Episode 194: Dr. Sue Johnson: Attunement, Attachment and the Development of Emotionally Focused Therapy
Matt Yegge, David Puder, MD
There are no conflicts of interest for this episode
In today’s episode of the podcast, I interview Dr. Sue Johnson, founder of Emotionally Focused Therapy, an intervention for relationships aimed at resolving distress by helping clients become attuned within a secure attachment bond. She has also written countless books and articles, a personal favorite being Hold Me Tight. She was the first person to teach me about the still face experiment in 2013. I, myself, have had the personal benefit of being in EFT with my wife for the past year. I remember watching a video of Sue doing therapy, and I thought, there is some sort of symphony happening here, and I really want to learn how to play the notes. I wanted this session to pull out as many practical pearls as possible from Dr. Johnson, more of the “how” of the process of helping people reconnect.
Dr. Johnson And The Development Of EFT
Dr. Sue Johnson is a world renowned Clinical Psychologist, award-winning researcher, Professor Emeritus, best-selling author, and director of the International Centre for Excellence in Emotionally Focused Therapy (ICEEFT).
In the early 1980s, Dr. Sue Johnson, along with colleague Dr. Leslie Greenberg, developed and established Emotionally Focused Therapy (EFT) as a new intervention for couples therapy that aimed at resolving distress by helping clients become attuned to their emotions and needs, and to reprocess their patterns of distressed responses into positive and secure attachment bonds.
Over the past 35+ years, EFT has become one of the most thoroughly researched, widely used, highly-regarded and clinically effective interventions in modern psychotherapy.
EFT has been successfully adapted for families and individuals, and continues to be a cornerstone of couples and marital therapy. Additionally, EFT has also been found to be a highly effective treatment for numerous maladies such as PTSD, borderline personality disorder, depression, anxiety, substance use disorders, eating disorders and sexual dysfunction.
As one of the researcher-founders of EFT, Dr. Johnson’s career has made a uniquely profound impact on the fields of psychology, psychiatry, social work and couples counseling.
She has been a critical figure in the development of the understanding that emotions are connected to needs, that the principles of attachment theory apply to adult relationships (not just parents and their children), and that relationships are built upon emotional bonds.
Dr. Johnson continues to inspire and train new generations of therapists through her work with ICEEFT. She remains a dedicated proponent of continued research into the efficacy and advancement of EFT, as a public speaker and by participating in and advising contemporary clinical research studies.
Through the publication of her books Hold Me Tight (2008), Love Sense (2013), and Attachment Theory in Practice (2019), Sue Johnson has extended the reach of her inspiring process of attunement and healing beyond the clinical setting in a way that is accessible to every-day readers across the globe.
From English Literature To Clinical Psychology
Born in Chatham, England, in 1947, Dr. Johnson attended college at the University of Hull and graduated with a B.A. in English Literature in 1968. Johnson turned her interests and attention towards psychology and moved to Canada to attend the University of British Columbia.
While at the University of British Columbia, she focused her research on intimate relationships and attachment bonding, emotion, clinical couples therapy, the process of change in psychotherapy and marital therapy, and the role of emotion in therapeutic change. It was during her time in graduate school that Dr. Johnson met Leslie Greenberg, who collaborated with her in the development of a new therapy model for couples. As researchers, they were interested in articulating the processes of change in psychotherapy, establishing clear goals for therapy, and developing an alternative to the Behavioral Marital Therapy model for couples interventions.
In 1984, Dr. Johnson earned her Doctorate in Education (EdD) from the University of British Columbia in Counseling Psychology.
The following year in 1985, Johnson and Greenberg published their first clinical research article together and introduced the world to Emotionally Focused Therapy. The article was called, “Emotionally Focused Couples Therapy: An Outcome Study,” published in the Journal of Marital and Family Therapy.
