Clinical Case: Emotionally Focused Therapy

Angela, a part-time teacher in her late 20s, requested an appointment for her and her husband, Dave, who was in his mid 30s. They had been married for three years and did not have children. She noted that they had always had a lot of conflict, nearly separating a few times. Both were tired of the conflict, and wondering if they were compatible or not. Angela stated that Dave, the owner of a small company, thought they should be able to resolve their problems on their own but had agreed reluctantly at her insistence to attend couple’s counselling.

The process of EFT Vancouver involves seven 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 Angela and Dave, a hypothetical distressed couple experiencing a lot of conflict.

Step I: Delineation of dimensions of conflict

In Step I, I develop a clear understanding of whether the couple’s conflict is primarily on the affiliation dimension of interaction, the influence dimension of interaction, or both. The former refers to how partners relate to each other in terms of emotional closeness; the latter refers to how partners share influence with each other.

When I asked what brought them to counselling, Angela commented that she wanted to learn to communicate better. Dave agreed, and also expressed a concern about how they fought a lot about trivial matters. In his mind, they could argue about anything. Both seemed puzzled about this because they saw themselves as intelligent people.

Exploration indicated that they were having conflict on both of the two dimensions of interaction: the affiliation dimension of interaction and the influence dimension of interaction (called a mixed, negative cycle). On the affiliation dimension, Dave was feeling comfortable with the degree of closeness and contact between them, but Angela was not. She had lots of resentment toward Dave – such as his giving more to his employees than to her and playing computer games at night rather than spending time with her. Also, she resented that he failed to show expressions of love and interest in her – such as writing her love notes or enquiring about how she was doing at work by text – despite her frequent requests. Dave indicated that he loved her very much and showed his love for her in other ways. He felt discouraged about his inability to make her happy.

On the influence dimension, Angela thought that she and Dave shared influence fairly equally, but Dave disagreed strongly. In his mind, he was easy going and she was bossy, constantly telling him what to do and criticizing how he did things. He complained that this was the only relationship in which he was bossed, that he didn’t like feeling like a subordinate, and that he was frustrated because she persisted in being bossy despite his complaints. Angela replied that if she didn’t take charge the house would be a mess and nothing would get done.

I validated both Angela and Dave by suggesting that their feelings were understandable in the present situation. It made sense that Angela was feeling resentful because she wanted more closeness and contact with Dave. Also, it made sense that Dave was feeling frustrated because he wanted her to “let him be” in order to do things in his own way. Validating their feelings not only indicated that I was taking both their sides, but also helped them to feel understood.

Step II: Identification of the mixed, negative cycle of interaction

In Step II, I identify the negative cycle of interaction that maintains the couple’s distress and undermines a secure attachment. By the end of Step II, I have also formed a strong therapeutic alliance with both partners in order to help them work toward their goals and establish a more secure attachment.

I pointed out to Angela and Dave that there was a pattern to their conflict on both dimensions of interaction, which is called a mixed, negative cycle. On the affiliation dimension, typically Angela would criticize Dave for not giving her enough contact or closeness in some way. Dave would respond defensively. Angela would then become more accusatory, and the fight would become more heated until Dave would withdraw. After a few days of little contact, Angela would initiate talking again.

Also, I suggested that they assumed predictable positions in this negative cycle on the affiliation dimension. Typically, Angela assumed the position of “pursuer” by being critical and blaming; Dave assumed the position of “distancer” by shutting down and exiting the conflict after his initial defensiveness. 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 distancing, and his distancing 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.

I suggested that their pattern on the influence dimension was as follows. Any time Dave perceived Angela to be defining reality for him in some way – such as by telling him what to do, insisting she knows best, making the decisions and criticizing how he does things – he would resist her control directly by arguing and later indirectly by acting passive-aggressively (e.g., forgetting what he had agreed to do). Also, I suggested that they assumed predictable positions in this negative cycle on the influence dimension.

Typically, Angela assumed the position of being one-up or dominant by defining reality in some way for both of them. Dave assumed the position of being one-down or subordinate by allowing her to define reality, albeit with protest. What they found interesting was how much impact they had on each other in this fight cycle. The position taken by Angela evoked recursively the position taken by Peter and vice versa. In other words, her control (defining reality) evoked his passive resistance in the form of under functioning, and his under functioning evoked her assuming more control in the form of over functioning. Once again, they were having significant impact on each other without realizing it.

Step III: Accessing unacknowledged feelings underlying partners’ positions in the mixed, negative cycle

In Step III, I help partners acknowledge feelings that typically underlie their positions in the negative cycle and are largely not in their awareness.

