353.
Johnson, S. M. (1996). The practice of emotionally focused
couple therapy: Creating connection. New York, NY:
Brunner/Mazel.
Johnson, S. M. (2004). The practice of emotionally focused
couple therapy: Creating connection (2nd ed.). New York,
NY: Routledge.
Johnson, S. M. (2005). Broken bonds: An emotionally focused
approach to infidelity. Journal of Couple and Family
Relationship Therapy, 4, 17–29.
Johnson, S. M., Bradley, B., Furrow, J. L., Lee, A., Palmer, G.,
Tilley, D., & Wooley, S. (2005). Becoming an EFT therapist:
The workbook. New York, NY: Brunner/Routledge.
Johnson, S. M., & Williams-Keeler, L. (1998). Creating healing
relationships for couples dealing with trauma: The use of
emotionally focused marital therapy. Journal of Marital
and Family Therapy, 24, 25–40.
Knowal, J., Johnson, S. M., & Lee, A. (2003). Chronic illness in
couples: A case for emotionally focused therapy. Journal
of Marital and Family Therapy, 29, 299–310.
Introduction xv

Lebow, J. L., Chambers, A., Christensen, A., & Johnson, S. M. (in

press). Marital distress. In D. Sprenkle & R. Chenail (Eds.),
Effectiveness research in marriage and family therapy.
Washington, DC: AAMFT.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adult-
hood. New York, NY: Guilford Press.
Snyder, D. K., & Whisman, M. A. (Eds.). (2003). Treating dif-
ficult couples: Helping clients with coexisting mental and
relationship disorders. New York, NY: Guilford Press.
Snyder, D. K., Castellani, A. M., & Whisman, M. A. (2006).
Current status and future directions in couple therapy.
Annual Review of Psychology, 57, 317–344.
 I

Foundations
for Innovation
 One

Emotionally Focused
Couple Therapy
Making the Case for
Effective Couple Therapy

James L. Furrow and Brent Bradley

Introduction
Emotionally focused therapy (EFT) for couples is considered a
leading approach in the treatment of relational distress. EFT is
well established in terms of its efficacy and innovative appli-
cation to the life challenges faced by partners in long-term
relationships (Lebow, Chambers, Christensen, & Johnson, in
press). It remains one of only two couple therapies recognized
as empirically supported treatments (Chambless & Ollendick,
2001; Lebow et al., in press).
Among couple therapies, EFT is also distinguished by two
other crucial features. First, it is the only couple interven-
tion based on a broad, systematic, and extensively researched
theory of adult love—namely, attachment theory (Johnson,
2003; Mikulincer & Shaver, 2007). Second, the practice of EFT
is supported by a series of process research findings (Bradley
& Furrow, 2004; Greenberg, Ford, Alden, & Johnson, 1993;
Johnson & Greenberg, 1988; Makinen & Johnson, 2006). These
studies inform EFT’s theory of change and provide specific
guidance to a therapist in the use of interventions aimed at
creating key emotional and interactional shifts in a distressed
relationship. This chapter briefly reviews the development
of EFT, the EFT process of change, and the breadth and sig-
nificance of EFT’s scientific support; it concludes with an

3
4 James L. Furrow and Brent Bradley

overview of the common challenges therapists face in learn-

ing this approach.