The initial study of the EFT process was a remarkable success. Not only were Johnson and Greenberg able to fill important gaps in the academic literature on couples therapy (identifying process of change, establishing clear therapeutic goals, etc.), the groundbreaking study suggested that the model had promise as a highly effective intervention. In fact, the study suggested that EFT may even have a higher efficacy rate than Behavioral Marital Therapy, which was the gold-standard for couples therapy at the time, yet only held an efficacy rate of around 50%.
These results gained worldwide attention, greenlit more funding, and created demand for additional research into EFT as a clinical therapeutic method. The next steps of the proving grounds would be to show that the results are repeatable and consistently effective, and to explain why the intervention works.
Over the next couple of years, Johnson and Greenberg set out to do just that, resulting in the publication of a co-authored debut book, Emotionally Focused Therapy for Couples (1988), and a follow-up research article in the Journal of Marital and Family Therapy titled, “Relating Process to Outcome in Marital Therapy” (1988).
This study outlined the general process of change for EFT and aimed to explain what variables contributed to successful outcomes in clients. Johnson and Greenberg hypothesized that (in couples settings) emotional experiences could give rise to new perceptions of one’s partner, and to new definitions of one’s relationship.
The study also articulated that the process of change works because:
Emotional responses underlying interactional cycles/positions are experienced and re-processed.
This reprocessing of emotions creates a change in positions, away from hostility and avoidance, toward increased accessibility and responsiveness.
This shift in perspective, known as a softening event, allows both partners to:
begin to develop attunement with each other’s emotions and needs.
establish and integrate a secure primary attachment bond with one another.
One of the key takeaways from this study was that they were able to show that successful outcomes with the therapy were linked to couples experiencing these softening events during their sessions.
“On average, five softening change events were found in the sessions of the successful couples and none were found in the sessions of the low-change couples.
These results confirmed the relevance of encouraging couples to explore their emotional responses and engage in tasks in which they express their attachment needs to their partner in a manner that facilitates emotional engagement.” (Johnson, 1999 EFCT Status & Changes)
It also demonstrated that the most successful couples scored higher on affiliation, and lower on dominance and hostility in their initial evaluations. Successful couples were often more open to experience and exploration of affect. Unsuccessful couples did not experience softening events, showed more hostility and were more closed off to affect exploration.
After this study’s publication, and the publication of the book Emotionally Focused Therapy for Couples, it was clear that EFT was proving itself as a highly effective and empirically-verified new therapy treatment.
Over the next 10 years, Dr. Johnson continued to lead research on EFT, conducting further studies to understand why the therapy is effective, how emotion and attachment impact relationships and self-identity, and to explore new applications for the EFT process. Johnson and her colleagues found that EFT could be useful in family and individual therapy settings. They also found that EFT was a highly effective treatment for PTSD, depression, and other mental and behavioral illnesses.
In 1998, Dr. Johnson crowned a decade of outstanding progress by founding the International Centre for Excellence in Emotionally Focused Therapy (ICEEFT) in Ottawa, Canada. ICEEFT offers specialized training, workshops, seminars, conventions and externships for mental health professionals. The organization also provides EFT certification for therapists and sponsors and advocates for the advancement of EFT research and treatment accessibility. Johnson continues to serve as the founding director and president of the organization.
Over the following 25 years since the opening of ICEEFT, Dr. Johnson has continued to publish books, embark on speaking and training tours for EFT, and continues to participate in and advocate for EFT research.
She also contributes to academics as Emeritus Professor of Psychology at the University of Ottawa, and as a Distinguished Research Professor at Alliant University in San Diego, California.
In 2016, Dr. Johnson was named “Family Psychologist of the Year” by the American Psychological Association’s Society for Couples and Family Therapy.
In 2017, she was awarded Membership of the Order of Canada, and awarded the Psychotherapy Networker Lifetime Achievement Award in 2022.
Below is a selection of Sue Johnson’s research publications and books.
