Clinical Case: Emotionally Focussed Therapy
(EFT)
The process of EFT involves nine steps, which for didactic
purposes are presented as discreet steps. In actuality, these
steps are
mutually overlapping and recursive. I will illustrate each
of the steps using the clinical case of a distressed couple.
Angela, a part-time teacher in her late 30s, requested an
appointment for her and her husband, Peter. She reported
that they had been
married 12 years, with two children ages eight and six. She
noted that they had been having more conflict recently, particularly
since
she had caught Peter viewing pornography on the internet
after he had promised not to do this again. Angela stated
that Peter, age 40,
an associate lawyer in a large law firm, thought they should
be able to resolve their problem on their own but had agreed
reluctantly at
her insistance to attend couples counselling.
Step 1: Delineation of Conflict Issues
Step 2: Identification of the negative interaction cycle
The first two steps of EFT constitute the assessment phase
of treatment and generally take several sessions. In step
1, the therapist
develops a clear understanding of what the couple fights
about, and in Step 2, identifies the negative interaction
cycle that maintains
the couples' distress and precludes a secure attachment.
By the end of Step 2, the therapist has also formed a strong
therapeutic
alliance with both partners and established a therapeutic
contract to help them reestablish a secure attachment.
When asked what brought Angela and Peter to counselling,
Angela commented that she wanted them to learn to communicate
better. Peter
agreed, and also expressed a concern about the lack of sex
in their marriage. An exploration of how they communicated
indicated that
they conversed with minimal conflict about many areas of
family life (e.g., finances, parenting, in-laws), but argued
typically about
emotional intimacy and sex. With respect to emotional intimacy,
Angela was critical of Peter's working long hours in his
law firm and
then retreating to his home office after the children went
to bed to work on files or watch TV rather than spending
time with her. Peter
defended himself, stating that he was only doing what it
took to move from an associate to a partner in the firm,
and that he was doing
this for the family. When Angela persisted in arguing, Peter
would become silent and withdraw to his office. Despite lots
of arguing
about this issue, it remained an ongoing source of conflict.
The other area of conflict was the sexual relationship.
Although both stated that their ideal sexual frequency was
two times per week,
their actual frequency of love-making was about every two
weeks. Angela complained that sex was too brief, without
talking and creating
a romantic mood before sex, pleasurable foreplay, or cuddling
and talking after sex. This left her feeling dissatisfied
and passively
avoiding sex. Peter stated that their sex life was okay,
but too infrequent. This left him feeling frustrated and
deprived sexually. He
had resorted to gratifying himself through self-stimulation
using internet pornography to heighten his arousal. About
once a month he
would accuse her of not giving him enough sex. She would
counter by saying that if he gave her more emotional intimacy,
she would give
him more sex. This conflict also remained unresolved. Although
Angela knew that Peter self-stimulated, she didn't know he
used
pornography.
I validated both Angela and Peter by suggesting that their
feelings were understandable in the present situation. It
was understandable
that Angela was feeling unattended to in the evening; it
was understandable that Peter was feeling unappreciated for
his efforts to
provide for the family. Moreover, it was understandable that
both were feeling dissatisfied with their sexual relationship.
Validating
their feelings not only indicated that I was taking both
their sides, but also helped them to feel understood.
When Angela had discovered Peter's use of pornography, the
frequency and intensity of their conflict had escalated.
Every few days,
Angela would question him about his use of pornography. Why
had he resorted to looking at pornography? What was he looking
for? Did he
not find her attractive? When Peter attempted to evade her
questions, Angela would become more upset, raise her voice,
and accuse him of
being insensitive and selfish. Now, when Angela began questioning
Peter, he would roll his eyes, walk into his offfice and
close the
door. Angela would feel furious and cut off. For the next
few days, they would say very little to each other, until
Angela initiated
talking again, generally about their children.
Finally, to get Angela off his back, Peter had promised
to stop using pornography. This helped to diminish their
conflict until Angela
had discovered that he was viewing pornography again. It
was this incident that precipitated their entering counselling.
I pointed out to Angela and Peter that there was a pattern
to their conflict. Typically, Angela would be critical of
Peter's behavior.
Peter would respond defensively. Angela would then become
more accusatory, and Peter would withdraw. After several
days of little
contact, Angela would initiate talking again. I also suggested
that they assumed predictable positions in this negative
fight cycle.
Angela typically assumed the position of "pursuer" by
being critical and blaming; Peter assumed the position of "withdrawer" by
becoming
silent and exiting the conflict.
What they found most interesting was how much impact they
had on each other in this fight cycle. The position taken
by Angela
recursively evoked the position taken by Peter and vice versa.
In other words, her pursuit evoked his withdrawal, and his
withdrawal
evoked her pursuit. Although they perceived that they were
having little impact on each other because neither were feeling
heard, in
actuality they were having enormous impact on each other.