Angela and Dave showed a lot of negative emotion in their marriage. Angela expressed anger in the form of criticism and blame. Dave expressed anger in the form of defensiveness and passive-aggressiveness. Neither was aware to any extent that they were avoiding deeper, underlying feelings with their anger. This is typical of distressed partners, who tend to avoid exposing their vulnerable feelings with their anger. Angela was unaware largely that beneath the criticism and blame of her position as pursuer, she was feeling anxious, neglected, and unloved. Dave was unaware largely that beneath the defensiveness and withdrawal of his position as distancer, he was feeling anxious and overwhelmed. In terms of the negative cycle on the influence dimension, Angela was unaware largely that beneath the control of her one-up position, she was feeling anxious; Dave was unaware largely that beneath the defensiveness of his one-down position, he was feeling anxious, diminished and inadequate.

In EFT, the angry, defensive feelings that partners use in the negative fight cycle to avoid either feeling and/or revealing their underlying feelings are called secondary feelings (see the article, Avoiding Feelings with Anger). Following Dr. Geoffrey Carr’s theory of intrusive feelings (see the article, Intrusive Feelings), the underlying, more vulnerable feelings – such as sadness and fear – are called intrusive feelings. Just as showing secondary feelings has an enormous negative impact by perpetuating the negative fight cycle, so expressing intrusive feelings has a positive impact in creating self-reinforcing positive cycles of interaction and a more 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 resentful of Dave when she perceived he was more attentive to his employees than to her. Also, I suggested it was understandable that Dave felt defensive when he perceived that she was being bossy in some way.

After validating their secondary emotions, I began to explore tentatively their underlying, intrusive feelings. For example, I said to Angela, “I’m wondering if you don’t feel neglected and unloved when Dave plays computer games rather than spending time with you at night.” When she answered affirmatively, I asked her what it was like to feel neglected and unloved. She began to tear and said, “It’s painful “. 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 a few hours before her parents returned from work.

I then asked if it would be okay if I introduced them to a new way of communicating, and with their consent, the following dialogue ensued:

Therapist (to Angela): I’d like you to tell him directly, “I find it so painful when at the end of a long day apart I want to spend some time with you and you seem to prefer computer games rather than being with me.” I

Angela (to Dave): “I find it painful when you seem to prefer computer games over time with me at night.”

Therapist (to Dave): I’d like you to tell her, “Let me see if I got you” and then paraphrase what you heard her say.

Dave (to Angela): “Let me see if I got you. You find it painful when I go on the computer at night rather than being with you.”

Therapist (to Dave): Now, I’d like you to ask her, “Did I get you?”

Dave (to Angela): “Did I get you?”

Angela (to Dave): “Yes.”

Therapist (to Dave): Now, I’d like you to ask her, “Is there more about that?”

Dave (to Angela): “Is there more about that?”

Angela (to Dave): “No.”

Therapist (to Angela): I’d like you say to him, “Thanks for listening.”

Angela (to Dave): “Thanks for listening.”

Dave (to Angela): “You’re welcome.”

Therapist (to Dave): I’d like you to say to Angela, “As I’ve been listening, what I’m experiencing is …”

Dave (to Angela): “As I’ve been listening, I’m concerned that you are feeling sad and neglected at night. I don’t want you to feel this way.”

Likewise, I explored the intrusive feelings that underlay Dave’s position as distancer. I said to Dave, “I wonder if you don’t feel anxious when you feel blamed by Angela for not spending time with her,” Dave stated, “I guess so, because I feel tense and on edge.” When asked if this was a familiar feeling, he stated that he often felt tense growing up when his mother was critical of his dad for coming home late which led to conflict between his parents. Next, I directed Dave to say to Angela, “I feel anxious when I experience you blaming me for not spending time with you”. Then, I directed Angela to respond by reflecting back what she had heard Dave say using the new way of communicating I had just introduced.

I validated both Angela and Dave for risking being more vulnerable with each other, and for their willingness to experiment with a new way of communicating with each other. Both said that they not only felt more heard and understood, but also felt some relief about understanding their feelings and relationship patterns more fully.

Step IV: Reframing the problem in terms of partners’ underlying feelings and attachment needs

In Step IV, I reframe the relationship problem in terms of partners’ underlying feelings and attachment needs, and the negative cycle as partners’ misguided attempt to reestablish their attachment. Because typically partners in distressed relationships view deficits in each other as the problem, reframing the relationship problem in terms of the feelings that underlie the negative fight cycle expands their view of the problem and helps them to unite together to change the negative cycle.

