Emotionally Focused Couples Therapy - Status and Challenges

8/3/2019 Emotionally Focused Couples Therapy - Status and Challenges

1/13

Emotionally Focused Couples Therapy:Status and ChallengesSusan M. Johnson, Universityof OttawaJohn Hunsley, Universityof OttawaLeslie Greenberg, York UniversityDwayne Schindler, Universityof Ottawa

This article presents the basis for, and the researchon, emotionally focused couples therapy (EFT), nowrecognized as one of the most researched and mosteffective approaches to changing distressed muit.1 re-lationships. Drawing on attachment theoy and the re-search on interactional patterns in distressed relatlon-ships, we describe the theoretical context of EFT. Wethen outline the nature of the clinical intenentionsused in EFT and the steps hypothesized to be crucialto couple change. The central role of accessing andworking with emotional issues in the relationship con-text is highllghted. Following this presentation, we re-view both the outcome and proc.sr rauNcch on EFTand present mobanalytic data from randomized clini-cal trials to substantiate the clinical impact of EFT oncouple adjustment. Finally, the empirical and clinicalchallenges facing EF T are summarized.Key wods: emotionally focused couples therapy,

marital relationships. fain Prychd Sci h e ~67-79,19993

Although the failure to developa satisfying intimate rela-tionship with ones partner is the single most frequentlypresented problem in therapy (Horowitz, 1979), couplestherapy, the modality that most directly addresses thisproblem, is a relatively young discipline. In this discipline,systematic approaches to changing distressed relationshipsare s t i l l being developed and evaluated. At present thereare only two clearly delineated treatments for marital dis-tress that have been empirically tested in a number of stud-Address correspondence to SusanM. Johnson, School of Psy-chology, University of Ottawa, Ottawa, Ontario, CanadaK1N6N5.

ies (Alexander, Holtzworth-Munroe, & Jameson, 1994;Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998):behavioral marital therapy and emotionally focused cou-ples therapy (EFT). Of these, EFT is the most recentlyformulated, being first described in the literature in 1985(Johnson & Greenberg, 1985a). This article summarizesthe development of EFT over the last decade, in terms ofboth outcome data and more clinical and theoreticalissues. We also consider the future challenges toEFT andthe field of couples therapy in general.

At the time EFT was formulated in the early 1980s,there were a number of particularly important questionsfacing the field of couples therapy. First, this modality hadbeen almost exclusively practice driven. The essential ele-ments of marital distress, and therefore the most appro-priate targets for intervention, were s t i l l undelineated byempirical study. Second, there wasa dearth of nonbehav-ioral, more dynamically oriented interventions that hadbeen clearly described and tested. There was no cleartechnology for relationship change outside the scope ofthe behavioral interventions (Gurman, 1978). There werealso concerns about the general efficacy of couples inter-ventions and an acknowledged need to continue todevelop such interventions (Jacobson, 1978; Jacobson,Follette, & Elwood, 1984). Third, there was a lack of aconsistent, empirically supported theoretical perspectiveon the nature of adult love and relationships that could beused to clarifjr the goals and focus the process of therapy.Fourth, couples interventions had focused on changingbehavior and, in a limited way, on restructuring cogni-tions, such as the attributions partners make about eachothers behavior. However, the roleof affect had not beensystematically addressed, although even behavioral ap-proaches acknowledged thatmodifying affect was a neces-sary part of treating distressed relationships (Jacobson&

0 1999 AM E RI CAN P S Y CHOL OGI CAL AS S OCI AT I ON D l 67


2/13

Margolin, 1979). EFT developed in response to theseissues and, as we describe below, reflects these key con-cerns of the couples therapy field.

EFT is a brief systematic approach to modifying dis-tressed couples constricted interaction patterns and emo-tional responses and to fostering the development of asecure emotional bond (Greenberg & Johnson, 1988;Johnson, 1996). The specific targets of the EFT changeprocess are the same variables identified in recent empiri-cal research as the crucial elements in marital distress(Gottman, 1979, 1993; Gottman, Coan, Carrere, &Swanson, 1998). Specifically, EFT targets absorbing statesof negative affect, that is, negative emotions suchas anger or fear that are difficult to quickly diminish.In the context of intimate relationships, interactionalcues associated with these affective states tend to overrideother cues and become self-reinforcing. EFT also targetsrigid self-reinforcing interaction patterns such as criticalpursuit, followed by distance and defensiveness. EFTintegrates the intrapsychic perspective afforded bypsychodynamic approaches with an interpersonal sys-temic perspective, and melds these perspectives into atechnology for change that is formulated in a 9-stepchange process. In this process, newly formulated emo-tional responses are expressed in such a way as to createspecific shhs in interaction that prime bonding events.These events then create new constructive cycles of con-tact and caring between partners.

EFT views relationships from an attachment perspec-tive. This perspective has been recently identified as themost promising theory of adult love to date and alreadyhas substantial empirical support (Bartholomew & Per-Iman, 1994; Collins & Read, 1990; Kobak & Hazan,1991; Simpson, Rholes, & Nelligan, 1992), providing apotential map of intimate relationships for couples thera-pists. Attachment theory helps the therapist understandpartners needs and how particular responses to theseneeds define close relationships. Lastly, in terms of theconcerns identified above, EFT addresses the role ofaffectin close relationships and in changing those relationships,both on a theoretical level and on the level of clinicalintervention (Johnson& Greenberg, 1994). It is then partof the recent zeitgeist that focuses on the facilitative roleof emotion in human fbnctioning and therapeutic change.

EFT also reflects the general context ofthe field ofpsy-chotherapy in the 1990s n that it isa brief, systematic inter-vention that has been empirically validated. Research on

EFT has attempted to address the basic questions ofall psy-chotherapy research. The first question concerns efficacy;that is, does it work? The second question concerns theprocess of change, or, how does it work? The third ques-tion concerns the matching of client to treatment, or, forwhom does it work? The research base supporting EFT issummarized in this article anda meta-analysis of the effectsofEFT on marital functioning s presented.E F T : T H E T H E O R E T I C A L MODELThe Nature of MaritalDistressE FT assumes that the key factors in marital distress are theongoing construction of absorbing states of distressedaffect and the constrained, destructive interactional pat-terns that arise from, reflect, and then in turn prime thisaffect. EFT combines an experiential, intrapsychic focuson inner experience, particularly affect, with a systemicfocus on cyclical, self-reinforcing interactional responses.The focuson affect arises from the humanistic experientialperspective, as outlined by Rogers (1951) and Perls(1 973), and reflects the individual therapy training of theoriginators of EFT (Greenberg &Johnson, 1988). Thefocus on how each partners responses constrain and dic-tate the others, and on interpersonal patterns, reflects theinfluence of systems theory, as exemplified by the workofMinuchin (Minuchin& Fishman, 1981). The focus onaffect is supported by the empirical work of Gottman(1991), who emphasizes the power of negative affect,asexpressed in facial expression, to predict long-term stabil-ity and satisfaction in relationships and the destructiveimpact of repeated cycles of interaction, suchas criticizingand defendmg oneself or complaining and stonewalling.The inability of distressed couples to sustain emotionalengagement is also noted by Gottman (Gottman& Lev-enson, 1986) and appears more central in maintaining dis-tress than disagreements per se or whether disagreementscan be resolved. Gottman (1991) notes that there appearto be differences in affect regulation between men andwomen. Women seem to be more able to regulate theiraffect in interpersonal conflict and therefore more oftenseem to take a critical and complaining position, whereastheir male partners withdraw and stonewall to containtheir affect. The cycle of critical complaint followed bydefense and distance is particularly destructive for couplesrelationships (Heavey, Christensen,& Malamuth, 1995).Gottmans thorough and empirically based description ofmarital distress and his models ability to predict marital

