EFT with Couples facing EFT with Couples facing End-of-LifeEnd-of-Life

Find your partnerFind your partner

Couples Movie ClipCouples Movie Clip

Couples who are faced with the Couples who are faced with the upcoming death of a partner experience upcoming death of a partner experience issues both on an individual level and on issues both on an individual level and on a relational levela relational level

Literature ReviewLiterature ReviewEnd-of Life ImpactEnd-of Life Impact

Literature ReviewLiterature ReviewEnd-of Life Impact: Partner with End-of Life Impact: Partner with IllnessIllness

PhysicalPhysical SocialSocial EmotionalEmotional

DepressionDepression AnxietyAnxiety

SpiritualSpiritual(Mohr, Moran, Kohn, Hart, Armstrong, Dias, Bergsland, & Folkman, 2003) (Mohr, Moran, Kohn, Hart, Armstrong, Dias, Bergsland, & Folkman, 2003)

Literature ReviewLiterature ReviewEnd-of Life Impact: Caregiver partnerEnd-of Life Impact: Caregiver partner

Need to provide emotional support Need to provide emotional support Need to provide instrumental support Need to provide instrumental support

likely to withdraw emotional support as need for likely to withdraw emotional support as need for instrumental support increases due to increased instrumental support increases due to increased distress, resentment, and burnoutdistress, resentment, and burnout

Emotional distress is often worse on the Emotional distress is often worse on the caregiving partner than the patient; they are caregiving partner than the patient; they are less likely to seek out or accept professional less likely to seek out or accept professional help help Common symptoms: increased fatigue, health Common symptoms: increased fatigue, health

problems, and social isolationproblems, and social isolation(Mohr et al., 2003)

CommunicationCommunication Adjustment to changes in rolesAdjustment to changes in roles Adjustment to demands of illnessAdjustment to demands of illness Coping strategiesCoping strategies

(McLean & Jones, 2007; Mohr et al., (McLean & Jones, 2007; Mohr et al., 2003)2003)

Literature ReviewLiterature ReviewEnd-of Life Impact: RelationalEnd-of Life Impact: Relational

Rationale for Couple Therapy Rationale for Couple Therapy at End of Lifeat End of Life

Adaptation to a diagnosis of cancer will be Adaptation to a diagnosis of cancer will be altered by the quality of the couple relationship altered by the quality of the couple relationship (Hannum, Giese-Davis, Harding, & Hatfield, (Hannum, Giese-Davis, Harding, & Hatfield, 1991)1991)

Provide opportunity for relational and personal Provide opportunity for relational and personal growthgrowth

Caregiving partner usually has the largest Caregiving partner usually has the largest impact on the overall well-being of terminally ill impact on the overall well-being of terminally ill partner (Mohr et al., 2003)partner (Mohr et al., 2003)

Case StudyCase StudyJim and SueJim and Sue

White, middle-class, professionalWhite, middle-class, professional Married for 10 years, no childrenMarried for 10 years, no children Sue has been battling a brain tumour for 3 Sue has been battling a brain tumour for 3

yearsyears Her prognosis was recently deemed terminalHer prognosis was recently deemed terminal Doctors are unable to estimate how much time Doctors are unable to estimate how much time

she has leftshe has left Jim has been withdrawing from SueJim has been withdrawing from Sue

Rationale for EFT use Rationale for EFT use Terminal cancer occurs in the context of relationship Terminal cancer occurs in the context of relationship

Circular reciprocity (Stiell, Naaman, & Lee, 2007) Circular reciprocity (Stiell, Naaman, & Lee, 2007) Avoidance of emotional expression by male partners of cancer Avoidance of emotional expression by male partners of cancer

patients perceived as insensitive and rejecting (Sabo, Brown, patients perceived as insensitive and rejecting (Sabo, Brown, & Smith, 1986)& Smith, 1986)

EFT creates a positive emotional environmentEFT creates a positive emotional environment Helps partners regulate emotional and physical functioning, Helps partners regulate emotional and physical functioning,

which reduces overall impact of disease (Steinglass, 2000)which reduces overall impact of disease (Steinglass, 2000)

Focus on power of emotional communication and Focus on power of emotional communication and attachment helps build resilience in the face of illness attachment helps build resilience in the face of illness (Stiell et al., 2007)(Stiell et al., 2007)

