Emotionally Focused Couples Therapy: A Systematic Review of Its Effectiveness over the past 19 Years

Toward a culturally sensitive application of Emotionally Focused Couples Therapy: A qualitative study of therapists' experience using EFT in Spanish-speaking countries/cultures

The purpose of the current study was to identify specific ways Emotionally Focused Couples Therapy (EFT; S. Johnson) could be adapted to better meet the needs of clients in Spanish-speaking countries throughout Europe and the Americas. The results were drawn from responses to a qualitative questionnaire regarding the experiences of learning and applying EFT; 103 therapists in 12 different countries where Spanish is spoken responded to the survey. Overall, the results suggest that the therapists surveyed consider EFT to be a "good fit" for many Spanish-speaking clients because of its focus on emotion, attachment theory, close interpersonal relationships, and model-specific interventions that match cultural values. Participants suggested a few culture-specific modifications regarding how to access and process emotion with men in therapy, translation of key EFT concepts and phrases into Spanish, and navigating the intersection of two cultural values (respeto and personalismo). Fewer modifications were suggested by therapists as they discussed application of the model than while learning it.

Exploring the effectiveness of emotionally focused therapy for depressive symptoms and relationship distress among couples in Taiwan: A single-arm pragmatic trial

This is the first study to explore the effectiveness of emotionally focused couple therapy (EFT) for depressive symptoms and relationship distress among couples in Taiwan. This one-arm pragmatic trial assessed the clinical outcomes of 17 couples using multilevel modeling to investigate changes in depressive symptoms and relationship distress throughout treatment. Over half of the participants were moderately depressed and moderately distressed at baseline. Multilevel models revealed decreased depressive symptoms over time, with a small increase toward the end of treatment. However, no significant changes were observed in relationship distress over time. The study was limited by the low "dose" of EFT (M = 7 sessions) received by participants and the small sample size (n = 17). A comprehensive discussion of the findings from a cultural perspective was provided. Future research is needed to further examine the effectiveness of EFT for couples in Taiwan and Asia.

Evaluating the Feasibility and Acceptability of a Psychosexual Intervention for Couples Post-allogeneic Hematopoietic Stem Cell Transplantation

PURPOSE

Allogeneic hematopoietic stem cell transplantation (HSCT) can have a long-term impact on patients' sexual functioning and consequently, their relationship satisfaction. This study aimed to examine the feasibility and acceptability of a 5-session psychosexual intervention for HSCT survivors and their partners.

METHODS

To be eligible patients were required to be more than 3 months post-allogeneic HSCT. The intervention comprised 2 components: (1) A psychosexual education session exploring medical/behavioral treatment options for sexual dysfunction, delivered by a specialist nurse; (2) A 4-session Emotionally-Focused Therapy-based relationship education program for couples delivered by a clinical psychologist. Measures assessing relationship quality, sexual functioning, anxiety, and depression were administered pre- and post-intervention. Feasibility was measured via participation rate, adherence and compliance with completing main measures. Acceptability of the intervention was assessed via patient/partner satisfaction surveys.

RESULTS

Eight of 85 (9.4%) eligible patients and their partners participated in the study. Reasons for declining participation included: feeling uncomfortable due to sensitive nature of intervention; did not have any relationship/sexual function issues; and experiencing ongoing medical issues. Six of 8 couples (75%) attended at least 4 intervention sessions and 5 of 8 (62.5%) completed the main study measures post-intervention. Four couples reported that sexual satisfaction and relationship satisfaction was somewhat or much better post-intervention; 1 reported no change.

CONCLUSION

Feasibility criteria were not met, with low enrolment rate, however the intervention was deemed acceptable. Couples who participated adhered to the intervention and considered it beneficial. Further strategies to identify and manage sexual concerns are required.