CLIN ICAL PSYCHOLOGY: SCIENCE AN D PRACTICE V6 N1, SPRING 1999 68


3/13

outcomes suggest that emotional responses and particularself-reinforcing interaction patterns are the most appro-priate targets of intervention in marital therapy (Gott-man, 1994).The Nature of Adult LoveTo understand why and how emotional responses and theinteractional patterns outlined above are so central to mar-ital distress, we need to place these empirical findings inthe context of a theory of relationships. Marital therapyhas, in general, lackeda clear theory of adult intimacy andtherefore a clear sense of the primary goals and targets forthe change process (Roberts, 1992; Segraves, 1990). Sucha theory would allow clinicians to define what specificchanges are necessary to encourage recovery from distressand promote long-term health and resilience in relation-ships.

In recent years attachment theory has been appliedmore and more to adult relationships rather than to par-ent-child bonds (Bowlby, 1988; Hazan & Shaver, 1987).From an attachment perspective, the description of mari-tal distress outlined above is best understood in terms ofseparation distress and an insecure bond. A bond hererefers to an emotional tie, a set of attachment behaviors tocreate and manage proximity to the attachment figure anda set of working models or what are usually termed sche-mas. These schemas are concerned with the dependabilityof others and the worth or lovableness of self.

Seeking and maintaining contact with others is viewedas the primary motivating principle in human beings andas an innate survival mechanism shaped by the process ofevolution. Secure attachment provides a safe haven and asecure base in a potentially dangerous world (Bowlby,1988).When attachment security is threatened, compel-ling affect organizes attachment responses into predictablesequences. Typically protest and anger will be the firstresponse to such a threat, followed by some form of cling-ing and seeking, which then gives way to depression anddespair. Finally, if an attachment figure does not respond,detachment and separation will occur (Bowlby, 1969).The potential loss of an attachment figure, or an ongoinginability to define the relationship as generally secure, issignificant enough to prime automatic fight, flight, orfieeze responses that limit information processing andconstrict interactional responses (Johnson, 1996). So, forexample, a husband evades and avoids his wife in anattempt to calm down the interaction and reduce her

anger, but his flight in fact heightens her anxiety andprimes her aggression toward him.

Attachment theory provides a map for adult intimaterelationships.It outlines adaptive needs for contact, com-fort, security, and closeness as the features that define thislandscape. This perspective focuses the couples therapiston attachment fears, longings, and needs, and stresses thesignificance of experiences ofloss of trust and connection.I t directs the process of therapy toward the creation of theaccessibility and responsiveness that foster safe emotionalengagement. In terms of the process of change, attach-ment theory directs the therapists attention to theaccessing and reprocessing of attachment-related affect,the modifjnng of interactions that block contact, and thecreation of bonding interactions. This theory, like Gott-mans research, stresses the importance of affect in thedefinition of close relationships. In attachment theory,emotion may be seen as alerting partners to the signifi-cance and nature of key relational experiences, evokingworking models in a state-dependent fashion (e.g., whenIm anxious about my relationship, I experience all myfears about myself), and, most importantly for the cou-ples therapist, priming attachment behaviors (Johnson,1996).

There are four key assumptions of EFT that arise outof these theoretical perspectives. First, emotional re-sponses and interactional patterns are reciprocally deter-mining and both must be addressed in therapy. Second,partners are stuck in negative patterns that preclude theresponsiveness necessary for secure bonding. They are notviewed as immature or unskilled but, rather, as needingsupport to formulate their attachment needs and fears in amanner that promotes secure bonding. Third, emotion isseen as a key element in the definition and the redefinitionof close relationships. New emotional experience andnew interactions are necessary for change to occur.Fourth, adult intimacy is best viewed as an attachmentprocess. This process gives couples interventions a specificfocus, target, and set of goals.EFT InterventionsThe process of change in EFT has been delineated in ninetreatment steps. The first four steps involve assessment andthe de-escalation of problematic interactional cycles. Themiddle three steps emphasize the creation of specificchange events where interactional positions shift and newbonding experiences occur. The last two steps of therapy

EFT STATUS JOHNSON ET AL. 69


4/13

address the consolidation of change and the integrationofthese changes into the everyday life of the couple. Thetherapist leads the couple through these steps in spiralfashion, as one step incorporates and leads into another. Inmildly distressed couples, partners generally work quicklythrough the steps a t a parallel rate. In more distressed,more insecure couples, the more passive or withdrawnpartner is usually invited to go through the steps slightlyahead of the other. The increased emotional engagementof hs partner then helps the other more active, criticalpartner shift to a more trusting stance.

The nine steps of EFT are as follows:Cycle De-escalation.

Step 1.Assessment-creating an alliance and explicat-ing the core issuesin the couples conflict using an attach-ment perspective.

Step 2. Identifjmg the problem interactional cycle thatmaintains attachment insecurity and relationship distress.

Step 3. Accessing the unacknowledged emotionsunderlying interactional positions.

Step 4. Refiaming the problem in terms of the cycle,the underlying emotions, and attachment needs.Changing Interactional Positions.

Step 5. Promoting identification with dlsowned needsand aspects of self and integrating these into relationshpinteractions.

Step 6. Promoting acceptance of the partners newconstruction of experience in the relationship and newresponses.

Step 7. Facilitating the expressionof specific needs andwants and creating emotional engagement.Consolidation/Zntegration.

Step 8. Facilitating the emergence of new solutions toold problematic relationship issues.

Step 9. Consolidating new positions and new cycles ofattachment behavior.