I suggested that Angela’s pursuit of Dave on the affiliation dimension in the form of criticism and blame was a protest, a determined effort to reach for Dave in order to avoid anxiety and emotional pain and instead to feel close and loved. Also, I suggested that Dave’s distancing after his initial defensiveness was his attempt to avoid anxiety triggered by conflict and to protect their attachment from the damage of escalating conflict. On the influence dimension, I suggested that Angela’s controlling behavior was a way of avoiding anxiety by being in control, and that Dave’s passive-aggressiveness after his initial protest was his way of avoiding anxiety and feeling diminished (shame).

I pointed out that unfortunately, each of their ways of avoiding anxiety triggered the other’s anxiety in relation to their mixed, negative cycle. On the affiliation dimension, Angela’s way of avoiding anxiety (blaming about lack of contact) triggered Dave’s anxiety about conflict, and Dave’s way of avoiding his anxiety (defensiveness followed by shutting down) triggered her anxiety and pain about loss of contact. On the influence dimension, Angela’s way of avoiding anxiety (being controlling/over functioning) triggered Dave’s anxiety about losing his individuality, and Dave’s way of avoiding his anxiety (protest followed by under functioning passive-aggressively) triggered Angela’s anxiety about loss of control.

This reframe of the problem, in which both were viewed as trying to avoid intrusive feelings such as anxiety, pain, and shame, in order to meet legitimate needs and to protect their attachment, made intuitive sense to them. Rather than perceiving Dave as indifferent or uncaring, Angela began to see him as anxious, trying to protect his self-esteem and their attachment. Rather than perceiving Angela as aggressive and controlling, Dave began to see her as attempting to reduce her anxiety and pain, to feel close to him, and to maintain their attachment. With this awareness came the realization that if they were both the creators and victims of their negative cycle, perhaps they could change it. Both began to feel a sense of hopefulness about change, particularly because they noticed that they were fighting much less.

Step V: Feeling the intrusive feelings that underlie the mixed, negative cycle

Whereas in Step III partners begin to develop an awareness of their underlying feelings, in Step V, I inform them that these feelings are best understood as intrusive feelings that derive from early trauma. In addition, I introduce them to the strategy of relating to intrusive feelings from a wise perspective. This enables them to contain, soothe, and heal the feelings rather than avoid them by trying to change their partner. I point out that trying to change one’s partner is counter productive, merely fueling the negative cycle.

Both Angela and Dave recalled experiencing distressing feelings growing up. Angela, the fifth in a sib line of six children, recalled feeling anxious and neglected as a child, particularly when her mother, who experienced recurring bouts of depression, was ill. Dave, the middle child in a sib line of three, recalled feeling afraid and ashamed, particularly when his dad was drinking and angry. Both seemed surprised when I suggested that these distressing feelings reinforced earlier trauma feelings that they couldn’t remember (see the article, Early Trauma Feelings: What We Don’t Remember Can Hurt Us).

I explained how Vancouver psychologist Dr. Geoffrey Carr’s book, Making Happiness, presents research showing infants are much more sensitive and aware of their environments than previously thought, and that all infants to some extent experience intense trauma feelings. In addition, I indicated there is evidence that the fetus is affected by the mother’s level of stress and anxiety, and that the birth experience can be highly traumatic if there are complications and unnecessary medical interventions.

According to Dr. Carr, in order to understand how an infant is traumatized, it is important to recognize that it is the infant’s experience of the event rather than the event itself that is traumatizing. From an adult’s point of view, if an infant is in a high level of distress crying alone in its crib, there is no danger. However, it is the infant’s experience that matters. Infants don’t understand why they are in distress, or when or if the distress will stop. The infant’s experience of mild distress quickly escalates into overwhelming feelings of helplessness and pain if the infant isn’t responded to in a timely and sensitive manner.

The only protection that an infant has against experiencing intense trauma feelings, therefore, is a highly attuned caregiver who responds sensitively to the infants’ needs before they reach high levels of distress and fall into the freezing response. The freezing response is a biologically in-wired physiological reaction that occurs in the animal kingdom whenever an animal can’t fight or flee from a predator and is utterly helpless. This freezing response, in which the animal looks dead from the outside but is highly activated internally, is adaptive biologically because the animal has a greater likelihood of survival by appearing dead.