By the end of the first two sessions of assessment, both
Angela and Peter commented that they were feeling comfortable
talking to me,
and that they had confidence that I understood them and would
be able to help them. Both also agreed that the goal of couples
therapy
was to help them find a new way of relating and feeling more
connected. Finally, both understood that achieving this goal
would be a
process rather than a quick fix, and that based on the research
literature it would likely require 8 to 20 sessions.
Step 3: Accessing unacknowledged feelings underlying partners'
interactional positions
Step 4: Reframing the problem in terms of partners' underlying
feelings and attachment needs
In Steps 3 and 4, the therapeutic task is to help partners
acknowledge underlying feelings that typically are excluded
from awareness in
conflictual relationships, and to reframe the relationship
problem in terms of the negative fight cycle, which is seen
as partners
misguided attempts to reestablish their attachment.
Angela and Peter showed a lot of negative emotion in their
marriage. Angela expressed anger in the form of criticism
and blame. Peter
expressed anger in the form of defensiveness and withdrawal.
Neither were aware to any extent of deeper feelings underlying
their anger. This is typical of distressed
partners, who tend to hide their vulnerable feelings from
themselves and each other.
Angela was largely
unaware that beneath the criticism and blame of her position
as pursuer, she was feeling rejected and unloved; Peter was
largely unaware
that beneath the defensiveness and withdrawal of his position
as withdrawer, he was feeling intimidated and inadequate.
In EFT, the angry, defensive feelings that partners exhibit
in the negative fight cycle are called secondary feelings.
The underlying,
more vulnerable feelings - such as sadness and fear - are
called primary feelings. Just as showing secondary feelings
has an enormous
negative impact by perpetuating the negative fight cycle,
so expressing primary feelings has a positive impact in creating
self-
reinforcing positive cycles of interaction and a secure attachment.
As I explored their conflict from both their points of view,
I began
by validating their secondary emotions. For example, I suggested
it was understandable that Angela felt critical of Peter
when he would
retire to his office after the kids went to bed without spending
some time talking. Also, I suggested it was understandable
that Peter
felt defensive in response to her criticism.
After validating their secondary emotions, I began to explore
tentatively their underlying, primary feelings. For example,
I said to
Angela, "I'm wondering if you don't feel unloved and
neglected when Peter retires to his office rather than spending
some time with
you?" When she answered affirmatively, I asked her what
it was like to feel unloved and neglected. She began to tear
and said, "It
sucks". When I asked if this was a familiar feeling,
she commented that she had often felt neglected as a child,
particularly when she
got home from school several hours before her parents returned
from work. When I asked her to tell Peter directly about
her feelings,
Peter responded supportively, saying he hadn't realized how
his retiring to his office triggered old, painful feelings
for her.
Likewise, I explored the primary feelings that underlay
Peter's position of withdrawer. I said to Peter, " I
wonder if you don't feel
inadequate when Angela criticizes you for not spending time
with her or pleasuring her sufficiently during sex?" Peter
concurred,
stating that he felt like a failure as a husband. When asked
if this was a familiar feeling, he stated that he often felt
like a
disappointment to his parents growing up. They had wanted
him to be an obedient, easy to manage child, and instead
he had been a
handful. When I asked Peter to tell Angela directly about
his feeling like a failure, she also responded positively.
She commented that
she hadn't realized her criticism and blame triggered old,
painful feelings for him.
I validated both Angela and Peter for risking being more
vulnerable with each other, noting that to be more open is
anxiety provoking.
Both agreed, but stated that they felt some relief about
understanding their emotions and relationship patterns more
fully.
I then began to reframe their relationship problem in terms
of the negative fight cycle in order to expand their view
of the problem
(typically partners view deficits in each other as the problem).
I suggested that Angela's pursuit of Peter in the form of
criticism and
blame was a protest, a determined effort to reach Peter and
to reestablish a secure attachment. Also, I suggested that
Peter's
withdrawal from her after his initial defensiveness was his
attempt to protect their attachment from the damage of escalating
conflict.
This reframe of the problem in terms of the negative fight
cycle, in which both were attempting to maintain their attachment,
made
intuitive sense to them. Angela now perceived Peter not so
much as indifferent or uncaring but rather as withdrawing
in order to protect
their attachment. Peter now perceived Angela's hostility
not as random aggression and volatility, but rather as an
attempt to
reestablish their attachment.
Both also became more aware of the enormous impact that
their positions had on each other in the negative cycle.
Angela began to
perceive Peter's withdrawal as a response to her criticism
and blame; Peter began to perceive Angela's attacks as a
response to his withdrawal. With this
awareness came the realization that if they were both the
creators and victims of this cycle,
perhaps they could
change it. Both began to feel a sense of efficacy and empowerment.