Useful in highly emotionally charged experiences Useful in highly emotionally charged experiences ((textbook reftextbook ref), such as terminal illness), such as terminal illness

EFT OverviewEFT OverviewOriginsOrigins

EFT is an integration of EFT is an integration of Experiential/GestaltExperiential/Gestalt approaches and approaches and Interactional/SystemicInteractional/Systemic approaches approaches

EFT OverviewEFT OverviewOrigins: Experiential/GestaltOrigins: Experiential/Gestalt

Therapeutic alliance itself is healingTherapeutic alliance itself is healing Acceptance and validation of client experienceAcceptance and validation of client experience Belief that people are to make healthy choicesBelief that people are to make healthy choices Examine how inner and outer realities define Examine how inner and outer realities define

each othereach other People are formed and transformed in People are formed and transformed in

relationship with othersrelationship with others Use here-and-now experience of therapy Use here-and-now experience of therapy

session to foster corrective experiencessession to foster corrective experiences

EFT OverviewEFT OverviewOrigins: Systemic InfluencesOrigins: Systemic Influences

Focus is on interaction between Focus is on interaction between members of systemmembers of system

Problems are due to interactionsProblems are due to interactions Breaking a negative cycle will effect Breaking a negative cycle will effect

positive changepositive change EFT focuses on using emotion to help EFT focuses on using emotion to help

break negative cycles and enact new break negative cycles and enact new patterns of interactionpatterns of interaction

EFT OverviewEFT OverviewOrigins: Experiential-Systemic SynthesisOrigins: Experiential-Systemic Synthesis

Focus on present experience, not pastFocus on present experience, not past Person is seen as fluid entityPerson is seen as fluid entity Experiential approaches focused within Experiential approaches focused within

the person; excluded relational influencesthe person; excluded relational influences Systemic approaches focused on Systemic approaches focused on

interactions; excluded individual internal interactions; excluded individual internal responses and meanings responses and meanings

EFT OverviewEFT OverviewOrigins: Influence of Attachment TheoryOrigins: Influence of Attachment Theory

Primary attachments create an internal Primary attachments create an internal working model of relationships which is working model of relationships which is played out in all of our relationships played out in all of our relationships (Bowlby in (Bowlby in Engler, 2003; Bowlby in Stiell et al., 2007)Engler, 2003; Bowlby in Stiell et al., 2007)

No person is inherently able to regulate No person is inherently able to regulate their emotions. This develops through their emotions. This develops through relationships. relationships. (McWilliams, 2004)(McWilliams, 2004)

Attachment injuries – traumatic events Attachment injuries – traumatic events that damage the bond between partners, that damage the bond between partners, such as chronic illness such as chronic illness (McWilliams, 2004)(McWilliams, 2004)

EFT OverviewEFT Overview Relationship Health Relationship Health

A healthy relationship is one in which there is a A healthy relationship is one in which there is a secure attachment bondsecure attachment bond

Mutual emotional accessibility and Mutual emotional accessibility and responsivenessresponsiveness

Depathologizes dependency in adultsDepathologizes dependency in adults Allows activation of attachment seeking Allows activation of attachment seeking

behavioursbehaviours Model of others as dependable and Model of others as dependable and

trustworthy, model of self as lovable and trustworthy, model of self as lovable and entitled to care entitled to care

EFT OverviewEFT Overview Relationship Distress Relationship Distress

Due to attachment insecurity and separation Due to attachment insecurity and separation distressdistress

Sequence of responses to threat against Sequence of responses to threat against attachment securityattachment security

AngerAnger Clinging and seekingClinging and seeking Depression and despairDepression and despair Mourning and detachmentMourning and detachment

Rigid interaction patterns such as Rigid interaction patterns such as demand-demand-withdraw withdraw can be disastrous can be disastrous

EFT OverviewEFT OverviewKey PrinciplesKey Principles

Collaborative alliance provides secure Collaborative alliance provides secure base from which to explorebase from which to explore Therapist is consultant to processTherapist is consultant to process

Emotion is primary in forming attachment Emotion is primary in forming attachment behaviours, guiding perceptions, behaviours, guiding perceptions, motivating attachment responsesmotivating attachment responses Therapist privileges emotional responsesTherapist privileges emotional responses