The freezing response in humans is called dissociation. When humans dissociate, they detach from their experience and feel numb. Dissociating provides relief from overwhelming, intense feelings of fear, shame, and pain. Unfortunately, when infants dissociate, the distressing feelings do not go away but become locked in the central nervous system, ready to be triggered by way of a conditioned response whenever there is a reminder internally (thoughts, feelings, memories) or externally (the environment) of the early trauma.

Although we are so accustomed to trauma feelings that intrude at a low level chronically in the form of mild tension and dullness that we accept this as normal, it is when these feelings are triggered – such as during conflict with our partner – and intrude at high levels of fear, shame, and pain that we feel distressed. All of our distressing feelings are best understood as intrusive feelings; that is, feelings that when triggered, intrude from the past into the present, colouring our experience of the world and causing us distress to varying degrees (see the article, Intrusive Feelings).

I suggested that both of their intrusive feelings were being triggered in the relationship and that these intense feelings underlay their mixed, negative cycle. In order to understand more about their intrusive feelings, I explored what they knew about the circumstances surrounding their mothers’ pregnancies, their births, and the first year of their lives.

Angela said that her mother had had difficulty coping while pregnant with her because she already had four children and her dad worked long hours. Although she recalled that her birth was normal, her mother became depressed after her birth and she had stayed with an aunt who was not particularly warm for most of the first six months of her life. I suggested that that likely she would have experienced overwhelming feelings of pain and helplessness as an infant as the result of being separated from her mother during this critical period of development, feelings that would have been reinforced as a child when her mother was ill and the home disorganized. Also, I suggested that these feelings were triggered in the marriage whenever she experienced Dave being distant or the home environment disorganized resulting in her blaming, critical behavior.

Dave said that his mother worked while pregnant with him because his parents struggled financially. He recalled that he had been born three weeks premature, and had spent about two weeks in the hospital separated from his mother before coming home. Once home, his mother returned to work after about four months and he had been cared for by his maternal grandmother, whom he recalls being cold. I suggested that likely he too would have experienced overwhelming feelings of pain and helplessness while separated from his mother as a preemie in the hospital. Also, I suggested that he would have felt bad about himself (shame) when he was dropped off at his grandmother’s each day and experienced her lack of interest in him, feelings that would have been reinforced as a child when his father was intoxicated and angry with him. Finally, I suggested that these feelings were triggered in the marriage whenever he experienced Angela being blaming and controlling, resulting in his initial defensiveness and subsequent passive-aggressive resistance.

Initially, Angela and Dave had a hard time believing that experiences they could not remember would have traumatized them, resulting in insecure attachments to their primary caregivers. However, when I told them that we learn a lot in the first year of life that we don’t remember – such as how to walk, talk, and recognize our parents, they were more open to accepting that the source of the intrusive feelings underlying their mixed, negative cycle was early trauma. Learning about each other’s early experiences in life and trauma feelings contributed further to seeing each other in a more positive and compassionate way. Both realized that they were insecurely attached as infants, and that they didn’t deserve to have the intense, intrusive feelings that caused them to be insecurely attached to each other.

I encouraged Angela and Dave to contain, soothe, and heal the intrusive feelings that were triggered in the relationship by relating to them from a wise perspective (see the article, Listening to Our Feelings from a Wise Perspective). As Dr. Geoffrey Carr articulates in Making Happiness, it is important to remind ourselves that although the strong feelings we experience are being triggered in the present by way of a conditioned response, the intensity of these feelings comes from the distant past. In other words, the distressing feelings are echoes from the past. The more we realize this, the more we are able to contain the feelings; that is, to feel the feelings without being overwhelmed by them. The more we allow and feel the feelings with an attitude of wisdom and compassion for ourselves rather than escape them, the more they diminish and resolve.

I encouraged Angela and Dave to experience their feelings on an emotional level rather than to relate to them on an intellectual level, because it is emotional experiencing rather than intellectual insight that heals. When Angela noticed herself feeling neglected or unloved (anxiety and emotional pain triggered on the affiliation dimension), or noticed herself feeling a loss of control (anxiety triggered on the influence dimension), I suggested that she allow herself to feel these feelings as fully as possible; for example, by telling herself, “I feel so anxious and in so much pain.” When Dave noticed himself feeling tense and defensive (anxiety triggered on the affiliation dimension), or noticed himself feeling controlled and diminished (anxiety and shame triggered on the influence dimension), I suggested that he allow himself to feel these feelings as fully as possible; for example by telling himself, “I feel so scared and bad about myself”. As they allowed themselves to feel their feelings, I encouraged them also to relate to the feelings from a wise perspective by saying: “These are old feelings. I don’t deserve to feel so scared, bad, and in so much pain. I am safe now”. Doing so helped them to contain, soothe, and heal the feelings.