Key Research Publications by Dr. Susan M. Johnson:
1985: EFCT Outcome Study
S. Johnson & L. Greenberg, Journal of Marital and Family Therapy
1988: Relating Process to Outcome in Marital Therapy
S. Johnson & L. Greenberg, Journal of Marital and Family Therapy
1997: Predictors of Success in EFT
S. Johnson & E. Talitman, Journal of Marital and Family Therapy
1999: EFCT Status and Changes
Susan M. Johnson et al., APA: Clinical Psychology: Science & Practice
2003: EFT and Depression: A Pilot Study
S. Johnson, A. Dessaulles, W. Denton, American Journal of Marital Therapy
2006: Resolving Attachment Injuries
S. Johnson, J. Makinen, Journal of Counseling and Clinical Psychology
2010: Integrating Sex and Attachment in EFCT
S. Johnson, D. Zuccarini, Journal of Marital and Family Therapy
2010: 3-Year Follow Up: Attachment Injuries using EFT
S. Johnson, J. Makinen, R. Halchuk, Journal of Couple and Marital Therapy
2012: BARE Scale for Measuring Attachment Behavior in Couple Relationships
S. Johnson, J. Sandberg, D. Busby, K. Yoshida, Family Process
2012: United We Stand: EFCT in the treatment of PTSD
S. Johnson, P. Greenman, Journal of Clinical Psychology
Johnson, Caron, Lafontaine, Bureau, Levesque, Canadian Journal of Behavioral Science
2013: Forgiveness and Reconciliation in EFCT
S. Johnson, T. Dagliesh, J. Makinen, D. Zuccarini, Journal of Marital Therapy
2013: Process Research on EFCT: Linking Theory to Practice
S. Johnson, P. Greenman, Family Process
2014: Emotion Regulation and Key Change Events in EFCT
Johnson, Burgess-Moser, McRae, Dagleish, Killian, Journal of Couple & Relationship Therapy
2015: Predicting Change in Marital Satisfaction Throughout EFCT
Johnson, Burgess-Moser, Dagleish, Lafontaine, Wiebe, Tasca, Journal of Marital & Family Therapy
2015: Predicting Key Change Events in EFCT
Johnson, Burgess-Moser, Dagleish, Wiebe, Tasca, Journal of Marital & Family Therapy
2016: Changes in Relationship-Specific Attachment in EFT
Johnson, Burgess-Moser, Dagleish, Lafontaine, Wiebe, Tasca, Journal of Marital & Family Therapy
Books by Dr. Susan M. Johnson:
1988: Emotionally Focused Therapy for Couples
Leslie S. Greenberg & Susan M. Johnson, The Guilford Press
1996: Creating Connection: The Practice of Emotionally Focused Marital Therapy
Susan M. Johnson, Brunner/Routledge
2002: Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds
Susan M. Johnson, Gulliford Press
2005: Becoming an Emotionally Focused Therapist: The Workbook
Susan M. Johnson, et al., Brunner/Routledge
2008: Hold Me Tight: Seven Conversations for a Lifetime of Love
Susan M. Johnson, Little Brown Publications
2013: Love Sense: The Revolutionary Science of Romantic Relationships
Susan M. Johnson, Little Brown Publications
2016: Created for Connection: The “Hold Me Tight” Guide for Christian Couples
Susan M. Johnson & Kenneth Sanderfer, Little Brown Publications
2019: Attachment Theory In Practice: Emotionally Focused Therapy for Individuals, Couples and Families
Susan M. Johnson, Gulliford Press
2021: A Primer For Emotionally Focused Individual Therapy (EFIT)
Susan M. Johnson, EdD. & Leanne Campbell, PhD., Routledge
2022: Edgar & Eloise - Sagas 1 & 2: For 9 to 90 Year Olds
Susan M. Johnson, Illustrated by Peter Loebel, FriesenPress
What Is Emotionally Focused Therapy?