By the end of Step 4, it was also clear that a deescalation
in their fight cycle had occurred (this is one of three change
events in
EFT). Although their interactions were not changed fundamentally,
Peter was withdrawing less in the face of Angela's criticism,
and
Angela was less actively hostile. Finally, both were less
rigid in their positions.
Step 5: Identification of disowned needs and aspects of
the self, and integrating these into the relationship.
Step 6: Promoting acceptance of the partner's experience
and being responsive to the partner's new behavior in the
interaction.
Step 7: Facilitating the expression
of needs and wants, and creating emotional engagement.
Whereas in Step 3 partners begin to develop an awareness
of their underlying feelings, in Step 5 they experience these
feelings more
fully and intensely. In addition, the attachment needs associated
with these feelings begin to emerge into awareness. In Step
6, the
other partner is encouraged to hear, process, and respond
to this disclosure in a supportive manner in order that it
can become part of
the couples' interactions. Finally, in Step 7, partners express
the wants and needs that have emerged from their deeper feelings,
which
results in a change event for both. For the less engaged
partner, this results in the change event, "Withdrawer
Engagement". For the
more critical partner, this is a "Softening" event.
These change events result in the creation of a new, self-reinforcing,
positive
cyle, which results in a more secure attachment between partners.
Although I will present Steps 5 through 7 in an abbreviated
manner in
order to illustrate clearly how these steps evolve, in actuality
these steps are complex, usually requiring more than six
sessions.
One of the partners, often the withdrawer, enters Step 5
ahead of the other partner. This was the case with Peter
and Angela. While
discussing their sexual relationship, I asked Peter what
it was like when Angela wanted to hold him and look into
his eyes after love-
making. Peter indicated that he felt uncomfortable, and that
he usually got out of bed and went to the washroom. I leaned
forward, and
asked in a slow, soft voice, what it would be like if he
allowed Angela to be close to him after sex. After a long
pause, Peter uttered
in a halting voice, "She will see how pathetic and inadequate
I am ." It was evident from the tone of his voice and
watering of his eyes
that he was experiencing fully his real fear of contact with
Angela. I helped Peter to process his fear (Step 5), and
then directed him
to share it with Angela. Peter stated, "I cannot let
you see me. Sometimes I feel you must loathe me." Angela
responded supportively,
saying she didn't realize that Peter distanced from her because
he was afraid she would see how unworthy he felt inside and
wouldn't
want to be with him (Step 6).
Peter then began to talk about why he engaged in perfunctory
foreplay before intercourse. He related an experience from
shortly after
their marriage, when he had gone down on her and was feeling
very aroused, and she had remarked, "You're clumsy.
Why can't you do me
more sensuously? Other men have." It was clear that
this was a very painful experience for Peter. In a low, soft
voice, I asked Peter to
express directly to Angela what it was like to feel criticized
in this way. He stated in a quiet but self-assured voice, "I
am not and
can never be like your other exciting lovers. I'm just me,
and I can never make it with you. I feel so empty inside." Angela
started to
respond defensively, but I interjected, "I know this
is hard for you to hear, Angela. It's important that you
struggle with what Peter
is telling you." With my validation, Angela began to
process her feelings about Peter's disclosure, as in "I
never expected this .... It
seems so sad .... I didn't know I was hurting you."
With my support, Peter stayed engaged with his own reactions
and the dialogue with Angela. As he did, he began to access
the wants and
needs implicit in his emotional experience. This included
what he could and could not, would and would not do in the
relationship. He
stated, "I won't spend my life trying to prove I'm worth
your caring, dealing with your criticism, and feeling too
scared to try and get
close. I'd rather sleep by myself, and just accept being
alone. I want to feel desired, like I just might be someone
you like and want
to be with (Step 7)."
After this change event, which is synonomous with "Withdrawer
Engagement", Peter appeared engaged with his emotions
rather than avoiding
them, and seeking for rather than avoiding connection. He
came into subsequent sessions talking about himself more
positively and
interacting with Angela differently. Whereas when Angela
was critical of him before, he would react defensively and
then withdraw, now
he avoided his old position in the negative fight cycle by
remaining engaged with Angela. He did this by working hard
to understand her
feelings and needs, all the while calming himself inside
and staying connected to his own experience.
Peter's staying out of the negative cycle precipitated Angela's
confronting her own position in this cycle. Angela began
to enter Step 5
as she talked about Peter's breaking his promise not to view
pornography again. In her mind, this constituted a relationship
trauma or "
crime" that had damaged her attachment to Peter. As
much as she had tried to put this incident behind her, she
hadn't been able to.
When I asked Angela to describe what it was like for her
to discover that Peter had broken his promise by looking
at pornography again,
she commented that it was like a switch had gone off inside
her, leaving her feeling betrayed and untrusting toward him.
