Emotionally focused therapy

Emotionally focused therapy and emotion-focused therapy (both EFT) are two related but distinct approaches to psychotherapy with individuals, couples, or families. Both EFT approaches include elements of experiential therapy (such as person-centered therapy and Gestalt therapy), systemic therapy, and attachment theory.[1] EFT is usually a short-term treatment (8–20 sessions).[2] Both EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships.[3] The approach now called emotion-focused therapy was originally known as process-experiential therapy,[4] and it is still sometimes called by that name.[5]

EFT should not be confused with emotion-focused coping, a category of coping proposed by some psychologists,[6] although clinicians have used EFT to help improve clients' emotion-focused coping.[7]

Shared beginnings

In spite of the divergent paths that emotionally focused therapy[8] and emotion-focused therapy[9] have taken (see § Divergence of the two EFT approaches below), EFT began in the mid-1980s as one approach for helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985,[10] and the first manual for emotionally focused couples therapy was published in 1988.[11]

To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behavior.[12] Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behavior cannot be considered outside of the whole situation in which they occur.[12] In this combined experiential–systemic approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners.[13] Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organizes the interactions between partners.[14]

Further viewing of couples therapy videos revealed attachment themes of fears of loss and connection. Attachment theory became a foundational part of Johnson's expansion of the original three-stage, nine-step EFT model of how distress occurs in romantic relationships and of the process for how distressed relationships could be repaired (see § Stages and steps in emotionally focused therapy for couples below).[15]

Similar terminology, different meanings

The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists.

In Les Greenberg's emotion-focused approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg "decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches."[16] He and colleague Rhonda Goldman noted their choice to "use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg's and Johnson's backgrounds) emotionally focused."[16] Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy.[17] He considers the focus on emotions to be a common factor among various systems of psychotherapy: "The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic."[18] Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:

In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations.... Furthermore, clinicians of different orientations recognized that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.[19]

Sue Johnson's use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation.[20] Emotionally focused therapy views attachment needs as a primary motivational system for mammalian survival. Emotionally focused therapy has expanded to be centered upon attachment theory as a theory of adult love wherein attachment, caregiving, and sex are intertwined.[21] Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, lovability and desire. Following attachment theory and emotion theory, emotionally focused therapy aims to reshape attachment strategies towards optimal interdependency and emotion regulation, for resilience and physical, emotional, and relational health.[22]

Divergence of the two EFT approaches

Historically, emotionally focused therapy and emotion-focused therapy diverged into related but distinct approaches.

Emotion-focused therapy

In 1986, Greenberg chose "to refocus his efforts on developing and studying an experiential approach to individual therapy".[23] Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy.[24] They attended to emotional experiencing and its role in individual self-organization. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, with detailed manuals of specific methods of therapeutic intervention. Goldman & Greenberg (2015) presents case formulation maps for this approach.

Greenberg & Goldman (2008) developed an emotion-focused approach for helping couples. This approach contains some elements from Greenberg and Johnson's original emotionally focused therapy approach but takes a different approach to attachment theory and adds several steps and stages. Greenberg and Goldman argue that there are three motivational dimensions—attachment, identity or power, and attraction or liking—that impact emotion regulation in intimate relationships.[25] See § Differences in couples therapy below for more on this emotion-focused approach to couples therapy.

Emotionally focused therapy

Johnson continued to integrate attachment theory with systemic and humanistic approaches,[26] explicitly expanding attachment theory's understanding of love relationships.[27] Johnson's model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion. Johnson's goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.[28]

Comparison of the two EFT approaches

The following sections compare the two EFT approaches by examining their shared experiential focus, their different approaches to working with emotion (maladaptive emotions vs. negative patterns of interaction), differences in individual therapy, differences in couples therapy, and differences in family therapy.