Overview
The introduction of EFT marked a significant shift in the
nascent field of couple therapy. During the late 1970s and
1980s Neil Jacobson and colleagues established behavioral
marital therapy (BMT) as the only research-validated couple
treatment of relationship distress (Baucom, Shoham, Mueser,
Daiuto, & Stickle, 1998). Therapists informed by this approach
followed principles of behaviorism and the social exchange
theory of relationships to promote relationship satisfaction.
Primary therapeutic interventions were designed to increase
positive interactions through behavior exchange, communi-
cation training, and problem solving (Jacobson & Margolin,
1979). This approach conceptualized a couple’s relationship in
quid pro quo terms, casting the therapist primarily as a coach
or facilitator of communication skills.
As behaviorism’s prominence grew in the emerging field
of couple therapy, alternative theories of couple intervention
were being proposed. Johnson (1986) questioned whether a
couple’s intimate relationship was best seen as a profit ver-
sus loss exchange of behaviors that couples negotiate. Instead,
Johnson called for a paradigm shift, suggesting that relation-
ships might be better understood as a relational emotional
“bond” rather than a negotiated rational “bargain.”
John Bowlby’s (1969) attachment theory offered an alterna-
tive theoretical perspective on human behavior that seemed
significantly relevant to the tasks of couple therapy. Bowlby’s
focus on “affectional ties” provided an “emotional rationale”
for the rigid patterns and ineffective actions common to cou-
ples ensnared in relational distress (Johnson, 2003). From
this perspective heightened periods of separation distress
undermine a couple’s felt sense of security and trigger fears
of abandonment, rejection, and isolation. In response, indi-
viduals react to a growing insecurity through actions that
follow increasingly predictable patterns of avoidance and
anxious pursuit.
Over time, these responses become set in rigid reactive pat-
terns of behavior. These stuck patterns, reinforced by a couple’s
ongoing experience of negative affect, foster greater insecurity
Emotionally Focused Couple Therapy 5

and a growing despair about the future of the relationship.

Attachment theory provides a map and an in-session compass
for guiding couples in restructuring the emotional ties that
hold sway in intimate relationships (Johnson & Best, 2002).

An Integrated Approach
The original formulation of EFT (Greenberg & Johnson, 1988) was
based primarily on experiential and family systems approaches.
EFT interventions were developed as a result of reviewing taped
therapy sessions and noting consistent patterns of practice that
led to desirable clinical outcomes (Johnson, 2009). This discov-
ery-oriented approach allowed for the description of a nine-
step change process and specific change events. Theoretically,
EFT draws on a synthesis of ­humanistic/­experiential and sys-
temic assumptions (e.g., Minuchin & Fishman, 1981; Rogers,
1951); each is evident in the dynamic use of new emotional
experience to engage partners in the enactment of more adap-
tive relational patterns. Shortly after Johnson and Greenberg’s
(1988) initial outcome study and the sudden growth of the lit-
erature on adult attachment (Hazan & Shaver, 1987), EFT began
to reflect a growing integration of attachment concepts into its
conceptualization of couple distress and therapist interven-
tions. The approach became increasingly focused on strength-
ening a couple’s bond through increased emotional accessibility
and responsiveness.
The current treatment manual for EFT (Johnson, 2004)
describes this brief systematic approach (8–20 sessions). EFT
combines a shared focus on interpersonal interaction patterns
and intrapsychic processes, which are understood in terms
of adult attachment theory (Mikulincer & Shaver, 2007). The
therapist serves as a process consultant keenly engaged in
facilitating in-session shifts in attachment related interactions
and associated inner emotional processes. She intently builds
a safe and collaborative therapeutic alliance that enables part-
ners to gently explore their emotional worlds. The EFT thera-
pist helps to provide a felt sense of security as each partner
takes steps to restructure his or her negative responses and
address unmet needs for security. The approach assumes that
couples have mutual goals and a workable commitment to
changing their relationship. EFT is not meant for use with vio-
lent partners or with couples demonstrating explicit incom-
patible relationship goals (Johnson, 2004).
6 James L. Furrow and Brent Bradley

Stages of Change
EFT is conceptualized within three stages of change built on a
progression of nine steps. These steps describe a shifting focus
from processing patterns and positions, accessing underlying
experiences, and building new patterns of interaction based on
the mutual sharing of underlying needs and vulnerability. For
a list of these stages and corresponding steps, see Table 1.1. As
couples progress through each stage, the therapist works differ-
ently with the positions and patterns that define relationships.
In Stage 1, the therapist facilitates a shift in the couple’s
complaints about their presenting problem to a focus on a prob-
lematic pattern or cycle that is currently defining the nature
of emotional engagement in their relationship. The therapist
helps a couple recast their common fights over household
chores, for example, and infrequent sex as a negative cycle
of pursuit and withdrawal. This problematic pattern is most
apparent in times of distress. The EFT therapist helps the
couple move toward de-escalation of their reactive pattern by
helping each partner acknowledge underlying primary attach-
ment emotions, such as sadness about feeling alone, and reac-
tive secondary emotional responses, such as numbing or anger
that fuels their negative cycle.