Attachment needs are healthy and Attachment needs are healthy and adaptiveadaptive

EFT OverviewEFT OverviewKey Principles Cont’dKey Principles Cont’d

Problems are maintained by interactional Problems are maintained by interactional organization and by dominant emotionsorganization and by dominant emotions Therapist deescalates negative patterns and Therapist deescalates negative patterns and

reactive emotions; help shape new, positive reactive emotions; help shape new, positive interactionsinteractions

Change occurs through new emotional Change occurs through new emotional experience in present interactionsexperience in present interactions

The actual “client” is the relationship, not The actual “client” is the relationship, not individual members of coupleindividual members of couple

EFT Overview: Three TasksEFT Overview: Three TasksTask 1 – Create and maintain Task 1 – Create and maintain therapeutic alliancetherapeutic alliance

Four qualities of building alliance:Four qualities of building alliance: Empathic attunementEmpathic attunement AcceptanceAcceptance GenuinenessGenuineness Continuous active alliance Continuous active alliance

monitoringmonitoring

EFT Overview: EFT Overview: Three TasksThree TasksTask 2 – Access and Reformulate Task 2 – Access and Reformulate EmotionsEmotions

EFT therapists recognize key universal EFT therapists recognize key universal emotions emotions

anger/rage, fear/anxiety, joy/elation, anger/rage, fear/anxiety, joy/elation, shame/disgust, sadness/despair, shame/disgust, sadness/despair, surprise/curiositysurprise/curiosity

Step-wise process of emotions:Step-wise process of emotions: Appraisal Appraisal ArousalArousal Reappraisal Reappraisal Action TendencyAction Tendency

EFT Overview: EFT Overview: Three TasksThree TasksTask 2 – Access and Reformulate Task 2 – Access and Reformulate Emotions Cont’dEmotions Cont’d

Emotions inform interactions and help in Emotions inform interactions and help in organizing adaptive responses to a person’s organizing adaptive responses to a person’s environmentenvironment

Primary emotionsPrimary emotions Secondary emotionsSecondary emotions Instrumental emotionsInstrumental emotions 3 key issues in focusing on emotion:3 key issues in focusing on emotion:

InvolvementInvolvement ExplorationExploration New emotionNew emotion

EFT Overview: EFT Overview: Three TasksThree TasksTask 2 – Access and Reformulate Task 2 – Access and Reformulate Emotions Cont’dEmotions Cont’d

Skills for Emotional EngagementSkills for Emotional Engagement RISSCRISSC ValidationValidation Evocative RespondingEvocative Responding HeighteningHeightening Empathic conjecture and interpretationEmpathic conjecture and interpretation Self-disclosureSelf-disclosure

EFT Overview: EFT Overview: Three Tasks Three Tasks Task 3 – Restructure Key Task 3 – Restructure Key InteractionsInteractions

Tracking and reflecting interactionTracking and reflecting interaction Simple reflection: when he does this, you do thatSimple reflection: when he does this, you do that

Framing and reframing interactionsFraming and reframing interactions Example EFT Reframes:Example EFT Reframes:

Fighting against the Enemy of the Negative CycleFighting against the Enemy of the Negative Cycle Withdrawal as an attempt to Protect the RelationshipWithdrawal as an attempt to Protect the Relationship Pursuing to Fight for a ConnectionPursuing to Fight for a Connection

Restructuring interactions using enactmentsRestructuring interactions using enactments Structured, focused, choreographedStructured, focused, choreographed

EFT OverviewEFT OverviewFurther InterventionsFurther Interventions

Resolving attachment injuriesResolving attachment injuries Help injured partner discuss the impact and the significance of Help injured partner discuss the impact and the significance of

the attachment the attachment Other partner then able to better understand how the event has Other partner then able to better understand how the event has

injured their partner in attachment terms. injured their partner in attachment terms. Aid injured partner in further discussing the injury in terms of Aid injured partner in further discussing the injury in terms of

expressing grief and fear.expressing grief and fear. Other partner realizes their role in the injury and expresses their Other partner realizes their role in the injury and expresses their

own emotions. own emotions. Injured partner is able to ask their partner for support in dealing Injured partner is able to ask their partner for support in dealing

with emotionswith emotions A new narrative of the event has been constructed by the A new narrative of the event has been constructed by the

couple and each partner is able to understand the other’s couple and each partner is able to understand the other’s experience of the event. experience of the event.