Emotionally Focused Therapy (EFT) is an attachment-theory centered clinical process of experiencing and reprocessing the emotions underlying distressful patterns of behavior or interaction. At the heart of this practice is an understanding that emotions are deeply connected to needs.
Through the process of becoming attuned to one’s own emotions and needs, and/or the needs and emotions of others, the destructive patterns of negative behavior can be broken, leading to the development of new secure-attachment bonds and the lasting resolution of distress.
In an article titled, “Emotionally Focused Couples Therapy: Status and Challenges” (1999), Johnson et al. describe EFT as:
“... a brief systematic approach to modifying distressed couples’ constricted interaction patterns and emotional responses, which fosters the development of secure attachment bonds between partners.”
Emotionally Focused Therapy is a synthesis of concepts from 4 key psychological models:
Experiential Therapy
EFT borrows from experiential therapy's emphasis on emotions and the therapeutic experience, focusing on creating a new emotional experience to foster attachment and strengthen the bond between partners.
Intrapsychic Perspective
EFT does involve introspection and exploration of the inner emotional world of each individual, helping clients gain awareness of their emotional responses and how they affect their interactions with others.
Interpersonal Systemic Perspective
EFT considers the patterns and cycles of interaction between partners, seeking to understand and reorganize the dynamics and roles within the relationship system to promote secure attachment and emotional responsiveness.
Attachment Theory
This is central to EFT, focusing on the importance of creating secure emotional bonds and exploring how attachment styles impact the relational dynamics and individual emotional responses.
EFT views the key factors contributing to distress are:
Continuous Development of Distressful Emotional States:
EFT recognizes that persistent and absorbing states of distressed emotions play a pivotal role in relational distress.
Destructive Interactional Patterns:
These patterns emerge from and amplify negative emotions, causing individuals to become ensnared in cycles of interaction that reinforce distress and emotional disconnection.
Impaired Attachment Bonds:
Negative emotional experiences often stem from distressed or undeveloped attachment bonds, which are pivotal in shaping emotional responses and interactions.
4 Key Assumptions of EFT:
Reciprocal Determination of Emotional Responses and Interaction Patterns:
Emotions and interaction patterns are interlinked and mutually shaping; addressing both is essential in therapy to facilitate meaningful change.
Pervasiveness of Negative Interaction Patterns:
Partners often find themselves entrapped in negative cycles that hinder the development of secure bonds; they are not seen as immature or unskilled, but rather in need of support to express their attachment needs and fears in ways that foster secure bonding.
Centrality of Emotion in Relationship Dynamics:
Emotion is fundamental in defining and reshaping intimate relationships; fostering new emotional experiences and interactions is pivotal for achieving transformative change.
Intimacy as an Attachment Process:
EFT views adult intimacy through the lens of attachment, emphasizing the creation and maintenance of secure attachment bonds as the cornerstone of healthy, fulfilling relationships.
The EFT Process
Emotionally Focused Therapy theorizes that it is the way people respond to their experience of negative emotions that leads to distressed behavior patterns. These negative emotional responses, such as fear or anger, can become self-reinforcing patterns, which act to perpetuate and exacerbate the intensity of distressed emotions and behavior. This is known as an absorbing state of cyclical, self-reinforcing negative affect, which often leads to crisis for couples, families and individuals alike.
At the root of these negative-affect cycles are incidents that have occurred in the client’s life which have caused “injuries” to their secure attachment needs. These incidents could directly impact the relationship, such as deception or infidelity, or the incidents could precede the relationship and be the result of earlier-life trauma, such as childhood neglect, bullying or abuse.
EFT views relationships through an attachment-centered lens which means that the development of a healthy, affectionate and secure relationship with oneself, or others, requires one’s attachment needs to be met securely. When those needs, such as trust and security, are neglected or damaged, then people can experience distress with one’s self-identity and in relationships with friends, family members or intimate partners.