Table 1.1 Nine Steps of Emotionally Focused Couple Therapy

Stage 1. Cycle de-escalation
1. Assessment: creating an alliance and explicating the core issues in the marital
conflict by using an attachment perspective
2. Identifying the problem interactional cycles that maintain attachment insecurity and
marital distress
3. Accessing the unacknowledged emotions underlying interactional positions
4. Reframing the problem in terms of the cycle, the underlying emotions, and attachment
needs

Stage 2. Restructuring interactional patterns

5. Promoting identification with disowned needs and aspects of self and integrating
these into relationship interactions
6. Promoting acceptance of the partner’s new construction of the relationship and new
interactional behavior
7. Facilitating the expression of specific needs and wants

Stage 3. Consolidation
8. Facilitating the emergence of new solutions to old relationship problems
9. Consolidating new positions and new cycles of attachment behavior
Emotionally Focused Couple Therapy 7

In Stage 2, the therapist’s focus is on moving partners into

more accessible and emotionally engaged positions. Here
the therapist concentrates treatment on a deeper accessing,
expanding, and processing of attachment-related experience
associated with each person’s position. As new experiences
and new awareness are shared, the therapist promotes each
partner’s acceptance of the softer, emerging vulnerability of
the other. This gradually facilitates partners taking new posi-
tions where they can coherently reach for and sensitively
respond to each other, creating a more secure bond.
In Stage 3, the therapist works to consolidate partners
taking new positions while ongoing processing of the chal-
lenges inherent in the effort to resist old patterns takes place.
Partners are now more available to each other and can begin
actively creating trust and attachment security in their rela-
tionship. The positive emotional experiences associated with
these new patterns enable couples to “broaden and build” the
resources that support a more resilient and flourishing rela-
tionship (Fredrickson & Losada, 2005; Mikulincer & Shaver,
2009). The following sections reviews each of these stages in
further detail.

Stage 1. Cycle De-escalation

A couple’s level of attachment insecurity and strategies
for dealing with this insecurity color each partner’s expe-
rience of their presenting problem. In the first stage of EFT
the therapist creates a process for understanding, accepting,
and de-­escalating a couple’s experience of distress. This is an
experiential process involving tracking predictable patterns
of behaviors and reflecting the underlying emotional reali-
ties that move partners into reactive and fixed positions. The
enduring pain and distance of distress devitalizes a couple’s
sense of efficacy and hope for their shared future. The ther-
apist provides a safe alliance for each partner and reframes
their negative patterns as self-defeating struggles to minimize
conflict and hopefully reconnect their negative pattern as a
self-defeating struggle to minimize conflict and reconnect.
In the cycle de-escalation phase of EFT, the therapist aids
partners in identifying and experiencing primary emotions
that have gone unacknowledged. These powerful, more vul-
nerable emotions are usually immediately tucked safely out
of harm’s way while secondary reactive anger and contempt
rush in to mask the real source of pain and fear. But as the
EFT therapist tracks these negative cycles and accompanying
8 James L. Furrow and Brent Bradley

secondary emotions, each partner slowly begins to become

experientially aware of underlying attachment affect, or pri-
mary emotion, as well.
Cycle de-escalation describes the change event that culmi-
nates in the transition from Stage I to Stage II. Here the cou-
ple is able to make sense of the ways in which they become
ensnared in a vicious cycle of defensive responses aimed at
managing the distress that defines their relationship. Early in
treatment, the pain in a couple’s relationship is usually attrib-
uted to the traits of the other partner. “I don’t like Steve’s per-
sonality. He is not the person I thought he was,” Carol states
contemptuously. In cycle de-escalation, the criticism and
contempt are lessened and the problem is seen in terms of
the couple’s pattern. Carol says, “We got caught again. I felt
the tension rising and I was ready to set him straight. Then I
thought to myself, ‘Here we go again, it’s our cycle. We both
get hurt here.’”
Rather than educating partners about couple patterns from
a top-down stance, the EFT therapist engages the lived experi-
ence of a couple’s cycle in-session through tracking behavior
patterns and reflecting emotional experience. As the thera-
pist validates the typical positions that partners take in times
of distress, the couple begins to recognize the powerful role
that “their cycle” plays in keeping them from the connection
they desperately seek. Cycle de-escalation results not only in a
general decrease in each partner’s reactive responses and an
increase in felt security. As a result, partners are better able to
own the ways that their individual ways of regulating emotion
(e.g., withdraw, pursuit) have fueled the couple’s perpetual
cycle of distress and distance.