Addressing power in couples therapy: Integrating socio-emotional relationship therapy and emotionally focused therapy

Romantic relationships are more satisfying and fulfilling when power is balanced relatively equally between partners (Leonhardt et al., Journal of Family Psychology, 34, 2020, and 1). Yet, few couples therapy models explicitly outline how to confront relational power issues (Knudson-Martin & Huenergardt, 2015, Socio-emotional relationship therapy: Bridging emotion, societal context, and couple interaction, Springer). Emotionally Focused Therapy (EFT; Johnson, 2020, The practice of emotionally focused couple therapy, Routledge) is a well-established, evidence-based therapy modality that many therapists use with couple clients, yet despite its effectiveness, it does not provide direction for explicitly addressing and treating power differentials in couple relationships. In this paper, we explore the integration of EFT with Socio-emotional Relationship Therapy (SERT), a model overlay that acknowledges the impact of social discourse on enactments of power in intimate couple relationships. We first address the importance of understanding power in couple relationships, addressing power in couples therapy, and provide a brief overview of SERT and EFT. We then introduce an integration of the models intended to help therapists balance power, increase connection, and secure attachment bonds between romantic partners.

The use of emotionally focused therapy with polyamorous relationships

Approximately 5% of people in the United States engage in some form of consensual non-monogamy (CNM; Archives of Sexual Behavior, 2018, 47, 1439). Therapists are becoming increasingly aware of the need to treat members of CNM relationships, including polyamorous relationships. To date, no research has been conducted and little has been written about applying existing couple therapy models normed on heterosexual, cisgender, monogamous relationships to CNM or polyamorous relationships. Emotionally focused therapy (EFT) is an empirically supported treatment for relationship distress that offers promise for working with polyamorous relationships due to the model's systemic and attachment theoretical foundations. We propose EFT is an ideal model for working with polyamorous relationships because of the focus on externalizing, interpersonal and intrapersonal emotional and experiential coherence, and the attachment bond. Building and sustaining multiple attachment relationships allows for the fulfilment of a diverse range of relational needs and wants as well as provides a secure base for individual and relational exploration. In this article, we first provide general information about polyamory and discuss the research on attachment theory and polyamory. We then provide a step-by-step conceptualization of how EFT therapists can expand the model to include extra-dyadic attachment relationships. In addition, we include specific ways in which the model would need to be adapted when working with polyamorous clients. We conclude with recommendations for EFT therapists working with polyamorous relationships.

Attachment Injury Severity, Injury-related Stress, Forgiveness, and Sexual Satisfaction in Injured Adult Partners

An attachment injury can occur when one partner violates the assumption that they will provide comfort and caring during a moment of increased need. For injured partners, unresolved attachment injuries can underlie an enduring stress reaction and lower relationship satisfaction. However, no research has examined the associations between the perceived severity of the injury and sexual satisfaction, a central component of relationship well-being. In this cross-sectional study, we examined the direct and indirect associations between the perceived severity of the attachment injury and sexual satisfaction via injury-related stress symptoms and levels of forgiveness, in injured partners. A total of 145 adults who reported having experienced an attachment injury in their current relationship completed self-report questionnaires measuring injury severity, event-related stress, forgiveness, and sexual satisfaction. An indirect association between the perceived severity of the attachment injury and sexual satisfaction through higher injury-related stress and lower forgiveness was found via a path analysis. Results suggest that fostering forgiveness and attending to injury-related stress may be key toward sexual satisfaction in couples where a partner reports an attachment injury. Clinical implications of these results are discussed in light of theory and potential treatment strategies for addressing an attachment injury in couple's therapy.

Psychological couple-oriented interventions for patients with heart disease and their partners: a scoping review and guidelines for future interventions

Objective

This scoping review aims to provide an accessible summary of available evidence on the efficacy of psychological couple-based interventions among patients with heart disease and their partners focusing on specific aspects and strategies by assessing different emotional and physical cardiac-related outcome measures.

Methods

A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the keywords "heart diseases" and "couple-based intervention." A literature search using systematic methods was applied. Data were extracted to address the review aims and were presented as a narrative synthesis.

Results

The database search produced 11 studies. Psychological couple-based interventions varied in terms of the type of intervention, personnel, format (group or individual, phone or in person), number of sessions, and duration. Most of the contributions also lacked adequate details on the training of professionals, the contents of the interventions, and the theoretical models on which they were based. Finally, although partners were involved in all the treatment, in most studies, the psychological strategies and outcomes were focused on the patient.

Conclusion

The variability of the psychological couple-based interventions of included studies represents a challenge in summarizing the existing literature. Regarding their impact, psychological interventions for patients with cardiovascular disease and their partners were found to moderately improve patients' and partners' outcomes.