EFT OverviewEFT OverviewProcess of ChangeProcess of Change

Nine treatment steps, organized into three Nine treatment steps, organized into three stagesstages

In mildly troubled couple, the partners usually In mildly troubled couple, the partners usually progress through steps at parallel rateprogress through steps at parallel rate

In more highly troubled couple, the more In more highly troubled couple, the more withdrawn or passive partner is invited to withdrawn or passive partner is invited to progress through the steps slightly ahead of progress through the steps slightly ahead of partnerpartner

Begin with one or two conjoint sessions, then Begin with one or two conjoint sessions, then one with each partnerone with each partner

Typically lasts 8 to 15 weekly sessionsTypically lasts 8 to 15 weekly sessions

EFT OverviewEFT OverviewMechanisms of ChangeMechanisms of Change

Levels of Change:Levels of Change: Expansion of Experience Expansion of Experience Engagement of the Partner in a Different Way Engagement of the Partner in a Different Way New View of the Partner is Offered to His/Her New View of the Partner is Offered to His/Her

Mate Mate New Cycle is Initiated New Cycle is Initiated A Bonding Event Occurs in the Session A Bonding Event Occurs in the Session Shifts in Both Partners’ Sense of Self Shifts in Both Partners’ Sense of Self

EFT OverviewEFT OverviewStage 1: Cycle De-Stage 1: Cycle De-escalationescalation

Goals Goals Couple to have overarching perspective of their Couple to have overarching perspective of their

interactionsinteractions Each partner’s reality is validatedEach partner’s reality is validated Partners are encouraged to unite against the Partners are encouraged to unite against the

negative cyclenegative cycle Initiate new cycle that promotes attachment Initiate new cycle that promotes attachment

securitysecurity

EFT OverviewEFT OverviewStage 1: Cycle De-Stage 1: Cycle De-escalationescalation

Step 1Step 1: Identify relational conflict issues: Identify relational conflict issues Step 2Step 2: Identify negative interaction cycle : Identify negative interaction cycle

where these issues are expressedwhere these issues are expressed Step 3Step 3: Access unacknowledged emotions: Access unacknowledged emotions

underlying the interactional position underlying the interactional position each partner takes in this cycle.each partner takes in this cycle.

Step 4Step 4: Reframe problem in terms of the : Reframe problem in terms of the cycle, accompanying underlying cycle, accompanying underlying emotions, and attachment needs.emotions, and attachment needs.

Scenario #1Scenario #1

Role Play: Stage 1Role Play: Stage 1

EFT OverviewEFT OverviewStage 2: Changing Interactional Stage 2: Changing Interactional PatternsPatterns

GoalsGoals Have withdrawn partners reengaged in Have withdrawn partners reengaged in

the relationship the relationship Partners are able to confide in and seek Partners are able to confide in and seek

comfort from each othercomfort from each other Partners are becoming mutually available Partners are becoming mutually available

and responsive and responsive

EFT OverviewEFT OverviewStage 2: Changing Interactional Stage 2: Changing Interactional PatternsPatterns

Step 5Step 5: Encourage each partner to identify : Encourage each partner to identify with disowned attachment needs and with disowned attachment needs and aspects of self. aspects of self.

Step 6Step 6: Promote acceptance by each partner : Promote acceptance by each partner of the other partner's experienceof the other partner's experience

Step 7Step 7: Promote expression of needs and : Promote expression of needs and wants to restructure the interaction; wants to restructure the interaction; create bonding eventscreate bonding events

Role Play: Stage 2Role Play: Stage 2

Scenario #2Scenario #2

EFT OverviewEFT OverviewStage 3: Consolidation and Stage 3: Consolidation and IntegrationIntegration

GoalsGoals To consolidate new responses and To consolidate new responses and

cycles of interaction cycles of interaction If you practice the new cycle enough If you practice the new cycle enough

times it will become the normtimes it will become the norm

EFT OverviewEFT OverviewStage 3: Consolidation and Stage 3: Consolidation and IntegrationIntegration