In all of these steps the therapist moves between (a)helping partners crystalhe their emotional experience inthe present, trachng, reflecting, and then expanding thisexperience and (b)setting interactional tasks that add newelements to and reorganize the interactional cycle. Thetherapist might, then, first help a withdrawn, guardedspouse formulate his sense of paralyzed helplessness thatprimes his withdrawal. The therapist will validate this

sense of helplessness by placing it within the context ofthe destructive cycle that has taken over the relationship.The therapist will heighten this experience in the sessionand then help his partner to hear and accept it, eventhough it is very different from the way she usually experi-ences her spouse. Finally, the therapist moves to structur-ing an interaction around this helplessness, as in, So canyou turn to her and can you tell her, I feel so helplessnessand defeated. I just want to run away and hide. This kindof statement, in and of itself, representsa move away fiompassive withdrawal and is the beginning of active emo-tional engagement. The steps of EFT are described ingreater detail elsewhere, as are the specific interventionsassociated with each step (Johnson, 1996). There are alsoa number of therapy transcripts in the literature (Johnson,1996, in press; Johnson& Greenberg, 1992, 1995) thatillustrate the stance of the therapist and the typesof inter-ventions employed in EFT.ASSESSING THE CLINIC AL EFFICACY OF EFTThe central focus of the empirical work on EFT has beento determine its efficacy as a treatment for marital distress.To date, seven studies have examined the impactof EFTon distressed couples,as assessed by a wide range of mea-sures, including indices of psychological and dyadlcadjustment, intimacy, and target complaints about therelationshp. The majority of these studies have beenran-domized clinical trials (RCTs) in which EFT was com-pared to pharmacological or psychological treatments, orto waiting list controls (Dessaulles, 1991; Goldman &Greenberg, 1992; James, 1991; Johnson & Greenberg,1985a; Walker, Johnson, Manion, & Cloutier, 1996); intwo studies, treated couples served as their own controls(Johnson & Greenberg, 1985b; Johnson & Talitman,1997). Additionally, to examine the extent to which EFTmay affect relationship issues other than marital distress,two RCTs have explored the ability of EFT to enhanceintimacy in maritally adjusted couples (Dandeneau &Johnson, 1994) and to modify low sexual desire in femalepartners (MacPhee, Johnson, & Van der Veer, 1995).Table 1 presents summary information on the characteris-tics of the couples who participated in these studies andthe design characteristics of these studies. As evident fromTable 1, all EFT trials have included treatment integritychecks that were performed on tapes of therapy sessionsand have had very low attrition rates, thus enhancing theinternal vahdity of the studles. Across the nine studies of

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V6 N1, SPRING 1999 70


5/13

Table 1. Sample and study characteristics in EFT studies

StudyRelationship n of TreatmentDuration Children no f n of IntegrityTherapists Sessions Check Attr itionn of AgeCouples (M years) OM years) (MI

Johnson & Creenberg (1985a)Johnson & Creenberg (1985b)James (1991)Coldman & Creenberg (1992)Dandeneau &Joh nson (1994)MacPhee e t al. (1995)Walker e t al. (1996)Dessaulles (1991)Johnson & Talitman (1997)

451428283649321234

34.033.037.038.540.941.536.937.042.0

8.66.99.6

11.315.714.011.310.913.0

1.81 o1.61.41.61.42.32.01.4

127

147

101076

13

81012109

10101512

YesYesYesYesYesYesYesYesYes

0%0%Unknown0%3%"8%3%33 %b5%

'One couple withdrew from the non-EFT treatment condition.bTwo couples withdrew from the EFT condition and fou r couples withdre w from the pha rmacological ntervention condition.

Table 2. E f f e c t s of EFT on marital adjustmentDASPrethcrapy Posttherapy

Improved Deteriorationtudy M SO M SD RecoveredJohnson & Creenberg (1985a) 92.8 8.8 112.7 10.8 46% 66% 0%Johnson & Creenberg (1985b) 93.9 n/a 103.9 n/a nfa n/a n/aJames (1991) 87.6 10.2 103.3 14.6 79% 86% 14%Coldman & Creenberg (1992) 86.3 8.3 100.1 13.1 67% 71% 0%Dandeneau &Johnson (1994)" 105.9 6.7 110.5 4.9MacPhee et al. (1993). 98.6 n fa 105.1 n/aWalker et al. (1996) 99.7 8.3 109.6 9.2 38% 69% 0%Dessaulles (1991)b 87.0 14.9 99.9 17.1Johnson & Talitrnan (1997) 88.0 7.9 102.8 13.3 50% 79% 6%Note: nf a means no t available.'The focus of these studies were, respectively, to enhanceaspects of the relationshipsof maritally adjusted couples and to improve couple's sexualfunction ing. Calculations of recovery, improvemen t, and dete rioration based on DAS scores are therefore not relevant.bAs only six couples received EFT in th is study, estimatesof clinical improvement are not prov ided.

EFT outcome, therapy has been provided by both noviceand experienced therapists. As almost al l of the studieshave been conducted by the two originators of EFT (S.Johnson and L. Greenberg), it is important to note thatthere has been only minimal therapist overlap across stud-ies (three therapists were common to the Walker et d . andthe Johnson and Talitman studies), thus enhancing theexternal validity of this program of research.

As the main god of EFT is to alleviate couples' rela-tionshp &stress, we concentrate most of our presentationof the effects of EFT on the results of treatment on cou-ples' Dyadic Adjustment scale (DAS; Spanier, 1976), the

most commonly used measure of dyadic adjustment in theliterature. Table 2 presents information on couples' DASscores prior .to and following treatment. In all studies inwhich the primary focusof treatment was marital distress(i,e., excluding the Dandeneau &Johnson and the Mac-Phee et al. studies), EFT has been found to result in sig-nificantly improved dyadic adjustment, compared both towaiting list controls and to couples' pretreatment DASscores. Using the criteria suggested by Jacobson andTruax(1991)for assessing clinically significant change, the over-whelming majority of EFT-treated couples reported clin-ical improvement on the DAS, and in most studies over

EFT STATUS * JOHNSON ET AL . 71


6/13

half of the EFT-treated couples met criteria for recovery(i.e., no longer maritally distressed). Additionally, thereappear to be only infrequent instances in which EFT-treated couples experienced deterioration in their rela-tionship over the course of treatment. Overall, theseresults generally meet or exceed the oft-reported findingthat approximately half of couples seen in marital therapyoutcome research are no longer maritally &stressed (Hah-lweg & Markman, 1988; Jacobson& Addis, 1993).

There have been a number of reviews of the couplestherapy outcome literature in recent years, including bothtraditional literature reviews (Lebow & Gurman, 1995;Piercy & Sprenkle, 1990) and meta-analytic reviews(Dunn & Schwebel, 1995; Shadish et al., 1993). Becauseof the recency of publication for some of the articlesdescribing the effects of EFT, these reviews do not pro-vide a comprehensive overview of the eficacy of EFT.Accordingly, we conducted a meta-analysis on the out-come measures (dyadic adjustment, intimacy, target com-plaints) reported in the four RCTs of EFT in whichcouples were seeking treatment for their relationship dis-tress (i.e., Goldman & Greenberg, 1992; James, 1991;Johnson & Greenberg, 1985a; Walker et al., 1996). Inconducting this meta-analysis reported below, we in-cluded only the EFT studies ofmaritally &stressed couplesthat involved RCTs, as there is evidence that effectsizes derived &om other types of research designs mayunderestimate the true effects of treatment (Shadish&Ragsdale, 1996). Additionally, given that the Dessaulles(1991) study had a very small sample and did not includea waiting list control group, we excluded this study fromour analysis. Using Schwarzers (1990) meta-analysis pro-gram, we calculated several meta-analytic indices for thefour RCT studies of EFT. First, effect sizes were calcu-lated for each dependent variable in each study. Averageeffect sizes were then calculated for each study. Finally, themean effect size, weighted by sample size, was calculatedacross studies. The resulting overall mean effect size was1.28. This isa large effect size for psychotherapy researchand is statistically significant, Z = 6.32, p < .001; theeffect sizes across studies were homogeneous, Q = 5.34,p > .05. For comparison purposes, we note that previousmeta-analytic estimates for the effect size of couples ther-apy have ranged from .60 (ShaQsh et al., 1993) to .90(Dunn & Schwebel, 1995).