Experiential focus

Both EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They both focus upon the value of engaging clients in emotional experiencing moment-to-moment in session.[29] Thus, the experiential roots of the approach remain strong in both approaches.[30] Both hold the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.[28]

The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of both approaches since their inception.[31] Both value emotion as the target and agent of change, honoring the intersection of emotion, cognition, and behavior.[32] Both approaches posit that emotion is the first, often subconscious response to experience.[33] Both also use the framework of primary and secondary (reactive) emotion responses.[34]

Maladaptive emotions vs. negative patterns of interaction

Emotion-focused therapy categorizes emotion responses into four types (see § Emotion response types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental.[35] Emotion-focused therapy also has six principles of emotion processing: (1) awareness of emotion or naming what one feels, (2) emotional expression, (3) regulation of emotion, (4) reflection on experience, (5) transformation of emotion by emotion, and (6) corrective experience of emotion through new lived experiences in therapy and in the world.[36] While primary adaptive emotion is seen as a reliable guide for behavior, primary maladaptive emotion is seen as an unreliable guide.[37]

Johnson's approach to emotionally focused therapy rarely distinguishes between adaptive and maladaptive primary emotions,[38] and rarely distinguishes emotion responses as dysfunctional or functional.[39] Instead, all primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called "separation distress".[40] Emotionally focused therapy, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element.[13] The patterns of interaction are amenable to change after accessing the underlying primary emotions that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotions and reprocessing newly accessed primary emotions is part of the change process.[41]

Differences in individual therapy

Emotion-focused therapy with individuals

Within emotion-focused individual therapy there is a 14-step case formulation process that regards emotion-related dysfunction as stemming from at least four different possible causes: lack of awareness or avoidance of emotion, dysregulation of emotion, maladaptive emotion response, or a problem with making meaning of experiences.[42] The theory features four types of emotion response (see § Emotion response types below), categorizes needs under "attachment" and "identity", specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers (see § Therapeutic tasks below), relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model[43] and an emotion schematic system.[44]

The emotion schematic system is seen as the central catalyst of self-organization, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of coactivated emotion schemes coapply, to produce a unified sense of self in relation to the world.[45]

Techniques used in "coaching clients to work through their feelings"[46] include the Gestalt therapy empty chair technique, frequently used for resolving "unfinished business", and the two-chair technique, frequently used for self-critical splits.[47]

Emotion response types

Although emotion-focused therapy posits that each person's emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time,[48] nevertheless emotion-focused theorists have posited that emotional responses can be classified into four broad types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.[35]

  1. Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolized and worked through in therapy. Primary adaptive emotion responses "are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving."[49][50]
  2. Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are generally dysfunctional responses based on emotion schemes that are no longer useful (and that may or may not have been useful in the past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person's angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful.[51] Secondary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.[49][52]
  3. Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. ("Secondary" means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defenses against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men's gender role), or expressing sadness when primarily angry (stereotypical of women's gender role).[52] "These are all complex, self-reflexive processes of reacting to one's emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse."[53] Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.[49][54]
  4. Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, "such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us."[51] Instrumental emotion responses can be consciously intended or unconsciously learned (i.e., through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.[49][55]

The therapeutic process with different emotion responses

Emotion-focused therapy posits that each type of emotion response calls for a different intervention process by the therapist.[56] Primary adaptive emotions need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotions need to be accessed and explored to help the client identify core unmet needs (e.g., for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotions need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotions need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client's situation.

It is important to note that primary emotion responses are not called "primary" because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client's situation and how to intervene appropriately.

Therapeutic tasks

A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients' cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change.[57] This kind of psychotherapy process research eventually led to a standardized (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.

The following table summarizes the standard set of these therapeutic tasks as of 2012.[58] The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.