Effectiveness of a marital relationship skills training intervention on marital adjustment among individuals in Hosanna Town, Southwest Ethiopia: A randomized-controlled trial

Marital distress increases the risk of morbidity and mortality by altering psychological and biological health, including cardiovascular and endocrine function. Numerous interventions have been developed to mitigate marital distress. However, most of these interventions had very specific content and were limited to certain segments of the population. This study was conducted to evaluate the effectiveness of a marital relationship skills training intervention on the marital adjustment of married people in Ethiopia. We conducted a randomized-controlled trial study on 80 married people with low marital satisfaction. We used STATA 14 statistical software to process the data. The results of an Independent sample's t test analysis showed that marital relationship skills training had a significant impact on the marital adjustment of distressed couples (p = 0.001, 95% confidence interval: 0.79-1.10). A marital relationship skills training intervention can effectively improve marital adjustment and can be used as a treatment for marital distress.

Attachment in Couples Coping with Cancer: Associations with Observed Communication and Long-Term Health

Cancer poses a threat to well-being that may activate the attachment system and influence interpersonal dynamics, such as communication. Research indicates that avoidant and anxious attachment, as well as communication, are independently associated with poorer psychosocial well-being, yet studies examining links between attachment, communication, and long-term physical well-being are lacking. We examined (a) associations between patient and partner attachment (measured with the adult attachment scale [AAS-Revised]) and observed communication (across affect [the Relational Affective Topography System (RATS) coding system] and behavior [the Asymmetric Behavior Coding System (ABCS) coding system]) and (b) the extent to which attachment and communication independently predicted long-term physical well-being (measured by the Functional Assessment of Cancer Therapy-General Population [FACT-GP]). Participants were 134 couples [mean age 53.9 (SD = 13.4), 86.2% Caucasian, 66% of patients, 36% of partners female]. Patient participants had either breast, colorectal, or lung cancer. Couples individually completed self-report measures of attachment (baseline) and physical well-being (baseline and 4, 8, and 12 months later). At baseline, couples engaged in a 15 min videorecorded cancer-related conversation coded for communication behavior and affective expression. Patients and partners with higher anxious and avoidant attachment exhibited more negative affect and negative approach behaviors. A greater avoidant attachment was associated with less positive affective expression. Attachment insecurity and affective expression were prospectively linked with physical well-being. Findings indicate that attachment is associated with overt communication behaviors and that insecure attachment and affective expression may be risk factors for poorer health outcomes.

Training therapists in emotionally focused therapy: A longitudinal and cross-sectional analysis

Using cross-sectional and longitudinal data, our study looks at the effectiveness of the Emotionally Focused Therapy (EFT) Externship and Core Skills trainings. It is the first study to evaluate EFT Core Skills trainings and the first to evaluate change longitudinally throughout the standardized EFT training program. We used the Hungarian EFT Knowledge and Competency Scale (Hungarian EFT-KACS) to examine self-perceived knowledge, competency, and alliance over three 4-day training blocks (Externship, Core Skills Modules 1&2, Core Skills Modules 3&4). Results indicate that each training block significantly increased self-perceived knowledge, competency, and alliance. During the Externship, participants' knowledge increased the most and remained at this level after each training block. Competency showed a more modest but significant increase during the Externship. However, by the end of the Core Skills training, competency showed a significant increase compared to post-Externship results, demonstrating the unique role of Core Skills training in developing competency in EFT.

The relationship between therapist interventions and couples' emotional injury resolution in emotion focused couples therapy

The primary purported change process in emotion-focused couples therapy (EFT-C) occurs as therapists assist one partner to access and reveal vulnerable emotions and needs and promotes a subsequent compassionate responding from the other partner. This study aimed to examine the association between therapists' views regarding their interventions during a given session and the degree to which partners reported the session as helpful in resolving their unfinished business. Data from 22 couples who took part in the York Emotional Injury Project and received 10-12 EFT-C sessions were analyzed using multilevel models. The primary findings revealed that when therapists reported using interventions that promoted acceptance of feelings and needs in a given session, both partners reported higher resolution levels in relation to their partner. Our results suggest that interventions that facilitate responsiveness between partners are particularly important in EFT-C, and perhaps in couples therapy in general.