Although the effect size obtained from the precedingmeta-analysis is useful in making general comparisons toprevious meta-analyses of the couples therapy literature,

Table 3. Meta-analysisof EFT effects on marital adjustment

Study ReportedE f f e c t Size N EFT) N Control)Randomized clinical trials including a no-treatment condition

Johnson & Greenberg (1985a) 2.19 15 1514 14ames (1991) .70Goldman & Greenberg (1992) 1.52 15 1516 16alker et al. (1996) 1.27

Other EFT studies with distressedcouplesJohnson & Greenberg (1985b) .94 14Dessaulles (1991) 1.49 7Johnson & Talitman (1997) 1.26 34

Note: Meta-analytic results from RCTs were as follows: Weighted meaneffect size: (d+) = 1.31. Significance of combined result: 2 = 6.42,p .05. Fail-safen = 49 studies.

it provides limited information about the effect of EFT.In the couples therapy literature, different researchers,examining various forms of couples therapy, use differingbatteries of measures. Meta-analytic estimates that com-bine these different measures may mistakenly give theimpression that one can precisely compare studiesor ther-apeutic approaches. Instead, to make accurate cross-studycomparisons, one must make comparisons based solely onmeasures that the studies have in common. In the couplestherapy literature, the only such measure is the DAS.Therefore, to provide more precise meta-analytic esti-mates of EFTS impact for future comparisons with othertreatment approaches, we repeated the meta-analysisusing only the DAS data from the four RCTs.

Table 3 presents the effect sizes reported in these stud-ies for couples DAS scores following treatment. For com-parison purposes, effect sizes from the three other studieswith maritally &stressed couples are included. As shownin Table 3, the weighted mean effect size ofthe four RCTsattained a statistically significant value of 1.31. No t sur-prisingly, given that al l couples in these studies were mari-tally distressed, the effect sizes across studies werehomogeneous. An effect size of 1.31 is very large for psy-chotherapy research, especially in light of Dunn andSchwebels (1995) estimate of .90 for the average effectsize of couples therapy on global inQces (including theDAS) of marital quality.

Our results are based on the data derived from onlyfour studies. It is possible, therefore, that they may notbe stable, On e method for examining this possibility is tocalculate Rosenthals (1984) hil-safe 11. This calculationyields an estimate of the number of studies reporting non-significant findings that would be required to reduce the

CLINICAL PSYCWOLOGV: SCIENCE AN D PRACTICE V6 N1, SPRING 1999 72


7/13

overall effect size estimate of the body of research to anonsignificant level. The fail-safe n for the EFT findingson the DAS is 49; that is, 49 studies reporting nonsignifi-can t results would be required to yield an overall effectsize that was statistically nonsignificant. Rosenthal (1984)has suggested that a tolerance level be set to determinewhat would constitute an unlikely number of nonsigni-ficant studies not included in a meta-analysis. Using histolerance level equation (Rosenthal, 1984, p. 1 lo) , thisnumber is 30 studies. Therefore, it is extremely unlikelythat the obtained results for EFT on the DAS are inflateddue to nonpublication of nonsignificant findings. Accord-ingly, based on our meta-analytic estimates for homoge-neity of effect sizes and the fail-safe n, t appears that theobtained effect size of 1.31 is stable and consistent acrossstudies.

Not only is EFT clearly effective in reducing maritaldistress, there also seems to be a tendency for couples tocontinue to improve after the termination of treatment.Fo r example, in the most recent study (Johnson & Talit-man, 1997), 70% of couples were found to be recovereda t 3-month follow-up, an improvement over the 50%who were recovered a t the end of therapy. The same kindof increase occurred in the first EFT study by Johnson andGreenberg (1985a;46% recovered at termination, 73% atfollow-up) and in the Walker et al. (1996) study (38%recovered at termination, 70% at follow-up). A 2-yearfollow-up of the couples involved in the Walker et al.(1996) study has also been completed, with very positiveresults (Walker & Manion, 1998), as all treatment effectswere maintained a t the follow-up assessment. Theseresults are particularly encouraging given that these cou-ples were the parents of chronically ill children and socoping with considerable ongoing stress that might beexpected to make treatment gains more difficult tomaintain.

Although EFT is primarily designed to alter maritalhnctioning, there are initial data indicating that EFTinterventions also reduce depressive symptoms (Dessaul-les, 1991; MacPhee et al., 1995; Walker, 1994). However,10sessions of EFT failed to significantly increase the sex-ual adjustment of couples in which the female partner wasexperiencing low sexual desire (MacPhee et al., 1995).Clinically, we found that many of these low-desire part-ners had been traumatized in past close relationships and10 sessions was not an adequate number to create newpositive interactions, particularly in the area of intimatetouch and sexuality. The results in this study were compa-

rable to others reported by researchers addressing low sex-ual desire (Schover & Lopiccolo, 1982) in that subjectsdid improve across time on some measures but significantpositive changes were less than optimal.THE PROCESS OF CHANGE IN EFTIn general, there has been very little research addressingthe process of change in couples therapy. To date, fourstudies of the process of change in EFT have beenreported in the literature, with the goal of this line ofresearch being a greater understandmg of the crucialingredients of change, from the point of view of both cli-ent performance and therapist interventions. The firststudy (Johnson & Greenberg, 1988) examined the processof therapy in best sessions for three couples whose DASscores increased by an average of 47 points (i.e., approxi-mately 2 .5 standard deviations) in the original EFToutcome study (Johnson & Greenberg, 1985a). T h ssuccessful process was compared with that of the threelowest change couples who did not show significantimprovement on the DAS. Videotapes of best sessions(chosen by the couples) were independently rated for lev-els of experiencing (Klein, Mathieu, Gendlin, & Miesler,1969) and for afiliative and autonomous responses ininteractions using the Structural Analysis of Social Behav-ior (SASB; Benjamin, 1986). A particular change event, asoftening, where a previously critical partner expressesvulnerability and asks for comfort and connection fromhis or her partner, was also defined using these measures.The high-change couples showed significantly higher lev-els of experiencing in best sessions. A x2 analysis alsofound that blaming partners in the high-change coupleswere more likely to move to demonstrating a more affil-iative and less coercive position toward their spouse in thesession. O n average, five softening change events werefound in the sessions of the successful couples and nonewere found in the sessions of the low-change couples.These results confirmed the relevance of encouragingcouples to explore their emotional responses and engagein tasks in which they express their attachment needs totheir partner in a manner that facilitates emotionalengagement.