In addition to the task markers listed below, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.[59]

Therapeutic tasks in emotion-focused therapy for individuals[58]
Task marker Intervention process End state
Empathy-based tasks Problem-relevant experience (e.g., interesting, troubling, intense, puzzling) Empathic exploration Clear marker, or new meaning explicated
Vulnerability (painful emotion related to self) Empathic affirmation Self-affirmation (feels understood, hopeful, stronger)
Relational tasks Beginning of therapy Alliance formation Productive working environment
Therapy complaint or withdrawal difficulty (questioning goals or tasks; persistent avoidance of relationship or work) Alliance dialogue (each explores own role in difficulty) Alliance repair (stronger therapeutic bond or investment in therapy; greater self-understanding)
Experiencing tasks Attentional focus difficulty (e.g., confused, overwhelmed, blank) Clearing a space Therapeutic focus; ability to work productively with experiencing (working distance)
Unclear feeling (vague, external or abstract) Experiential focusing Symbolization of felt sense; sense of easing (feeling shift); readiness to apply outside of therapy (carrying forward)
Difficulty expressing feelings (avoiding feelings, difficulty answering feeling questions) Allowing and expressing emotion (also experiential focusing, systematic evocative unfolding, chairwork) Successful, appropriate expression of emotion to therapist and others
Reprocessing tasks [situational-perceptual] Difficult/traumatic experiences (narrative pressure to tell painful life stories) Trauma retelling Relief, validation, restoration of narrative gaps, understanding of broader meaning
Problematic reaction point (puzzling over-reaction to specific situation) Systematic evocative unfolding New view of self in-the-world-functioning
Meaning protest (life event violates cherished belief) Meaning creation work Revision of cherished belief
Action tasks [action tendency] Self-evaluative split (self-criticism, tornness) Two-chair dialogue Self-acceptance, integration
Self-interruption split (blocked feelings, resignation) Two-chair enactment Self-expression, empowerment
Unfinished business (lingering bad feeling regarding significant other) Empty-chair work Let go of resentments, unmet needs regarding other; affirm self; understand or hold other accountable
Stuck, disregulated anguish Compassionate self-soothing Emotional/bodily relief, self-empowerment

Emotion-focused therapy for trauma

The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors.[60] A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published.[61] For example, modifications of the traditional Gestalt empty chair technique have been developed.

Emotionally focused therapy with individuals

The approach of Johnson and colleagues maintains an emphasis on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation.[62] The EFT therapist follows the attachment model by addressing deactivating and hyperactivating strategies.[63] Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide EFT in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of "effective dependency" (following John Bowlby) upon one or two safe others, depathologizing emotion by normalizing separation distress responses, and shaping change processes.[8] The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.[8]

The relevance of attachment theory to understanding change in adult psychotherapy, whether individual or couple therapy, has become clearer because of the enormous amount of research applying attachment theory to adults in the last two decades (Cassidy & Shaver, 2008). Attachment theory is now used explicitly to inform interventions in individual therapy (Fosha, 2000; Holmes, 1996), and... the attachment perspective helps the humanistic experiential therapist address individual problems such as anxiety and depression, as well as the relationship distress that accompanies and maintains these problems.[64]

Differences in couples therapy

There are two primary differences between emotion-focused and emotionally focused therapy for couples. Both differences revolve around the different prominence that attachment theory has in each approach. In Greenberg and Goldman's emotion-focused approach, although they "fully endorse"[65] the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking.[25] In Johnson's emotionally focused approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.[66]

In emotion-focused therapy the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change.[67] In emotionally focused therapy the primary goal is to reshape attachment bonds and create "effective dependency" (including secure attachment).[26]

A systemic perspective is important in both approaches, but tracking conflictual patterns of interaction, often referred to as a "dance" in Johnson's popular literature,[68] has been a hallmark of the first stage of Johnson's emotionally focused therapy for couples since its inception in 1985.[69] In Goldman and Greenberg's newer approach to emotion-focused therapy for couples, therapists help clients "also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change."[70] Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:

In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person's core emotion is one of shame and they feel "rotten at the core" or "simply fundamentally flawed," soothing or reassuring from one's partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.[71]

Stages and steps in emotion-focused therapy for couples

Deviating from the original three-stage, nine-step EFT framework developed by Johnson and Greenberg,[10] Greenberg and Goldman's emotion-focused therapy for couples has five stages and 14 steps.[72] It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.[73]

Stages and steps in emotionally focused therapy for couples

Emotionally focused therapy for couples retains the original nine-step model of restructuring the attachment bond between partners.[74] In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and "effective dependency", increasing individuals' self-regulation and resilience.[75] In good-outcome cases, the couple is helped to respond and thereby meet each others' unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to traumatic experience from within and outside of the relationship.