The EFT process works to identify the presenting negative-affect cycles and uncover the attachment injuries at the root of the distress. The process of uncovering the attachment injuries is the source of a great deal of emotion, and the therapist works with the client(s) to accept, welcome and experience these difficult emotions.
The process of experiencing these emotions requires allowing vulnerability on the behalf of the clients, which is the start of the softening event in EFT. Softening events are pivotal moments that allow both partners in a relationship, or an individual, to experience empathy and shift from a rigid, afraid, closed-off or defensive position to a receptive, accepting and supportive position. This marks the disruption of the cyclical negative-affect pattern.
Before Softening:
Man (Partner A):
Expresses frustration and anger about the lack of sexual intimacy, potentially feeling rejected and undesired.
Partner B:
May feel pressured and criticized, leading to withdrawal or defensive reactions, creating a cycle of demand and withdrawal.
Softening Process:
Creating Safety:
The therapist creates a safe, non-judgmental space where both partners can openly explore their feelings, needs, and desires related to intimacy.
Exploring Underlying Emotions:
Partner A is guided to explore and communicate the deeper emotions and needs underlying the desire for more sex, such as the need for closeness, affirmation, or connection.
Expressing Vulnerabilities:
Partner A shares feelings of rejection and longing for closeness, instead of focusing solely on the desire for more sexual intimacy.
Understanding and Empathy:
Partner B is encouraged to listen, understand, and empathize with Partner A’s underlying needs and vulnerabilities, without feeling blamed or pressured.
After Softening:
Partner A:
Feels heard, understood, and valued, reducing feelings of frustration and rejection.
Partner B:
Feels less pressured and criticized, able to respond more openly and warmly, fostering mutual understanding and connection.
Outcome:
The softening event allows both partners to break the cycle of demand and withdrawal and to understand and respond to each other’s deeper emotional needs, thereby fostering a closer emotional connection and a more fulfilling sexual relationship.
Before Softening:
Woman (Partner A):
Feels unheard and invalidated, expressing frustration and disappointment.
Man (Partner B):
May feel criticized and defensive, potentially withdrawing or responding with defensiveness, perpetuating a cycle of miscommunication and disconnection.
Softening Process:
Creating Safety:
The therapist fosters a safe and supportive environment where both partners can openly express and explore their feelings and experiences.
Exploring Underlying Emotions:
Partner A is encouraged to explore and communicate the deeper emotions and needs associated with feeling unheard, such as feeling unimportant or uncared for.
Expressing Vulnerabilities:
Partner A shares her longing for understanding, connection, and validation, moving beyond the surface-level complaint of not being listened to.
Responsive Attunement:
The therapist assists Partner B in tuning into, understanding, and empathetically responding to Partner A’s underlying needs and vulnerabilities.
As the therapist and client(s) work through their emotional experiences they begin to articulate the client’s needs and fears. They then work to reprocess their emotional experiences using therapeutic tasks that establish “prime bonding events”.
Examples of Needs:
Need for Validation:
The desire to feel understood, accepted, and valued by significant others.
Need for Affection:
The longing for physical warmth, touch, and closeness.
Need for Security:
The need to feel safe, secure, and protected within a relationship.
Need for Responsiveness:
The desire for partners to be responsive, attentive, and emotionally present.
Need for Appreciation:
The longing to feel appreciated, valued, and acknowledged.
Need for Emotional Support:
The desire to receive comfort, empathy, and support during times of stress or distress.
Examples of Fears:
Fear of Abandonment:
The fear that one’s partner will leave or abandon them emotionally or physically.
Fear of Rejection:
The anxiety about being rejected, dismissed, or not being good enough.
Fear of Enmeshment:
The fear of losing one’s identity or sense of self within the relationship.
Fear of Criticism:
The fear of being judged, criticized, or devalued by significant others.
Fear of Isolation:
The fear of being alone, unloved, or uncared for.