Stage 2. Restructuring Positions

The process of de-escalating conflict cycles makes way for a
more intense focus on the vulnerabilities and attachment fears
that underlie fixed and reactive ways of responding in times of
distress. The therapist moves in a deliberate fashion to expand
a withdrawing partner’s underlying affect. Increasing a with-
drawn partner’s availability and responsiveness provides a first
step toward replacing the anxious and critical responses of the
other partner with expressions of vulnerability and need.
For example, as Steve shrinks away in the face of Carol’s
angry disapproval, he struggles to name what he feels. The
therapist joins Steve in exploring and deepening his experience
Emotionally Focused Couple Therapy 9

through focusing on his present felt experience, such as a tight-

ness in Steve’s chest, an image of a dark cloud descending, and
an overwhelming sense of despair. The therapist aids Steve in
staying with his present emotion and to move into actively feel-
ing his sadness and fear. As Steve’s emotional world becomes
more vivid and new meanings rise into awareness, the therapist
actively draws connections between his vulnerable state and
his tendency to avoid or withdraw, typically hiding his feelings
of insecurity from Carol. Specific attention is then given to help-
ing Carol process her experience of this new “Steve” unfolding
in session and promoting her acceptance and responsiveness
to his emerging needs and longing. This prepares the way for
supporting Steve in sharing his attachment fears and associated
needs with Carol, which represents a clear shift into reengage-
ment. A similar process is followed with Carol that enables her
to move from her critical defending stance to a softer, more vul-
nerable position in their relationship.
In Stage 2, the therapist’s focus is more explicitly on the
underlying emotional processes of each partner as he or she
informs the positions partners take in the couple’s pattern of
distress. The process of restructuring interactional patterns in
Stage 2 entails accessing, expanding, deepening, and sharing
attachment-related emotion (e.g., fears and longings). Bowlby
(1988) argued that the experience of dysregulated fear dis-
torts and blocks effective bids for responsiveness from attach-
ment figures. Steve hides his insecurity from Carol for fear
she would reject him if she were really to see his need for
her support. His still silence, designed to calm her down, trig-
gers her distress and proximity-seeking behaviors (Hazan &
Shaver, 1987). Since neither partner’s signals are successful
in prompting support from the other, Carol becomes caught
in escalating intensifying strategies to deal with her anxiety;
while Steve turns to dismissing strategies and becomes more
silent (Mikulincer & Shaver, 2005). In a distressed couple,
these strategies become fixed ways of responding that then
serve to reinforce the insecurity of the relationship and per-
petuate negative interaction patterns.
The EFT therapist provides safety with an empathic emo-
tional presence that enables partners to access and process these
emotional responses. Bowlby (1988) concludes that changes in
enduring attachment strategies, or what he termed “internal
working models,” requires the use of emotional communica-
tion. EFT has long focused on the role of heightened emotional
10 James L. Furrow and Brent Bradley

experience as the basis for change—particularly change in

interactional positions. Therefore, in Stage 2 the EFT therapist
intensifies her focus on evocative interventions. Interventions
are framed in attachment terms to prompt a couple’s shared
experience and to create a context for their mutual attempts to
gain felt security.
In the preceding example, Steve’s sadness and loneliness
are framed in terms of his relationship to Carol: “So, Steve,
you feel so empty and alone, wishing there was some way to
connect with Carol?” Through his emotional experience, the
therapist appeals to his most basic sense of seeking comfort in
a relationship of attachment significance. The therapist uses
empathic conjecture, heightening, and evocative respond-
ing to move Steve to a more profound experience of his fear
of abandonment and rejection. Steve can then ask for the
reassurance and acceptance he needs from Carol. When he
asserts his needs in a congruent way, he trusts his experience,
feels more competent, and becomes more present and engaged.
He becomes, in effect, a viable secure attachment figure for
his wife. A couple’s ability to risk to reach for each other, and
to actively respond to attachment longings and desires is the
basis for a more secure bond. The resulting felt security acts as
an antidote to the anxious responses that trigger their pattern
of distress (Johnson, 2003).