Three additional small studies ofEFT change processes(Greenberg, Ford, Alden, &Johnson, 1993) demonstratedthe same kinds of effects, In one study EFT couples werefound to demonstrate more shifts from hostility to affilia-tion on the SASB than wait-list couples who were begin-ning treatment. In another study, peak or best sessions of

EFT STATUS JOHNSON ET AL. 73


8/13

EFT as identified by couples were characterized by moredepth of experiencing and affiliative and autonomousstatements than were sessions identified by couples aspoor. The final study demonstrated that intimate, emo-tionally laden self-disclosure (as coded on the SASB) wasmore likely to lead to afiliative statements by the otherpartner than other randomly selected responses. Reveal-ing underlying experience in an intimate manner thus ledto a change in interaction. In general, the results of thesestudies are consistent with the theory of EFT. They implythat change in EFT is associated with the expression ofunderlying feelings and needs that leads to a positive shifiin interaction patterns and fosters accessibility and respon-siveness.P R E D I C T I N G S U C C E S S IN E F TThe program of research on EFT is now beginning toconsider the question of who is best suited to this formof couples intervention. Clinically, EFT has never beenrecommended for couples where abuse is an ongoing partof the relationship. Abusive partners are referred to groupor individual therapy to help them deal with their abusivebehavior. They are offered EFT only after this therapy iscompleted and their partners no longer feel at risk. Addi-tionally, for couples who are separating, EFT is used onlyin an abbreviated form to clarify the redefinition of therelationship and support partners as they separate.

The results of a recent study on predictors of successin E F T (Johnson & Talitman, 1997) provide some initialevidence on who is likely to benefit most &om EFT. Hier-archical multiple regression analyses were used in thisstudy to assess the unique contribution of the predic-tor variables to improvement or recovery fiom marital&stress, beyond that due to initial satisfaction level. Inaddition to posttreatment assessment of participants, a 3-month follow-up was conducted.

Based on regression analyses, the quality of the alliancewith the therapist was a strong predictor of success in EFT.This is to be expected, as it is a general finding in researchon all forms of psychotherapy that a positive alliance isassociated with therapeutic success. More important,though, the quality of the da n c e in EFT seemed to be amuch more powerful and general predictor of treatmentsuccess than was initial distress level. In this study, initialdistress level was not an important predictor of success atthe 3-month follow-up assessment (it accounted for only4% of the variance in outcome). This is an unusual finding

because initial &stress level is usually by far the best pre-dictor of long-term success in marital therapy, accountingfor as much as 46%of the variance in marital satisfaction(Whisman &Jacobson, 1990). In addition, the task rele-vance aspect of the alliance was more predictive ofimprovement than was a positive bond or a sense of sharedgoals. EFT was more successful with couples who saw therelevance of formulating and expressing their attachmentneeds and fears and then addressing issues of connectionand trust.

Several other characteristics were associated withimprovement in therapy. Older males (over 35 years ofage) tended to report greater relationship adjustment atfollow-up and to make more gains in therapy, perhapsfinding issues of intimacy and attachment more relevantthan did the younger male partners. This is an interestingfinding in that previous studies of couples therapy havefound an inverse relationship between age and outcome,leading some to suggest that treating older people appearsto be more &&cult (Jacobson& Addis, 1993).

A statistically and conceptually significant finding wasthat a female partners initial level of faith that her partnerstill cared for her predicted the couples adjustment andintimacy levels at follow-up. In a culture where womenhave traditionally taken most of the responsibility formaintaining close bonds, this finding suggests that if thefemale no longer has faith in her partner, the emotionalinvestment necessary for change may be stifled. This isconsistent with accumulating evidence that emotionaldisengagement, rather than factors such as the inability toresolve dsagreement, is predictive of marital unhappinessand instability (Gottman, 1994) and lack ofsuccess in cou-ples therapy (Jacobson & Addis, 1993). Low levels of thiselement of trust may be a bad prognostic indicator forcouples engaging in any form of couples therapy.

Several partner characteristics were found to be unre-lated to improvement in couple adjustment. Lack ofemo-tional expressiveness or awareness did not predict progressin EFT; in fact, EFT seemed to be particularly helphl formales who were described by their partners as inexpres-sive. Traditionality in relationships (i.e., where the malepartner is oriented to independence and the female toaffiliation) also did not affect progress in EFT.

Overall, then, the findings of this study suggest that afemales level of faith in her partners caring and the cou-ples ability to engage in an alliance with the therapist andrespond to the tasks of EFT are more important prognos-

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V6 N I . SPRING 1999 74


9/13

tic indicators for the EFT therapist than are initial distresslevel or factors such as emotional inexpressiveness. Futureresearch is necessary to substantiate these important find-ings and to expand our knowledge on the range of clientand couple characteristics that may influence the impactof EFT.S U M M A R Y A N D F U T UR E D I R E C T IO N SFrom a theoretical perspective, there is more and moreevidence that the targets of EFT interventions, emotionalresponses and patterned interactional cycles, are the mostsignificant features of marital distress. These variables reli-ably predict long-term relationship distress and dlsruption(Gottman, 1994). Evidence is also accumulating thatattachment theory can provide a theoretical basis forunderstanding the nature of marital distress and adult lovein general. Attachment theory offersa theoretical basis forinterventions such as EFT. It would seem to be a consider-able advance for the field of couples therapy to begin tohave systematic forms of intervention that are based onclear evidence of the nature of marital distress and thenature of adult love relationships. Eficient, short-termchange strategies require a clear set of targets and goalsthat focus interventions on the variables most likely tomediate recovery from marital distress. EFT offersa clearsequenced set of interventions and change processes,based on the phenomenology ofmarital distress anda the-ory of adult love that has empirical support.

From a clinical perspective, perhaps the main generalcontribution the work on EFT has made to the field ofcouples therapy is to offer an orientation to and specificways ofworking with emotion. It also offers a way ofinte-grating a focus on the individual and the relationship, onboth within- and between-person variables and processes.Clinical change processes in EFT seem, fkom the smallnumber of studies described above, to be consistent withthe conceptualization of emotion in this model and howemotional experience and expression &e seenas hcilitat-ing change. The literature on psychotherapy process(Rice & Greenberg, 1984) emphasizes the needto specifj.not just the variables associated with change but changeevents where a number of variables occur in a specificcontext. This research can then be used to provide someguidance for therapist interventions.T h i s kind of researchhas begun with EFT in the description of a softeningchange event (Johnson& Greenberg, 1988)and will con-tinue in the future. The active ingredients of a treatment

can also be delineated by conducting constructive studles,wherein particular interventions are added to the treat-ment protocol and the effects on outcome are noted.Only one study of EFT has used this constructive designapproach (James, 1991), finding that the addition of acommunication skills component to the usual EFT in-terventions did not increase the effectiveness of thetreatment.