Johnson (2008) summarizes the nine treatment steps in Johnson's model of EFT for couples: "The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other."[76]

Stage 1. Stabilization (assessment and de-escalation phase)

During this stage the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple's positive and negative interactions from past and present and is able to summarize and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

Stage 2. Restructuring the bond (changing interactional positions phase)

This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognizing their attachment needs, and then changing their interactions based on those needs. At first their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behavior from reemerging.

Stage 3. Integration and consolidation

This stage focuses on reflection of new emotional experiences and self-concepts. It integrates the couple's new ways of dealing with problems within themselves and in the relationship.[77]

Styles of attachment

Johnson & Sims (2000) described four attachment styles that affect the therapy process:

  1. People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
  2. People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
  3. People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner's attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
  4. People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility.

Differences in family therapy

Emotion-focused family therapy

Greenberg and colleagues have not produced a manual for emotion-focused therapy with families, but they have mentioned that emotion-focused therapy can be combined with family-based treatments,[78] implying that their emotion-focused approach is not appropriate for families by itself, but it can be combined with other treatments appropriate for families.

One group of clinicians, inspired in part by emotion-focused therapy, developed a treatment protocol specifically for families of individuals struggling with an eating disorder.[79] The treatment is based on the principles and techniques of four different approaches: emotion-focused therapy, behavioral family therapy, motivational enhancement therapy, and the New Maudsley family skills-based approach.[80] It aims to help parents "support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences".[81] The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg's emotion-focused approach and influenced by John Gottman: (1) attending to the child's emotional experience, (2) naming the emotions, (3) validating the emotional experience, (4) meeting the emotional need, and (5) helping the child to move through the emotional experience, problem solving if necessary.[82]

Emotionally focused family therapy

Emotionally focused family therapy (EFFT) aims to promote secure bonds among distressed family members.[83] It is a therapy approach consistent with the attachment-oriented experiential–systemic emotionally focused model[66] in three stages: (1) de-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children; (2) restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base; (3) consolidation of the new responsive cycles and secure bonds.[84] Its primary focus is on strengthening parental responsiveness and caregiving, to meet children and adolescents' attachment needs.[85] It aims to "build stronger families through (1) recruiting and strengthening parental emotional responsiveness to children, (2) accessing and clarifying children's attachment needs, and (3) facilitating and shaping caregiving interactions from parent to child".[85] Some clinicians have integrated EFFT with play therapy.[86]

Efficacy

Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.[87]

The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression.[88] Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.[89]

Studies have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results.[90] Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy[10] had a larger effect size than any other couple intervention had achieved to date. 70 to 73% of couples reported recovery from relationship distress, according to the Dyadic Adjustment Scale measure of relationship satisfaction, and 86% reported significant improvement over controls.[91] Studies have consistently shown clinically significant improvement post therapy and excellent follow-up results.[92] A study with an fMRI component suggested that emotionally focused couples therapy reduces the brain's response to threat in the presence of a romantic partner.[93]

Strengths

Some of the strengths of both EFT approaches can be summarized as follows:

  1. EFT aims to be collaborative and respectful of clients, combining experiential person-centered therapy techniques with systemic therapy interventions.[94]
  2. Change strategies and interventions are specified through intensive analysis of psychotherapy process.[95]
  3. EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.[96]
  4. EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.[96]
  5. EFT for couples is based on conceptualizations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.[97]

Criticism

In a 2015 article in Behavioral and Brain Sciences on "memory reconsolidation, emotional arousal and the process of change in psychotherapy", Richard D. Lane and colleagues summarized a common claim in the literature on emotion-focused therapy that "emotional arousal is a key ingredient in therapeutic change" and that "emotional arousal is critical to psychotherapeutic success".[98] In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:[99]