Stage 3. Consolidation
In the final stage the therapist facilitates the consolidation of a
couple’s efforts to strengthen their bond and new opportunities
for strengthening their bond are explored as issues of past
conflict are revisited in new ways. Couples may now confront
enduring disagreements related to everyday preferences and
dispositions (e.g., finances, parenting, sexual practices) that
provoked their previous problem pattern. In these final stages,
a couple can reprocess past issues by sharing the underlying
fears and hurts that often triggered these historic issues and
cooperatively reach for support from one another. Problem
solving is exponentially less difficult when both partners
experience the relationship as a safe haven and a secure base.
Carol and Steve regained confidence in the trust and close-
ness they shared; yet, ongoing differences in parenting expec-
tations left Steve ceding responsibility to Carol for disciplining
their two children. Carol felt anxious and resentful as Steve
remained disinterested, placating her wishes. The couple came
Emotionally Focused Couple Therapy 11

to therapy after a “classic blowup,” nervous that their new-

found connection was eroding. The therapist guided them
through this fight and the familiar pattern they soon recog-
nized. Catching on, Steve offered his fears of disappointing
Carol and his struggle with her expectations. The therapist
helped Steve explore and share his fears and needs with Carol,
who was responsive and hoped to better understand his con-
cerns. Carol expressed her struggle, feeling alone in parenting,
and expressed her need for his support. They each concluded
that parenting was difficult enough without its coming between
them and agreed on ways they could support each other.
As the couple succeeds and confidence is strengthened in
their renewed bond, the EFT therapist fosters a new under-
standing of their relationship based on these new experiences
of safety. Attachment rituals are encouraged that help couples
find ways to symbolize their ongoing commitment and deepen
their shared bond (Johnson et al., 2005). The therapist’s work
with emotion and attachment continues in helping couples
celebrate their successes and reflect upon the new connec­t ions
they have made.

Research Support
There is broad empirical support for the effectiveness of EFT.
Conceptually, the core assumptions of EFT’s model of rela-
tional distress are consonant with empirical research on the
nature of marital distress (Gottman, 1998; Huston, Caughlin,
Houts, Smith, & George, 2001). Rigorous clinical trials con-
tinue to find that EFT demonstrates significant effects when
tested against wait list control groups and other interventions.
The breadth of EFT research is evident in the various stud-
ies conducted by researchers other than the originators of the
model (e.g., Denton, Burleson, Clark, Rodriguez, & Hobbs, 2000;
James, 1991) and in the successful treatment of couples with
other problems and comorbidities (Lebow et al., in press).
The effects of EFT are broad and have been found to have a
positive impact not only on relationship adjustment and sat-
isfaction, but also on intimacy, trust, forgiveness of injuries,
depression, and anxiety. The effect sizes found in a meta-
­a nalysis of EFT studies have not been achieved by other models
of couple therapy and, most importantly, the data on the stabil-
ity of results and lack of relapse remain consistently strong. As
an intervention, EFT appears to obtain relatively large effects
12 James L. Furrow and Brent Bradley

with many different kinds of distressed couples and these

effects seem to last. The following section examines a series of
primary studies supporting the strong empirical base of EFT.