The effectiveness of cognitive developmental hypnotherapy on differentiation of self, meaning in life and marital conflicts in married women

The aim of the present study is to investigate the effectiveness of Cognitive Developmental Hypnotherapy (CDH) on Differentiation of Self, Meaning in Life and Marital Conflicts in married women. The method is quasi-experimental pretest and posttest with a control group. The statistical population of this study includes married women who came to FUM Counseling and Psychological Services Center to receive psychological services. The sample of this study included 40 married women who were selected by targeted sampling method and randomly assigned to two experimental and control groups. Participants in the pretest and posttest study answered the Differentiation of Self Inventory, the Marital Conflicts questionnaire by Sanaei, and the Meaning in Life questionnaire. The research data were analyzed using ANCOVA and MANCOVA with SPSS-21. The findings showed CDH led to an increase in Differentiation of Self and Meaning in life, and a reduction in Marital Conflicts in women. Accordingly, CDH through using techniques such as induction and empowerment of the Ego is effective in marital conflicts of married women. Therefore, using it as a means to improve the quality of married women's lives is recommended.

Emotionally focused therapy: Attachment, connection, and health

In this review, we suggest attachment science as a framework for understanding the negative impact of loneliness and social disconnection on mental and physical health and for guiding the interventions of clinicians. We provide an overview of current findings linking loneliness and social isolation to mental health problems such as depression and anxiety, as well as to physical illnesses such as heart disease. We propose emotionally focused therapy for couples, families, and individuals to enhance the quality of people's emotional ties to significant others and their subjective sense of social connectedness. We conclude by suggesting that the strengthening of emotional, interpersonal bonds, which is the primary focus of all forms of emotionally focused therapy, can help restore emotional balance, thereby protecting people from chronic feelings of isolation and the host of health problems that they can cause.

Measuring the Effectiveness of the Emotionally Focused Therapy Externship Training in Hungary done through Translation

Our study adds to the rising field of dissemination and implementation research on Emotionally Focused Therapy. We evaluated the psychometric characteristics of the Hungarian EFT-KACS, examined the impact of the EFT Externship training done through translation on Hungarian therapists, and we investigated how therapist background characteristics related to outcomes. A total of 340 Hungarian professionals completed the questionnaires (N = 152 in 2016; and N = 188 in 2018) at three data collecting points-prior to (N = 329), after the training (N = 254), and 6 months later (N = 101). Results suggest the Hungarian EFT-KACS has similar psychometric properties as the original English version and shows high internal consistency. The 4-day EFT Externship trainings done through translation provided significant, lasting increases in perceived EFT-specific knowledge and competency, and in alliance, similar to findings in English- and Spanish-speaking countries. Externship outcomes were also found to be related to specific therapist experience and background characteristics.

Cognitive-Behavioral Therapy for Relationship Distress: Meta-analysis of RCTs with Social Work Implications

PURPOSE

The purpose of the present meta-analysis is twofold: 1) determine the aggregated statistical effect of cognitive-behavioral couples therapy (CBCT) for relationship distress in randomized controlled trials and 2) use the findings to inform clinical social work practice and research.

METHODS

A systematic review was conducted using electronic databases and the reference lists of included studies. The random effects model meta-analysis used a hedges' g effect size.

RESULTS

After the removal of an outlier, a homogeneous (Q = 16.66, df = 12, p = .16, I ² = 27.96), significant, moderate effect favoring CBCT (Hedges' g summary effect = .421, Z = 4.51, p < .0001, 95% confidence interval: 0.238 to 0.604, standard error = .093, variance = .009, k =  13) was obtained.

DISCUSSION

It is anticipated that cognitive-behavioral/evidence-based social work clinicians and researchers will use the findings to support their clinical practice and advance their clinical research, respectively.

Coping and Mental Health Differences among Active Duty Service Members and Their Spouses with High and Low Levels of Marital Warmth

This study examined the relationship between marital warmth (e.g., openly expressing affection, supportive behaviors) and assessments of coping (i.e., challenges coping with military life and self-efficacy in the context of stress) and mental health (i.e., depressive symptoms and anxiety symptoms) in a sample of active duty men and their spouses/romantic partners (N = 234 military couples). Results from a series of multivariate analysis of variance tests indicate that service members and spouses who reported higher levels of marital warmth also reported better coping skills and mental health compared to individuals in couple relationships that demonstrated lower levels of marital warmth. Intervention and prevention implications targeting social support and marital warmth are provided.