The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). [...] The same considerations imply that "changing emotion with emotion" (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one's learned model. "Changing model with mismatch" is the core phenomenology.[99]

Other responses to Lane et al. (2015) argued that their emotion-focused approach "would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems",[100] and that their model needed further development to account for the diversity of states called "psychopathology" and the relevant maintaining and worsening processes.[101]

See also

Notes

  1. ↑ Occasionally both approaches are called by the same name, even when they are differentiated from one another; for example, Fromme (2011) calls both by the same name but still clearly differentiates between two approaches. Examples of psychotherapy survey textbooks that have covered one or both EFT approaches include: Fromme 2011, pp. 233–261, 385–389; Corey 2013, pp. 83–92; Goldenberg & Goldenberg 2013, pp. 267–272; Wedding & Corsini 2013, pp. 102–103; Gehart 2014, pp. 449–465; Prochaska & Norcross 2014, pp. 161–168; Corey 2015, pp. 167–168, 480. Examples of texts on EFT for individuals include: Elliott et al. 2004; Greenberg 2011; Greenberg 2015. Texts on EFT for couples (sometimes called EFT-C) include: Greenberg & Johnson 1988; Johnson 2004; Greenberg & Goldman 2008; Johnson 2008; Ruzgyte & Spinks 2011. Examples of texts on EFT for families (sometimes called EFFT) include: Heatherington, Friedlander & Greenberg 2005; Sexton & Schuster 2008; Stavrianopoulos, Faller & Furrow 2014.
  2. ↑ Johnson & Greenberg 1992, pp. 220–221, 223; Goldenberg & Goldenberg 2013, p. 267
  3. ↑ The connection between human needs and emotions is explored in, for example: Greenberg & Safran 1987; Safran & Greenberg 1991; Greenberg, Rice & Elliott 1993; Greenberg & Paivio 1997; Greenberg 2002a; Johnson 2004; Flanagan 2010
  4. ↑ Prochaska & Norcross 2014, p. 162; examples of early texts using the term process-experiential include: Rice & Greenberg 1990, p. 404; Greenberg, Rice & Elliott 1993
  5. ↑ For example: Wedding & Corsini 2013, pp. 102
  6. ↑ Emotion-focused coping is typically contrasted with problem-focused coping and relationship-focused coping, for example: Folkman et al. 1986, p. 571; Greenberg & Goldman 2007, p. 391; Morgan 2008, p. 185; Cormier, Nurius & Osborn 2013, p. 407
  7. ↑ For example: Baker & Berenbaum 2008, p. 69; Baker & Berenbaum 2011, p. 554; Stanton 2011, p. 370, 378
  8. 1 2 3 For example: Johnson 2004; Johnson 2008; Ruzgyte & Spinks 2011; Johnson & Brubacher 2016
  9. ↑ For example: Greenberg, Rice & Elliott 1993; Greenberg & Goldman 2008; Prochaska & Norcross 2014, pp. 161–168
  10. 1 2 3 Johnson & Greenberg 1985a; Johnson & Greenberg 1985b; Johnson & Greenberg 1987; Johnson & Greenberg 1988
  11. ↑ Greenberg & Johnson 1988
  12. 1 2 Johnson et al. 2005, p. 13