Clinical Trials and Couple Distress

Results from six randomized clinical trials demonstrate that
EFT is a beneficial and efficacious treatment for couple distress
(Dandeneau & Johnson, 1994; Denton et al., 2000; Goldman &
Greenberg, 1992; James, 1991; Johnson & Greenberg, 1985a;
Walker, Johnson, Manion, & Cloutier, 1996). These findings,
based on treatment of over 200 couples, show that couples
receiving EFT treatment consistently reported increased mar-
ital satisfaction as compared to wait-list and alternate treat-
ment controls. Results from a meta-analysis based on four EFT
clinical trials indicated an effect size of 1.3. In these studies
70–73% of treated couples moved out of the range for dis-
tress and 86% experienced significant improvement in levels
of distress (Johnson, Hunsley, Greenberg, & Schindler, 1999).
Denton and colleagues (2000) demonstrated that EFT treat-
ment effects were robust even under demanding conditions
(e.g., novice therapists, limited sessions). Additionally, three
related studies—not including randomized control condi-
tions (Johnson & Greenberg, 1985b; Johnson & Talitman, 1997;
Makinen & Johnson, 2006)—also offer support for EFT as an
efficacious treatment for couple distress.
EFT has shown superior treatment results when compared to
alternate couple therapy interventions. Johnson and Greenberg
(1985a) found that couples in EFT treatment reported higher
levels of relationship satisfaction compared to couples in a
cognitive behavioral treatment comparison group. These find-
ings included evidence of posttreatment change. James (1991)
examined the effects of EFT treatment and EFT with the addi-
tion of communication training. Study findings demonstrated
that, as a whole, EFT couples reported lower rates of marital
distress at posttreatment and at follow-up follow-up. The addi-
tion of a communication training component to the EFT treat-
ment failed to improve the effects of EFT significantly. In a
study comparing EFT and cognitive marital treatment (CMT)
to enhance intimacy among a sample of nondistressed cou-
ples, Dandenau and Johnson (1994) found significantly higher
scores for the EFT couples on observational meas­u res of empa-
thy and self-disclosure at posttest and self-reported intimacy
at follow-up. These results also suggest greater durability of the
enhancements made by EFT couples because their treatment
Emotionally Focused Couple Therapy 13

gains did not recede at follow-up as was the case for the CMT
couples.
Some reviewers have questioned the generalization of these
EFT findings to populations of more severely distressed cou-
ples (e.g., Baucom et al., 1998). While further evaluation of this
concern requires more definitive study (e.g., randomized clini-
cal trials with severely distressed couples), existing research
does offer support for the use of EFT with couples in severe
relational distress. Every clinical study of EFT has in fact
contained severely distressed couples who scored well below
the treated group mean on marital adjustment; Johnson and
Talitman (1997) found that a couple’s level of distress played
only a minor role (4% of the variance in treatment outcome) in
predicting relationship adjustment at follow-up assessment.
Further, EFT has been found to demonstrate significant
results among populations at high risk for relational distress
and divorce (Walker et al., 1996) and with couples where rela-
tionship distress is accepted as particularly difficult to treat
(MacIntosh & Johnson, 2008). The application of EFT to couples
facing various physical and mental illnesses, as illustrated
in the chapters of this book, provides new opportunities to
study the treatment effects of EFT with couples facing signifi-
cantly high levels of personal and relationship distress (e.g.,
aphasia, cancer, trauma exposure, and depression).

EFT and Couples With Related Psychological Problems

The empirical support for EFT includes a broadening array
of studies evaluating its use with a variety of related clinical
problems. These include inhibited sexual desire (MacPhee,
Johnson, & Van Der Veer, 1995), depression (Dessaulles,
Johnson, & Denton, 2003), trauma associated with childhood
sexual abuse (Dalton, Johnson, & Classen, 2010), complex
PTSD associated with childhood sexual abuse (MacIntosh
& Johnson, 2008), attachment injuries requiring forgiveness
(Makinen & Johnson, 2006), distress in relationships in par-
ents coping with chronically ill children (Walker et al., 1996),
and distress in couples coping with breast cancer (Naaman,
Johnson, & Radwan, in press). Also, a small study with bulimic
adolescents found positive results for the use of EFT as a fam-
ily intervention (Johnson, Maddeaux, & Blouin, 1998). Findings
from these studies provide further evidence of the systemic
and robust effects of EFT on relationship and mental health
outcomes associated with couples facing psychological issues
that are comorbid with couple distress.
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