As Angela and Dave made a conscious effort to allow their intrusive feelings and to relate to them from a wise perspective rather than avoid them by trying to change each other, the intensity of their feelings began to diminish, they experienced less conflict, and they began to feel more securely attached to each other.

Step VI: Expressing intrusive feelings and associated needs responsibly

As Angela and Peter allowed themselves to feel their intrusive feelings more fully, I encouraged them to express these feelings and associated needs responsibly (see the article, Responsibility for Feelings).

The close, temporal relationship between what people say or do and the feelings that they experience has given rise to the popular notion that people or events cause our feelings. In Making Happiness, Vancouver Psychologist Dr. Geoffrey Carr discusses the notion of responsibility for feelings and says that people are the stimulus but not the cause of our feelings. He notes that what comes between what a person says or does (the stimulus) and an individual’s feelings is the “self” of the individual. In other words, if someone says or does something in relation to me (the stimulus), and I have big feelings about it, it is important that I realize that what comes between the stimulus and my big feelings is myself, how I interpret the stimulus based on my own trauma feelings and history. Someone else may experience the same stimulus and feel very different feelings based on how they interpret the stimulus through the lens of their trauma feelings and history. In this view, although we are entitled fully to whatever we feel (see the article, About Feelings), it is best to own and take responsibility for whatever we feel as belonging to the self rather than blaming others for our feelings.

Expressing feelings responsibly also includes revealing responsibly the needs associated with our feelings. Feelings are like a compass in that they orient us to what we need, to what matters to us (see the article, About Feelings). For example, Angela’s experience of intrusive feelings of helplessness and anxiety informed her of her needs for contact and a sense of control. Dave’s experience of intrusive feelings of fear and diminishment (an aspect of shame) informed him of his needs for safety and respect.

I encouraged Angela and Dave to reveal their feelings and needs responsibly to each other using “I” statements. For example, rather than saying, “Why didn’t you text me at work today?”, Angela learned to say, “I’m not blaming you for my feeling, and I want you to know that I feel uncared for when I don’t receive a text from you asking me how my day is going. It means a lot to me when I hear from you.” Rather than saying, “Why are you bossing me again”, Dave learned to say, “I’m not blaming you for my feeling, and I want you to know that I feel diminished when you tell me how to drive. I want to feel respected.”

As Angela and Dave expressed their feelings and needs more responsibly, they felt less defensive and found it easier to validate each other (see the article, About Feelings). Even when either of them expressed themselves less responsibly by blaming or becoming defensive, realizing that one’s partner is responsible for his or her feelings helped the other to remain present and calm. When this occurred, I encouraged each of them to validate the partner’s experience without feeling responsible for it.

Step VII: Creating positive interactions and a more secure attachment

Changes were now evident in Angela and Dave’s mixed, negative cycle. On the affiliation dimension, there was a softening on Angela’s part and an engagement on Dave’s part. Angela’s softening was apparent in how she expressed her feelings and needs for contact more responsibly without blame; Dave’s engagement was apparent in how he stayed present and responsive rather than withdrawing. For example, Dave chose to reduce the amount of time that he spent on the computer at night in order to spend more time with Angela. He also started to text her daily at work enquiring about how her day was going. What is interesting is that as Dave made these changes, he liked the increased contact with Angela and the appreciation that she showed for his efforts. It pleased him to know that he was contributing to her happiness.

On the influence dimension, there was an increased openness to influence on Angela’s part and a greater assertion of influence on Dave’s part. Dave’s greater assertion of influence was evident in how he expressed his feelings and need to be respected as an equal in a clear, responsible manner. Angela’s increased openness to influence was apparent in how she modified her controlling behavior and expressed the need for practical support in a responsible manner. For example, Angela refrained from being a back seat driver and insisting that he clean the kitchen in her way. What is interesting is that as Angela made these changes, she liked the increased support he offered resulting in her over functioning less. It pleased her to know that she was contributing to his happiness.

As well as establishing new, positive interactions, they began to feel more securely attached to each other. Both felt increasingly comfortable, safe, and accepted by the other. Also, they experienced an increasing basic trust that their partner loved them and wanted to meet their legitimate, dependency needs.

As we terminated counselling, I congratulated Angela and Dave for their efforts and changes, suggesting that, because change is uneven, likely they would hit some bumps moving forward. Also, I expressed confidence that by feeling their feelings and revealing them responsibly they would continue to make progress.

Dr. Paul James is a registered psychologist in Vancouver, BC.