Step 8Step 8: Facilitate the emergence of : Facilitate the emergence of new solutions to old new solutions to old

problemsproblems

Step 9Step 9: Consolidate new positions : Consolidate new positions and cycles of and cycles of

attachment attachment behaviour behaviour

Role Play: Stage 3Role Play: Stage 3

Scenario #3Scenario #3

EFT OverviewEFT OverviewTerminationTermination

During stage three the therapist is less During stage three the therapist is less directive directive

Therapist outlines positive changes that Therapist outlines positive changes that have occurred during therapyhave occurred during therapy

Discuss goals for the future and any Discuss goals for the future and any feelings about terminationfeelings about termination

Couples are welcomed to return Couples are welcomed to return

EFT OverviewEFT OverviewPredictors of SuccessPredictors of Success

Positive therapeutic alliance = successPositive therapeutic alliance = success With male partners who have been described With male partners who have been described

by their partners as “inexpressive” by their partners as “inexpressive” With female partners who feel that their partner With female partners who feel that their partner

still cares for themstill cares for them Areas that have NOT influenced the success of Areas that have NOT influenced the success of

EFT with couples include: age, education, EFT with couples include: age, education, income, length of marriage, cognitive income, length of marriage, cognitive complexity, or religiosity. complexity, or religiosity.

EFT OverviewEFT OverviewApplicability & DiversityApplicability & Diversity

Used with diverse ages, classes, backgrounds, Used with diverse ages, classes, backgrounds, and sexual orientations and sexual orientations

Positive outcomes for males and females Positive outcomes for males and females Often used with gay and lesbian couples Often used with gay and lesbian couples Couples with issues of low sexual desire are Couples with issues of low sexual desire are

often difficult to treat in a few sessions often difficult to treat in a few sessions Effective with traumatized partners, depressed Effective with traumatized partners, depressed

partnerspartners Can be used with couples where there is mild Can be used with couples where there is mild

and infrequent violence and/or emotional and infrequent violence and/or emotional abuseabuse

Popular Notions of End-Popular Notions of End-of-Life Issuesof-Life Issues

Resources for CouplesResources for Couples

Group Member ReactionsGroup Member Reactions

Topic: Couple Therapy at End-of-LifeTopic: Couple Therapy at End-of-Life SimilaritiesSimilarities DifferencesDifferences

We engaged in much discussion about whether the illness We engaged in much discussion about whether the illness should be chronic (e.g. MS) or something terminalshould be chronic (e.g. MS) or something terminal

Approach: EFTApproach: EFT Similarities Similarities

We appreciated the importance of focusing on attachment We appreciated the importance of focusing on attachment during this difficult time of life, so EFT seemed a great fitduring this difficult time of life, so EFT seemed a great fit

Most of us found that EFT was a very dense and Most of us found that EFT was a very dense and complicated approachcomplicated approach

DifferencesDifferences

ReferencesReferencesEngler, B. (2003). Engler, B. (2003). Personality theories: An introduction, 6Personality theories: An introduction, 6 thth ed. ed. Houghton Mifflin: New Houghton Mifflin: New

York.York.

Hannum,J. W., Giese-Davis, J., Harding, K., & Hatfield, A. K. (1991). Effects of Hannum,J. W., Giese-Davis, J., Harding, K., & Hatfield, A. K. (1991). Effects of individual and marital variables on coping with cancer. individual and marital variables on coping with cancer. Journal of Psychosocial Journal of Psychosocial Oncology, 9(2)Oncology, 9(2), 1-20., 1-20.

McLean, L.M., & Jones, J.M. (2007). A review of distress and it’s management in couples McLean, L.M., & Jones, J.M. (2007). A review of distress and it’s management in couples facing end-of-life cancer. facing end-of-life cancer. Psycho-Oncology, 16Psycho-Oncology, 16, 603-616, 603-616

McWilliams, A.E. (2004). Couple psychotherapy from an attachment theory perspective: McWilliams, A.E. (2004). Couple psychotherapy from an attachment theory perspective: A case study approach to challenging the dual nihilism of being an older person and A case study approach to challenging the dual nihilism of being an older person and someone with a terminal illness. someone with a terminal illness. European Journal of Cancer Care, 13European Journal of Cancer Care, 13, 464-472., 464-472.