EFT change strategies have also been adapted andapplied to different populations, and some of these appli-cations have been researched, such as the use of EFT withdepressed spouses (Dessaulles, 1991; MacPhee et al.,1995; Walker, 1994). EFT is presently used in a wide vari-ety of settings, including private practices, university clin-ics and counseling centers, and hospital outpatient clinics(Blanchard, 1994). EFT has also been taught to a largenumber of therapists, varied in age, sex, and experience,and has proved itself to be replicable in the outcome stud-ies completed to date. In terms of outcome data, the effectsizes for EFT are large and treatment outcomes generallyexceed the reported average 50% success rate for couplestherapy (Jacobson & Addis, 1993). The empirical evi-dence is consistent and clear: EFT is an effective treatmentfor marital distress.

In terms of research design, the studles completed onEFT have several strengths. They have, in general, usedrandom assignment to group, valid control groups, treat-ment implementation checks with very acceptableinterrater reliability, reliable measures of process and out-come, follow-up analyses, and appropriate research meth-odology. The size of the groups in these studles wasrelatively sma l l , the largest being 45, but this is typicalofthe field of couples therapy as a whole. Outcome mea-sures were mainly self-report; however, it has been arguedthat this is appropriate in this particular field (Jacobson,1985a , 1985b). When EFT has been compared to othertreatments (Dandeneau & Johnson, 1994; Johnson &Greenberg, 1985a), therapists have been nested withintreatment, except for one, study (Goldman& Greenberg,1992). This decision was based on the ecological validityof the treatment and the clinical perception that therapistsdo best when they are trained in and committed to theinterventions they use.

There are two important methodological limitations tothe current body of research on EFT. The first is that allbut one study involved one or both of the developersof EFT as a research investigator. Many meta-analytic

EFT STATUS J O H N S O N E T AL. 75


10/13

reviews of psychotherapy outcome have found thatresearcher allegiance to a treatment is positively associatedwith the treatments effect size; moreover, this phenome-non may be particularly important in the early stages ofevaluating a treatment (Gaffin, Tsaousis, & Kemp-Wheeler, 1995). Accordingly, research is needed whereEFT is evaluated by investigators less directly affiliatedwith its development. Such research is beginning to sur-face and report positive results (Denton, Burleson, Clarke,Rodriguez, and Hobbs, in press). The second limitation isone common to almost all current psychotherapies shownto have significant clinical effects in research trials, namely,the generalizability of the research findings to the routineuse of the treatment in clinical settings (see Clarke, 1995).An important task facing us is to begin examining whetherthe strength of the reported EFT effects is maintained inclinical settings where therapists have received less trainingand supervision in EFT than the therapists in the RCTsand where clients may have greater marital and psycho-logical distress or concomitant problems such as eatingdisorders or anxiety disorders.

The data on how change occurs in EFT are also lim-ited. Dismantling studies, which identify and examinethe effects of specific ingredients in a specific treatmentapproach, have not been conducted. Although a link be-tween engagement in emotional experience, a specifickind of interactional shift, and treatment outcome wasfound in one study (Johnson & Greenberg, 1988), itwould enhance the model if the contribution of differentinterventions and processes to positive outcome wasdelineated. In the process studies completed so far, thepossibility exists that the process variables were the resultof improvement rather than the mediator of improve-ment. Therefore, in a dismantling study, it would be usefulto determine the effectiveness of simply naming the nega-tive cycle and linking it to underlying attachment emo-tions. These interventions constitute Steps2 and 3 in EFTand are designed to create a de-escalation of the negativecycle. The study might then examine how adding inter-ventions designed to foster the reprocessing of emotionalresponses (Step 5) and the shaping ofspecific new interac-tions (Step 7) might add to treatment effectiveness. It mayalso be tiUitfLl to examine the process of change in spe-cific intermediate outcomes that partners face in therapy,such as achieving closure on past betrayals and learning todepend on the other partner again.

There has been little attention in the EFT research tothe role of individual differences and how they affect the

EFT process. It is possible, for example, that EFT mightbe more effective for partners displaying an anxiousattachment style (i.e., those who are prone to hyperactiva-tion of attachment behaviors when distressed) than forthose displaying an avoidant attachment style (i.e., thosewho minimize attachment behaviors when &stressed).How EFT might be tailored to such individual differencesis just beginning to be described in the literature (John-son & Whiffen, in press).

Future research needs to address the limitations out-lined above concerning what therapy ingredients are nec-essary and sufficient for clinically significant change,which couples are particularly suited to EFT, and how theprocess of treatment might be tailored to accommodateindividual differences. Additional questions remain as tohow successful EFT can be in reducing individual symp-tomatology that accompanies relationship distress and theeffectiveness of emotionally focused interventions fordifferent populations. Some recent research has attemptedto test the limits of EFT by exploring the type of thera-peutic effects possible when couples present with otherproblems in addition to marital distress (e.g., depression,stress due to a childs chronic illness). In our view, the test-ing of the limits of EFTS clinical utility is a crucial ingre-dient in further developing and refining an establishedtreatment that has the promise to improve the ability ofclinicians to alleviate marital distress.

A pilot evaluation has been conducted on the use ofemotionally focused interventions to create change infamilies of eating-disordered adolescents (Johnson, Mad-deaux, & Blouin, 1998) and a pilot is planned on the useofEFT when one partner suffers from posttraumatic stressdisorder. The work with traumatized couples is particu-larly interesting in that initial indications are that EFTinterventions appear to not only improve the couplesrelationship but to create a healing environment thatallows the trauma survivor to deal more constructivelywith trauma symptoms such as flashbacks and emotionalnumbing (Johnson & Williams-Keeler, 1998). However,the change process with this population appears to belonger and to contain specific pitfalls and difficulties, par-ticularly regarding the creation of trust.

A second research direction involves the continuationof our efforts to understand the process of therapeuticchange in EFT by examining the effect ofEFT on specificclient cognitions, in this case schemas or working modelsconcerning the acceptability and worthiness of self and thedependability of others. These types of cognitions are

C LI N I C A L P S Y C HOLOGY : S C I E N C E A N D P R A C TI C E V6 N1, SPRING 1999 76


11/13

c i ted in the a t t achm ent l i t e ra tu re as c ruc ia l e lemen ts indef in ing t he secur i ty of an a t tachm ent bond and as be ingsignif icantly related to variables such as resi l ience in theface of stress and f lexibi l i ty in information processing(Mikulincer, 19 97; Mikulincer, Florian, & Weller, 1993).One prel iminary s tudy suggests that a ch ang e in how t h epartner is perceived is associated with success in EFT(Gre enberg e t a l ., 1993) . O th er p rocess-o r ien ted researchis a l so underw ay t o exam ine c l ien ts exp er ience of E F Tcomp ared t o m ore cogn it ive ly o r ien ted mar i ta l inte rven-tions.

One of the cu rren t c r i t i c i sms of marital and familyinterventions is that the cl ients perspect ive o n th e chan geprocess has be en largely i gno red by researchers; th is per-s p ec t iv e n eed s t o b e m o r e hl ly considered in subsequentstudies of EFT. Th ere a re a lso plans to e xpand the w orkon p red ic to rs of success in E F T i n o r der t o f aci li ta te th eo p t i m a l m a t ch i n g of cl ients to t reatments . Final ly, webelieve that research e xam ining the in-session ef fects ofspecif ic therapis t in terventions, a t specif ic points in ther-apy where cl ients are involved in part icular tasks, wouldalso be useful in th is regard and wo uld enhan ce the u t i li tyof E FT in terven t ions to cou ple therapis ts.