  13. 1 2 Fromme 2011, pp. 367–400
  14. ↑ Johnson 1998
  15. ↑ Johnson 1986; Goldenberg & Goldenberg 2013, pp. 267–272
  16. 1 2 Greenberg & Goldman 2008, p. x
  17. ↑ Greenberg 2002b; Greenberg 2008; Thoma & McKay 2015, p. 240
  18. ↑ Greenberg 2011, p. 141
  19. ↑ Boswell et al. 2014, p. 117
  20. ↑ Johnson 2004; Gehart 2013, pp. 449–465; Goldenberg & Goldenberg 2013, pp. 267–272
  21. ↑ Shaver & Mikulincer 2006; Fromme 2011, pp. 384–390; Cassidy & Shaver 2016
  22. ↑ Johnson, Lafontaine & Dalgleish 2015
  23. ↑ Greenberg & Goldman 2008, p. viii
  24. ↑ The major books that they published during this period include: Greenberg, Rice & Elliott 1993; Elliott et al. 2004
  25. 1 2 Greenberg & Goldman 2008, pp. 4–7; Woldarsky Meneses & Greenberg 2011; Goldman & Greenberg 2013, pp. 64–67; Woldarsky Meneses & Greenberg 2014
  26. 1 2 Johnson 2004
  27. ↑ Attachment theory of love relationships is outlined in, for example: Mikulincer & Shaver 2016; Cassidy & Shaver 2016
  28. 1 2 Johnson 2009a
  29. ↑ Client experiencing can be measured, for example, by the Client Experiencing Scale (Klein, Mathieu-Coughlan & Kiesler 1986), the Levels of Emotional Awareness Scale (Lane et al. 1990), or the Assimilation of Problematic Experiences Scale (Honos-Webb et al. 1998).
  30. ↑ For example: Goldman, Greenberg & Pos 2005; Johnson 2009a; Johnson 2009b; Elliott et al. 2011
  31. ↑ Greenberg & Safran 1987; Greenberg & Johnson 1988; Greenberg, Rice & Elliott 1993
  32. ↑ Greenberg & Safran 1987; Greenberg & Johnson 1988; Greenberg 2012
  33. ↑ Greenberg & Safran 1987, pp. 62–64, 127–128; Johnson 2004, p. 22; Johnson et al. 2005, p. 46; Lane et al. 2015, pp. 4–6
  34. ↑ Fromme 2011, pp. 233–261; Gehart 2014, pp. 449–465
  35. 1 2 Greenberg & Paivio 1997, p. 35; Elliott et al. 2004, pp. 28–32; Fromme 2011, pp. 236–237; Elliott 2012, p. 111; Goldman & Greenberg 2015, pp. 25–27
  36. ↑ Greenberg 2010, pp. 35–38
  37. ↑ Goldman & Greenberg 2015, pp. 22–24
  38. ↑ For example: Johnson & Greenberg 1994, pp. 13–19
  39. ↑ For example: Johnson 2004, pp. 206-207
  40. ↑ For example: Johnson 1986; Johnson & Greenman 2006, p. 599; Johnson, Lafontaine & Dalgleish 2015, p. 414; Cassidy & Shaver 2016, pp. 29, 417–423
  41. ↑ Johnson 2004, pp. 45-46
  42. ↑ Goldman & Greenberg 2015, p. 5
  43. ↑ Goldman & Greenberg 2015, pp. 8, 27, 50, 139
  44. ↑ Goldman & Greenberg 2015, pp. 3–42
  45. ↑ Goldman & Greenberg 2015, p. 92
  46. ↑ Greenberg 2015
  47. ↑ Elliott et al. 2004, pp. 219–241; 295–296; Goldman & Greenberg 2015, pp. 36–38
  48. ↑ For example: Greenberg, Rice & Elliott 1993, p. 65; Greenberg & Paivio 1997, p. 117; Thoma & McKay 2015, p. 240–241
  49. 1 2 3 4 Elliott et al. 2004, pp. 31
  50. ↑ Greenberg & Paivio 1997, p. 38
  51. 1 2 Elliott 2012, p. 111
  52. 1 2 Greenberg & Paivio 1997, p. 41
  53. ↑ Greenberg & Paivio 1997, p. 43
  54. ↑ Greenberg & Paivio 1997, p. 42