Study protocol of a pilot study evaluating feasibility and acceptability of a psychosexual intervention for couples postallogeneic haematopoietic stem cell transplantation

INTRODUCTION

Sexual dysfunction is one of the most common side effects of allogeneic haematopoietic stem cell transplantation (HSCT) for haematological cancers. Problems can persist between 5 and 10 years post-transplant and impact mood, couple intimacy and relationship satisfaction. Few intervention studies, however, target sexual dysfunction in patients post-HSCT. This pilot study aims to examine the feasibility and acceptability of implementing a psychosexual intervention for HSCT survivors and their partners post-transplantation.

METHODS AND ANALYSIS

Fifteen allogeneic HSCT survivors and their partners will be recruited. Patients who are more than 3 months post-transplantation will be sent invitation letters describing the couples' psychosexual intervention that will be offered through this study. The intervention will comprise two components: (1) psychosexual education about medical and behavioural treatment options for sexual dysfunction delivered by a haematology nurse consultant; (2) emotionally focused therapy-based relationship education programme for couples delivered by a clinical psychologist (four sessions of 1.5 hours each). Couples who consent to participate will be administered a series of measures assessing mood, relationship satisfaction and sexual dysfunction preintervention and post-intervention, as well as satisfaction with the intervention postintervention. Feasibility of the intervention will be examined via recording enrolment rate, adherence, compliance with completing outcome measures and fidelity of intervention delivery.

ETHICS AND DISSEMINATION

Ethics approval has been obtained at the Peter MacCallum Cancer Centre in Melbourne, Australia. Results will be presented at national and international conferences and published in a peer-reviewed journal so that in can be accessed by clinicians involved in the care of allogeneic HSCT patients. If this intervention is found to be feasible and acceptable, its impact will be examined in a future randomised controlled trial and subsequently implemented as part of routine care in the allogeneic HSCT population.

Cognitive-behavioral and emotion-focused couple therapy: Similarities and differences

Background

Couples and families often seek therapy to deal with relational distress, which is a result of external or internal factors of the relationship. Two approaches are acknowledged to be most effective in dealing with relationship distress or psychological disorders in couples: (a) cognitive behavioral couple therapy with new directions (CBCT) and (b) emotion-focused couple therapy (EFCT). In this article we investigate how much CBCT and EFCT really differ with regard to working with emotions, which is claimed to be a major focus of EFCT, and whether there exist significant differences in efficacy between these two approaches.

Method

This article critically reviews the theoretical background, process, techniques and outcomes associated with CBCT and EFCT in an effort to challenge the assumptions noted above.

Results

There is no evidence that EFCT is more emotion-focused than CBCT. Both approaches were repeatedly examined with RCT studies with follow-ups. In sum, no significant differences in effect size were found between CBCT and EFCT.

Conclusion

CBCT and EFCT are both effective in reducing couples’ distress.

CBCT and EFCT are both effective in helping couples deal with relationship distress.

Both are similarly effective in helping couples to better understand and cope with their presenting concerns.

Both approaches address the importance of personal schema, triggering relevant cognitions and emotions.

Both approaches help couples wherein one partner has been diagnosed with a clinical disorder.

Interventions for Couples

Because relationship discord and dissolution are common and costly, interventions are needed to treat distressed couples and to prevent distress among vulnerable couples. We review meta-analytic evidence showing that 60-80% of distressed couples benefit from behavioral and emotion-focused approaches to couple therapy, but we also note that treatment effects are weaker in actual clinical practice than in controlled studies, dissipate following treatment for about half of all couples, and may be explained by factors that are common across models. Meta-analyses of prevention programs reveal reliable but smaller effects, reflecting a need to know more about whether and how communication mediates effects, about how risk and diversity moderate effects, and about how technology-enabled interventions can reduce attrition in vulnerable populations. Interventions for couples are improving and expanding, but critical questions remain about how and for whom they work.