Fear of Vulnerability:
The anxiety about opening up and revealing one’s true self, with the risk of being hurt or rejected.
While working with couples (or families), the clients begin to bond by learning to understand why each person has been responding the way they have and how, instead of being reactive towards one another, they can begin to consciously offer acceptance and support to one another.
Working with an individual client is the same process. However, it takes place in a context of a relationship with themselves or with an imagined other person (such as a parent that might not be available).
This process is all about attunement. By becoming attuned to the emotions and needs of others, or with themselves, clients are then able to begin to establish secure attachment bonds.
The process of therapy is considered successful when the clients are able to integrate their newly reprocessed emotions into responses and active behaviors that reinforce and maintain their secure attachment bonds.
The clinical practice of EFT is broken down into a 9-step systematic process.
9 Steps of Emotionally Focused Therapy
Phase 1: Assessment, Alliance & De-escalation
Step 1: Assessment, creating a therapeutic alliance and explicating the core issues in the couple’s conflict using an attachment perspective.
Step 2: Identifying the problem interactional cycle that maintains attachment insecurity and relationship distress.
Step 3: Accessing the unacknowledged emotions underlying interactional positions.
Step 4: Reframing the problem in terms of the cycle, the underlying emotions, and attachment needs.
Phase 2: Creation of Specific Change Events/Shifting Interactional Positions
Step 5. Promoting identification with disowned needs and aspects of self, integrating these into relationship interactions.
Step 6: Promoting acceptance of the partner’s new construction of experience in the relationship and acceptance of new responses.
Step 7: Facilitating the expression of specific needs and wants, creating emotional engagement.
Phase 3: Consolidation of Change
Step 8: Facilitating the emergence of new solutions to old problematic relationship issues.
Step 9: Consolidating and integrating new positions and new cycles of attachment behavior into the functioning processes of day-to-day life.
Before the process can begin, the therapist must assess whether the clients are likely to respond positively to the therapy, or if they would be better suited for other interventions. It has been established that EFT is most useful for clients who show an openness to experiencing their emotions and to sharing their feelings.
Because this process requires an openness to experiencing personal emotions that may be troubling or triggering, clients who may be experiencing an acute crisis, such as active self-harming, suicidal ideation with plans or who are actively abusing their partners or family members, are considered best suited for other stabilizing interventions before attempting EFT.
Once clients have been approved to begin the EFT process, the therapist will begin to establish a strong therapeutic alliance (which has itself been shown in studies to be a critical factor in successful outcomes).
Without the establishment of a strong therapeutic alliance, clients may struggle to feel secure enough to share and experience their emotions. By trusting in the therapist, the clients are more likely to allow themselves to trust the process and open up to experiencing vulnerable feelings and to new ways of processing those feelings.
From there, over a number of sessions, the therapist will work through each step of the process until the client(s) and therapist are in agreement that a meaningful resolution has been reached and that the positive outcomes have been successfully integrated into the clients’ lives.
The therapist will, sequentially, work to help the clients identify the troubling interaction patterns, then work to identify attachment injuries at the root of the negative patterns. The therapist and clients will then work towards achieving a softening event through a process of experiencing their emotions and expressing their needs. Once softening events have been achieved, the clients can begin to shift their positions from distress to attunement, support, and security.
Why Was Emotionally Focused Therapy Developed?
In the early 1980’s, the practice of couples, family, and marital therapy was gaining mainstream popularity through a surge in publications of self-help books and family-oriented magazines and the broadcast of daytime television talk-show programs spotlighting marital distress and dysfunctional families.
This increase in public awareness resulted in an increased demand for therapy services, which, in turn, resulted in an increased demand for research into the development of new, effective therapeutic methods.
In the late 70’s, Dr. Johnson was a clinical psychology researcher looking for ways to advance the science and efficacy of couples therapy.