Mohr, D.C., Moran, P.J., Kohn, C., Hart, S., Armstrong, K., Dias, R., Bergsland, E., & Mohr, D.C., Moran, P.J., Kohn, C., Hart, S., Armstrong, K., Dias, R., Bergsland, E., & Folkman, S. (2003). Couples therapy at end of life. Folkman, S. (2003). Couples therapy at end of life. Psycho-OncologyPsycho-Oncology, , 1212, 620-627, 620-627

Sabo, D., Brown, J., & Smith, C. (1986). The male role and mastectomy: Support Sabo, D., Brown, J., & Smith, C. (1986). The male role and mastectomy: Support groups and men’s adjustment. groups and men’s adjustment. Journal of Psychosocial Oncology 4Journal of Psychosocial Oncology 4(1-2), 19-30.(1-2), 19-30.

Stiell, K., Naaman, S.C., & Lee, A. (2007). Couples and chronic illness: Attachment Stiell, K., Naaman, S.C., & Lee, A. (2007). Couples and chronic illness: Attachment perspective and emotionally focused therapy interventions. perspective and emotionally focused therapy interventions. Journal of systemic Journal of systemic therapies, 26therapies, 26(4). 59-74.(4). 59-74.

Steinglass, P. (2000). Family processes and chronic illness. In Steinglass, P. (2000). Family processes and chronic illness. In Cancer and the FamilyCancer and the Family, , Baider, L., Cooper, C.L., & Kaplan-DeNour, A. (Eds.), pp. 3-15. John Wiley: West Baider, L., Cooper, C.L., & Kaplan-DeNour, A. (Eds.), pp. 3-15. John Wiley: West Sussex, England.Sussex, England.

Rationale for Couple Therapy at Rationale for Couple Therapy at End of Life optional slide –already End of Life optional slide –already covered in videocovered in video

Reduce psychosocial distressReduce psychosocial distress For ill partner, it can ameliorate the perception of For ill partner, it can ameliorate the perception of

severity of symptoms (Mohr et al., 2003)severity of symptoms (Mohr et al., 2003) For caregiver, it can ease bereavement (McLean & For caregiver, it can ease bereavement (McLean &

Jones, 2007)Jones, 2007)

Dying represents a threat to the Dying represents a threat to the attachment and attachment behaviours attachment and attachment behaviours are activated in times of threat are activated in times of threat (McWilliams, 2004)(McWilliams, 2004)

Potential relationship issuesPotential relationship issues Securely attached relationships show ability to Securely attached relationships show ability to

take turns in being caregiver and care take turns in being caregiver and care receiver receiver (McWilliams, 2004)(McWilliams, 2004)

Withdraw-pursue or withdraw-withdraw cycles Withdraw-pursue or withdraw-withdraw cycles (Stiell, Naaman, & Lee, 2007)(Stiell, Naaman, & Lee, 2007)

Application of Attachment TheoryApplication of Attachment Theory

Important to be comfortable with grief processImportant to be comfortable with grief process Issues of countertransference Issues of countertransference Higher awareness of end of life, become fearful Higher awareness of end of life, become fearful

of own lifeof own life Self care (depression, burn out)Self care (depression, burn out) Awareness of own philosophy and theoretical Awareness of own philosophy and theoretical

base (ensure that it works with group base (ensure that it works with group participants) participants)

Use of SelfUse of Self

StrengthsStrengths WeaknessesWeaknesses

- Bridging a gap in available Bridging a gap in available servicesservices- Providing individuals with Providing individuals with supportsupport- Uses evidence based practice Uses evidence based practice in thein the development of a successful development of a successful groupgroup- Participants are invited to co-Participants are invited to co- construct the group experienceconstruct the group experience- Group invites participants to Group invites participants to reflectreflect on presently occurring on presently occurring interactionsinteractions

- Pilot group so there are no - Pilot group so there are no previously previously established guidelines or established guidelines or outcomeoutcome studiesstudies- Lack of clarityLack of clarity - What will happen when - What will happen when clientsclients diedie - Is it beneficial to have a - Is it beneficial to have a closedclosed groupgroup - Length of group- Length of group - Diversity in age group- Diversity in age group

Critical AnalysisCritical Analysis