R E F E R E N C E SAlexander,J . F., Holtzworth-Munroe, A., & Jameso n, P. (1994).The process & outcome of marital & family therapy:

Research review and evaluation. In A. B ergin & S. Garfield(Eds.), Handbook ofpsychother apy and behavior change (pp. 565-607). New York Wiley.

Bartholomew, K., & Perlman, D . (Eds.). (1994). Attachmentpro-cesses in adulthood: Advances in personal relationships (Vol. 5).London: Jessica Kingsley.

Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., &Stickle, T.R. 1998). Empirically supported couple and fam-ily interventions for marital distress and adult mental healthproblems. Journal of Consulting and Clinical Psychology, 66,

Benjam in, L. (1986). Adding social and intra-psychic descriptorsto axis I of DSM-III. In T. Millon & G. Her ma n (Eds.), Con-temporary directions in psychopathology (pp. 215-232). Ne wYork: G uilford Press.

Blanchard, J. J. (1994). Directory of research opportunities or clinicalpsychology interns. Albany, N Y : Graywind.

Bowlby, J. (1969). Attachment G loss: Vol. I . Attachment. N e wYork: Basic Books.

Bowlby,J. (1988).A secure base. N ew York: Basic Books.Clarke, G. N. (1995). Improving the transition from basic efE-

cacy resea rch to effectiveness studies: Methodo logical issues

53-88.

and procedures. Journal qf Consulting and Clinical Psychology,Collins, N., & Read, S. (1990) Adult attachment, working mod-

els and relationship quality in dating couples.Journal qfPerson-ali ty arid Social Psychology, 58, 644-663.Dandeneau, M., &Johns on, S. (1994). Facilitating intima cy: Acomparative outcome study of emotionally focused and cog-nitive interventions. Journal ofMarital G. Family Therapy, 20,

Dento n, W., Burleson, B. R., Clarke, P. E., Rodriguez, C. l?, &Hobbs, B. V., (in press). Outcomes of emotionally focusedtherapy for couples in a training clinic.Journal o fMari tal andFamily Therapy.

Ilessaulles, A. (1991). T h e treatment ofclinical depression in the con-text ofmari tal distress. Unpublished doctoral dissertation, Uni-versity of Ottawa.

Dunn , R. L. , & Schwebel, A. I. (1995). Meta-analytic review ofmarital therapy outcome research. Journal of Family Psychol-Gaffin, E. A., Tsaousis, I . , & Kemp-Wheeler, S. M. (1995).

Researcher allegiance and meta-analysis: The case of cogni-tive therapy for depression.Journal of Consulting and Clinical

Goldman, A,, & Greenberg, L. (1992). Comparison of inte-grated systemic and emotionally focused approaches to cou-ples therapy.Journal of ConsuLing and Clinical Psychology, 60,962-969.

Gottman, J. (1979). Marital interaction: Empirical investigations.Gottma n, J. (1991). Predicting the longitudinal course of mar-

riages.Journal ofMarital and Family Therapy, 17 , 3-7.Gottma n, J. (1993).A theory ofmarital dissolution and stability.

Journal ofFamily Psychology, 7 , 57-75.Gottman , J. (1994). An agenda for marital therapy. In S. M .

Johnson & L. S. Greenb erg (Eds.), Theh e m qf the matter: Per-spectives qfemotion in marital therapy (pp. 256-296). Ne w York:Brunner/Mazel.

Gottman, J., & Levenson, R. W. (1986). Assessing the role ofemotion in marriage. Behavioral Assessme nt, 8, 31-48.

Gottman, J. M., Coan, J. Carrere, S., & Swanson, C. (1998).Predicting marital happiness and stability from newlywedinteractions.Journal of Mamage and the Family, 60, 5-22.

Greenberg, L. S. , Ford, C., Alden, L., & Johnson, S. M.(1993).Change processes in emotionally focused therapy.

Journal of Consulting and Clinical Psychology, 61, 78-84.Greenberg, L. S., &Johnson , S. M. (1988). Emotionallyfocused

therapyfor couples. N ew York: Guilford Press.Gurman, A. S. (1978). Contem porary marital therapies: A cri-

tique and comparative analysis of psychoanalytic behavioraland systems theory approaches. In T.J. Poalino & B. S.McCrady (Eds.), Marriage and marital therapy (pp. 445-566).Ne w York: Brunner/Mazel.

63, 718-725.

17-33.

Ogy, 9, 8-68.

l s y ~ h ~ l ~ g y ,3, 966-980.

Ne w York: Academic Press.

EFT STATUS JOHNSON 1 AL. 77


12/13

Hahlweg, K., & Marknian, H . J. (1988). Effectiveness ofbeh av-ioral marital therapy: Empirical status of behavioral tech-niques in pre venting and alleviating marital &stress.Journal qfConsulting and Clinical Psychology, 56 , 440-447.

Hazan, C., & Shaver, P. (1987). Conceptualizing ro mantic loveas an attachment process.Journal ofPersonality and Social Psy-Heavey, C. L., Christensen, A., & Malaniuth, N. M. (1995).

Th e longitudinal impact of demand and withdrawal duringmarital conflict. Journal of Consulting and Clinical Psychology,

Horowitz, L. M. (1979). Cognitive structure of interpersonalproblems treated in psychotherapy.Journal of Consulting andClinical Psychology, 47 , 5-15.

Jacobson, N. S. (1978). A review of the research o n the effec-tiveness ofma rital therapy. In T.J. Paolino & B. S . McCrady(Eds.), Marriage and marital therapy (pp. 395-444). Ne w York:Brunner/Mazel.

Jacobson, N. S. (1985a). Th e role of observational measures inbehavior therapy outcome research. Behavioral Assessm ent, 7,

Jacobson, N. S. (1985b). Uses versus abuses of observationalmeasures. Behavioral Assessmen t, 7, 323-330.

Jacobson, N. S. , & Addis, M. E. (1993). Research on couplesand couple therapy: What do we know? Where are wegoing?Journal $Consulting and Clinical Psychology, 61, 85-93.

Jacobson, N. S., Follette, W. C., &Elwood, R. W. (1984). Ou t-com e research in behavioral marital therapy: A methodologi-cal and conceptual reappraisal. In K. Hahlweg & N. S .Jacobson (Eds.), Marital interaction: Analysis and modification(pp. 113-129). N ew Y or k Guilford Press.

Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategiesbased on social learning and behavior exchange principles. N ewYork BrunnedMazel.

Jacobson, N. S., & Truax, I? (1991). Clinica l significance: A sta-tistical approac h to defining m eaningfkl change in psycho-therapy research. Journal o Consulting and Clinical Psychology,

James, P. (1991). Effects of a communication training compo-nent added t o an em otionally focused coup les therapy.Journa1ofMarita1 and Fam ily Therapy, 17, 263-276.Johnson, S. M. (1996). The practice of emotionally focused maritaltherapy: Creating connection. N ew Y ork Brunner/Mazel.