At that time, Behavioral Marital Therapy (BMT) was the only empirically-validated clinical framework for successful marriage and couples counseling. This modality was developed in the 1970’s and focuses on behavioral cognition as the key to behavioral change.
While this model of treatment was clinically effective, it left a number of important questions unanswered. It was apparent to researchers that the next steps in advancing therapeutic technology would require:
Clarifying the role of emotions in relationship interaction dynamics, especially distress.
Establishing consistent goals for the application of therapy: What is specific therapeutic success supposed to look like?
Identifying the process of change: What is actually causing successful outcomes?
Defining the target client demographics for successful therapeutic outcomes: Who is most likely to benefit from this method of treatment?
Developing new empirically verified treatment models to provide other reliable options in addition to BMT.
Johnson has stated that she felt there was something inherently flawed with a popular academic idea at the time that relationships were merely complex agreements between people, and that marital distress can be mediated through cognitive negotiation strategies.
Instead, she noticed that cognitive negotiation methods frequently didn’t work in couples therapy. She found herself inspired by Bowlby’s attachment ideas and speculated that relationships were built upon our fundamental human needs for emotional bonding.
Johnson then collaborated with fellow clinician and researcher Leslie Greenberg to explore the role of affect in relationship distress by applying principles of attachment theory (i.e., bonding, emotional and behavioral dysregulation), systems theory, and experiential and intrapsychic perspectives. They also drew upon John Gottman’s studies of interactional distress in couples and his emphasis on the importance of emotional responses in the creation of cyclic patterns of negative interaction.
Johnson and Greenberg developed their research model with the hypothesis that (a) negative interaction cycles were distressing secure attachment bonds between partners, (b) that using emotional experiences could allow partners to reprocess the emotions underlying their responses to each other, and finally that (c) the reprocessed emotions can be integrated into the creation of new, secure attachment bonds and the resolution of the couples’ distress.
Furthermore, Johnson and Greenberg’s study set about articulating clear goals for their therapy model, to understand the process of change in their therapy model, and to articulate the influence of emotional experience and attachment bonds on resolving conflict in relationships.
Over a few short years, Johnson and colleagues were able to develop and empirically validate their new intervention which was aimed, not specifically at clients’ problematic behaviors, but at reprocessing the emotions connected to clients’ unmet needs underlying their behaviors.
Attachment Theory & EFT
Understanding How To Read The Map
Dr. Johnson frequently identifies attachment theory as the “map” that EFT therapists use to help their clients work from distress to secure resolution.
This map leads to the “attunement of one’s needs,” which helps the therapist to:
Identify the pattern of distressed interaction.
Identify the needs connected to the clients’ emotional responses.
Lead the client(s) through the process of becoming attuned to their emotions, reframing their responses, and cultivating secure bonds.
It is the idea that our emotions are deeply connected to our needs, and that unmet needs cause distress, that renders this map useful to the EFT therapist. This is attachment theory in practice.
Attachment theory is a conceptual framework for understanding how human beings develop bonds and relationships with one another, and how the kinds of bonds we develop with primary attachment figures in our lives can shape the way we form our sense of self-identity and how we build relationships later in life.
Developed by John Bowlby in the 1950s, attachment theory insists that bonding is an intrinsic human need and that disruptions to attachment bonds cause developmental distress.
Mary Ainsworth built upon Bowlby’s initial studies through her Strange Situation tests, developing the idea of the “attachment figure” and establishing a structured list of “attachment styles” to explain the different patterns of observed behaviors in children during the Strange Situation tests.
Psychologist Mary Main continued Ainsworth’s work on attachment theory and developed a definition and criteria for a problematic attachment style pattern that Ainsworth was not able to explain: disorganized attachment. These three figures established the key framework of attachment theory that researchers and clinicians continue to build upon today.
Attachment theory was originally conceived as a framework for understanding the development of bonds, or lack of bonding, between mothers and their children. Over the decades, this theory has been expanded to account for the different attachment needs people experience in early childhood, adolescence, and through the adult lifespan.