  55. ↑ Greenberg & Paivio 1997, p. 44
  56. ↑ Greenberg & Paivio 1997, p. 85
  57. ↑ Rice & Greenberg 1984
  58. 1 2 Adapted from: Elliott 2012, p. 118; Fromme 2011, pp. 242–243
  59. ↑ Angus & Greenberg 2011, pp. 59–79; Baljon & Pool 2013
  60. ↑ Fosha et al. 2009
  61. ↑ Pavio & Pascual-Leone 2010
  62. ↑ Gehart 2014, pp. 449–465
  63. ↑ Johnson 2009a; Johnson 2009b
  64. ↑ Johnson 2009a, p. 410
  65. ↑ Greenberg & Goldman 2008, p. 4
  66. 1 2 Johnson 2004; Johnson 2008; Greenman & Johnson 2013; Johnson & Brubacher 2016
  67. ↑ Greenberg & Goldman 2008; Goldman & Greenberg 2013
  68. ↑ Woolley et al. 2016, p. 329
  69. ↑ Johnson & Greenberg 1987; Best & Johnson 2002
  70. ↑ Goldman & Greenberg 2013, p. 62
  71. ↑ Goldman & Greenberg 2013, p. 77
  72. ↑ Greenberg & Goldman 2008, pp. 137–170
  73. ↑ Goldman & Greenberg 2013, pp. 68–70
  74. ↑ Johnson 2004, p. 17
  75. ↑ Johnson et al. 2013; cf. Mikulincer & Shaver 2016
  76. ↑ Johnson 2008, p. 116
  77. ↑ Johnson 2008, pp. 116–117; Jordan 2011
  78. ↑ Goldman & Greenberg 2015, p. 66
  79. ↑ Lafrance Robinson, Dolhanty & Greenberg 2015; Lafrance Robinson et al. 2016
  80. ↑ Lafrance Robinson, Dolhanty & Greenberg 2015, pp. 75–76; Lafrance Robinson et al. 2016, pp. 15–17
  81. ↑ Lafrance Robinson, Dolhanty & Greenberg 2015, p. 77
  82. ↑ Lafrance Robinson et al. 2016, pp. 15–16
  83. ↑ Early publications on EFFT include: Johnson, Maddeaux & Blouin 1998; Johnson & Lee 2000; Palmer & Efron 2007. A key text for emotionally focused therapy includes a chapter on EFFT titled "Emotionally focused family therapy: restructuring attachment" (Johnson 2004, pp. 243–266).
  84. ↑ Brassard & Johnson 2016
  85. 1 2 Palmer 2015, pp. 5–6
  86. ↑ Hirschfeld & Wittenborn 2016
  87. ↑ See, for example, the literature reviews in: Elliott et al. 2013; Wiebe & Johnson 2016
  88. ↑ APA 2013; Lebow 2008, p. 87; Greenberg 2011; Wedding & Corsini 2013, pp. 103
  89. ↑ For example: Paivio & Nieuwenhuis 2001; Watson et al. 2003; Greenberg & Watson 2005; Goldman, Greenberg & Angus 2006; Paivio & Pascual-Leone 2010; Pascual-Leone et al. 2011; Pos 2014
  90. ↑ For example: Johnson et al. 1999; Dessaulles, Johnson & Denton 2003; Najafi et al. 2015; Wiebe & Johnson 2016
  91. ↑ Ruzgyte & Spinks 2011, p. 347
  92. ↑ Wiebe & Johnson 2016
  93. ↑ Johnson et al. 2013
  94. ↑ Elliott et al. 2004, pp. 7–14; Furrow, Johnson & Bradley 2011, p. 20
  95. ↑ Rice & Greenberg 1984; Pascual-Leone, Greenberg & Pascual-Leone 2009; Elliott 2010
  96. 1 2 Greenberg 2011; Elliott et al. 2013
  97. ↑ Johnson 2008; Ruzgyte & Spinks 2011; Cassidy & Shaver 2016
  98. ↑ Lane et al. 2015, pp. 1, 8
  99. 1 2 Ecker, Hulley & Ticic 2015; see also Patihis 2015 for a similar criticism from a cognitive behavioral therapy perspective
  100. ↑ Kimbrel, Meyer & Beckham 2015
  101. ↑ Mancini & Gangemi 2015

References

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