Johnson, S. M. (in press). Emotiona lly focused couples therapy:Straight to the heart. In J. Donovan (Ed.), Short term couplestherapy. New York Guilford Press.

Johnson, S., & Greenberg, L. (1985a). The mfferential effec-tiveness of experiential and prob lem solving interventions inresolving marital conflict. Journal $ Consulting and Clinical

Johnson, S.,& Greenberg, L. (1985b). Emotionally focused cou-

chology, 52, 511-524.

6 3 , 797-801.

297-308.

59, 12-19.

P ~ ~ c h o l o g ~3, 175-184.

ples therapy: An outcome study.Journal $Mar ital and FamilyTherapy, 1 1 , 313-317.

Johnson, S . M ., & Greenberg, L. S. (1988). Relating process tooutcome in marital therapy.Journal ofMar ital and Family Ther-apy, 14, 175-183.Johnson, S. M ., & Greenberg, L. S . (1992). Emotionally focusedtherapy: Restructuring attachment. In S. Budman, M.Hoyt, & S . Friedman (Eds.), First sessions in time-e fectiveps y-chotherapy: A casebook (pp. 204-224). New York: GuilfordPress.

Johnson, S. M ., & Greenberg, L. S . (Eds.). (1994). The heart ofthe matter: Perspectives on emotion in marital therapy. Ne w York:Brunner/Mazel.

Johnson, S. M ., & Greenberg, L. S. (1995). The emotionallyfocused approach to problems in adult attachment. In N . S.Jacobson & A. S. Gurm an (Eds.), Th e clinical handbook ofmari-tal therapy (2nd ed., pp. 121-141). N ew York: Guilford Press.Johnson, S. M., Maddeaux, C. , & Blouin, J. (1998). Emotionallyfocused family therapy for bulimia. Psychotherapy, 35, 238-247.

Johnson, S . , & Talitman, E. (1997). Predictors of outcome inemotionally focused marital therapy. Journal of Marital andFamily Therapy, 2 3 , 135-152.

Johnson, S . M ., & Wh iffen, V. (in press). Made to measure:Adapting emotionally focused couples therapy to partnersattachm ent styles. Clinical Psychology: Science and Practice.

Johnson, S . M ., & Williams-Keeler, L. (1998). Creating healingrelationships for couples dealing with trauma: The use ofemotionally focused marital therapy. Journal o Marital andFamily Therapy, 2 4, 25-40.

Klein, M. H., Mathieu, P. L., Gendlin, E. T., & Miesler, D. J .(1969). The experiencing scale: A research and training manual(Vol. 1). Mahson: University of Wisconsin, Bureau ofAudiovisual Instruction.

Kobak, R. , & Hazan, C. (1991). Attachm ent in marriage: Effectsof security and accuracy ofwork ing models.Journal ofperson-ality and Social Psychology, 60, 861-869.

Lebow,J. L., & Gurm an, A. S. (1995). Research assessing coup leand family therapy. Annual Review of Psychology, 46, 27-57.

MacPhee, D.C., Johnson, S. M ., & Van der Veer, M . C . (1995).Low sexual desire in wom en: The effects of marital therapy.Journal $Se x and Marital Therapy, 21, 159-182.

Mikulincer, M. (1997). Adult attachment style and informationprocessing: Individual differences in curio sity and cognitiveclosure.Journal of Personality and Social Psychology, 7 2 , 1217-1230.

Mikulincer, M., Florian, V., & Weller, A. (1993). Attachmentstyles, copin g strategies and post-trau matic psycholog ical dis-tress.Journal $Personality and Social Psychology, 6 4 , 817-826.

Minuchin, S . , & Fishman, H. C. (1981). Family therapy tech-niques. Cam bridge, MA: Harvard U niversity Press.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V6 N l , SPRING 1999 78


13/13

Perk, F. (1973). Thegestalt approach and eyewitness to therapy. SanIiercy, F. P., & Sprenkle, D. H. (1990). Marriage and family

therapy: A decade review.Journal ofMarriage and the Family,Rice, Z . N., & Greenberg, L . S . (1984). Patterns qfchange: Inte n-

sive analysis ofpsychotherapyproces ~.New York: Guilford Press.Roberts, T. W. (1992). Sexual attraction and romantic love: For-

gotten variables in marital therapy. ournal qfMarital and Fam-ily Therapy, 18 , 357-364.

Rogers, C. (1951). Client-centered therapy. Boston: Houghton-Mifflin.

Rosenthal, R. (1984). Meta-analytic proceduresfor social research.Beverly Hills, C A Sage.

Schover, L. R., & Lopiccolo,J. (1982). Treatment effectivenessfor dysfunctions of sexual desire. Journal of Sex and MaritalTherapy, 8, 179-197.Schwarzer, R. (1990). Meta-analysis Programs (Version 5.1)[Computer software]. Berlin: Author.

Segraves,R. J. (1990).Theoretical orientations in the treatmentofmarital discord. In F. D. Fincham& T. N. Bradbury (Eds.),Th e psychology of marriage (pp. 281-298). New York Guil-ford Press.

Shamsh, W. R., Montgomery, L. M., Wilson, P, Wilson,M. R., Bright, I. , & Okwumabua, T. (1993). Effects offam-ily and marital psychotherapies: A meta-analysis. Journal ofConsulting and Clinical Psychology, 61, 992-1002.

Francisco: Science & Behavior Books.

52, 1116-1 126.

Shadish, W. R., & Ragsdale,K. (1996). Random versus nonran-dom assignment in controlled experiments: Do you get thesame answer? ournal of Consulting arid Clinical Psychology, 64,

Simpson,J. A., Rholes, W. S., & Nelligan, J. S. (1992). Supportseeking and support giving within couples in an anxiety pro-voking situation: The role of attachment styles.Journal $Per-sonality and Social Psychology, 62, 434-446.

Spanier, G. B. (1976). Measuring dyadic adjustment: New scalesfor assessing the quality ofmarriage and similar dyads.Journa/qfMarriage and the Family, 38, 15-28.

Walker, J. (1994). A marital intervention program fo r couples withchronically ill children. Unpublished doctoral dissertation, Uni-versity of Ottawa.

Walker, J., Johnson, S. , Manion, I., & Cloutier, P. (1996). Anemotionally focused marital intervention for couples withchronically ill children. Journal of Consulting and Clinical Pry-

Walker, J., & Manion, I. (1998).A two-yearfollow-up on an emo-tionally ocused intervention or couples with chronically ill children.Manuscript in preparation.

Whisman, M. A., &Jacobson, N. S. (1990). Power, maritalsatis-faction, and response to marital therapy.Journa1ofFamily Psy-

1290-1305.

cholog~ 4, 1029-1036.

chology, 4, 202-212.Received November 2, 1997; revised March 31, 1998; acceptedMarch 31, 1998.

EFT STATUS - JOHNSON ET AL. 79

Documents

Emotionally Focused Couples Therapy - Status and Challenges