When asked if
this was a familiar feeling for her, Angela became quiet,
nodding affirmatively. Angela then related how when she was
a young teenager,
her dad had had an affair and separated from the family.
When I leaned forward and suggested in a soft voice that
this must have been
very painful for her, she started to tear. Her next words
were, "My dad looked at pornography. I discovered his
pornography." In a quiet
voice, I suggested, "You're so scared that if Peter
looks at pornography, this will happen to you. Yes?" At
this, Angela burst into
tears saying, "I'm so afraid you won't want me, that
you'll leave me for someone younger and prettier (Step 5)." I
replied, "Right, so
since Peter broke his promise, you've turned off inside.
You won't be hurt like your mother was." Angela replied, "I
have a wall around
me so he can't get in. I see an image of him fantasizing
about other woman and I go cold, cold." I then suggested
that Angela speak
directly to Peter about her fears. Angela said, "I'm
so afraid of you hurting me. I can't let you do that. I can't
let you in." W hen
asked what it was like to hear Angela say this, Peter reached
out for Angela's hand and said, "I didn't know my looking
at pornography
frightened you so much. The last thing I want to do is to
hurt you (Step 6)."
Because Peter had responded to Angela's vulnerable feelings
in a caring manner, I encouraged her to formulate her attachment
needs and
longings, and to share these with Peter. Angela stated, "I
want you to hold me, to help me feel safe and loved (Step
7)." When Peter
said he was happy to do this for her, I suggested that he
might want to hold Angela right then and there. He accepted
this suggestion,
and they engaged in a tender embrace, in which the contact
between them was intense and authentic.
After Angela experienced this intense change event, which
in EFT is termed a "Softening", she appeared not
only less critical but also
more responsive in her interactions with Peter. Angela's
greater responsiveness in turn made it easier for Peter to
remain open and
accessible. It was clear that Angela and Peter were engaged
in new cycles of bonding interactions, which were self-reinforcing
and
creating permanent change.
Step 8: Facilitating the emergence of new solutions to old
issues and problems.
Step 9: Consolidating the new positions the partners take
with each other.
The atmosphere of safety and trust created by the emotional
bonding events in the previous steps fosters in Step 8 the
exploration of
old issues and problems, as well as the ability of each partner
to stay engaged in the process of discussion. The relationship
now
becomes a secure base from which to resolve previously unresolved
issues. In Step 9, partners develop insight into ways they
have found
to exit from the negative cycle and create positive interactions.
This helps to consolidate the new, more responsive positions
partners
now take.
As the result of the change events in the previous steps,
in Step 8 Angela and Peter were able to discuss and resolve
old issues because
these issues were no longer arenas in which they played out
emotional struggles. Discussing issues became a process of
addressing a
common problem from a secure attachment rather than conducting
negotiations with the enemy. For example, they were able
to discuss and
resolve the issue of emotional intimacy. In the past, Angela
had accused Peter of being emotionally unavailable after
the kids went to
bed, which had triggered their negative cycle. Now, they
agreed that if Angela was wanting contact with Peter in the
evening, she would
ask for this. If Peter was unable to respond, he agreed to
let her know when he would be available and to follow through.
Another unresolved issue had been the sexual relationship.
Now, both wanted to revitalize their sex life, and agreed
to experimenting
with exercises of sensuous touch in order to learn how to
communicate their sexual preferences and to experience the
pleasure of touch.
They were then able to incorporate these learnings into foreplay
and afterplay, leaving them both feeling more satisfied and
connected
sexually.
In terms of the emotionally laden issue of pornography,
this was no longer a "hot button" for Angela. She
stated that she was okay with
his viewing pornography, provided he did so when she was
not at home. Peter was comfortable with this, and noted that
his interest in
pornography had diminished since he was feeling more satisfied
sexually with Angela.
In Step 9, consolidating new positions, I validated Angela
and Peter for avoiding the fixed, rigid positions they had
assumed in the
past. I validated Angela for avoiding the critical, accusatory
position of pursuer; I validated Peter for avoiding the defensive,
silent
position of withdrawer. I noted how healthy it was that both
could get angry and critical and withdraw momentarily, but
also recover
quickly by responding in an open, caring way. At the end
of counselling, it was clear that the quality of their contact
had shifted
towards safety, closeness, and trust. Angela and Peter's
relationship had become a safe haven and healing environment
for both of them.
Duration of EFT
Research indicates that distressed couples require 8 to
20 sessions of EFT to experience substantive change. Although
this is a
considerabole investment of time and resources, couples who
participate in EFT report that it is a small investment given
the potential
for a closer attachment.
For more information about EFT, see www.eft.ca.
For further information about my approach, and how it applies
to individual and couples, see the links provided. I welcome
new clients,
and invite you to contact me by email or by telephone
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