From this attachment perspective, stress or trauma that disrupts the establishment of healthy attachment bonds, at various stages in one’s life, can lead to the development of problematic coping responses. These coping responses can, in turn, lead to a number of interpersonal and intrapersonal problems.
Healthy, or secure, attachment bonding, however, allows one to develop a sense of security and trust in others. Through secure attachment bonding, young children learn to trust themselves and to trust that their needs will reliably, consistently, be met. With that sense of security, they are able to focus more on safely exploring the world around them and building friendships with others, instead of focusing their efforts on developing coping skills to compensate for insecure attachments.
As children age, they become more and more self-reliant. During teen years, children’s attachment needs shift from primary caregivers towards being accepted by their peers. Through secure attachment at this stage in their life, adolescents are able to more easily establish their own sense of self-identity and avoid developing problematic behavior patterns based around their pursuit of peer and romantic acceptance. Attachment bonding allows individuals to develop enough trust in those they rely on the most so that they can explore who they are as a person and how they fit into the world around them.
Throughout adulthood, one’s attachment needs focus less on care providers and peer acceptance and shift more to finding and maintaining meaningful intimate partnerships. Adults generally begin to focus on building their careers and following their own paths in life. Finding life-partners and starting their own families are often central goals in an adult’s life. As such, adults tend to find themselves less concerned with peer approval and more concerned with the approval of a potential partner to share their life with. Thus, establishing secure attachment bonds with one’s intimate partners allows adults to continue to grow as a person, to feel grounded and confident in their ability to navigate life’s challenges and pursue their life goals, and to potentially become a secure and supportive attachment figure to their own children.
Attachment Injury
In a 2006 study, "Resolving Attachment Injuries in Couples Using EFT: Steps Toward Forgiveness and Reconciliation," Sue Johnson and Judy Makinen define attachment injuries as “attachment-related incidents that stem from an abandonment or betrayal of trust during a critical moment of need in one’s life.”
Attachment injuries may stem from such issues as childhood traumas and abuse, abandonment or neglect, manipulative or toxic friendships, infidelity, addictions, deception, inconsistency, unreliability, professional or financial struggles, communication issues (condescension, insults, misunderstandings), inattentiveness, or unattuned affect.
Johnson states that injurious incidents “define relationships as insecure and maintain relationship distress because they are continually used as a standard for the dependability of the offending partner.” In other words, partners in relationships often become fixated on incidents that cause attachment injuries and, instead of working to resolve the issue at hand, one partner may hold a grudge against the other.
These negative emotional responses perpetuate more negative reactions, gradually becoming a self-reinforcing feedback loop of negative emotional interactions. This cycle creates an impasse that blocks relationship repair.
To better understand how attachment injuries influence relationship distress and how EFT can mend these injuries, Johnson and Makinen developed an 8-Step Attachment Injury Resolution Model.
8-Step Attachment Injury Resolution Model
Attachment Injury Marker
In a highly emotional manner, the injured partner describes the incident in which they experienced a violation of trust that damaged their belief in the relationship. The emotional experience is a vivid encounter in the present moment, not a passive, calm recollection of past feelings.
The offending partner discounts, denies or minimizes the incident, and their partner’s pain, moving into a defensive position.
Differentiation of Affect
The injured partner stays in touch with the injury and begins to articulate its impact and attachment significance.
The offending partner begins to hear and understand the significance of the injurious event.
Re-engagement
The injured partner tentatively moves toward a more integrated articulation of the injury and allows the other to witness his or her vulnerability by expressing grief and fear concerning the specific loss of the attachment bond.
The offending partner becomes more emotionally engaged and acknowledges responsibility for their part. They express empathy, regret and remorse.
Forgiveness and Reconciliation
The injured partner then risks asking for comfort and caring that was unavailable at the time of the injury.
The offending partner responds in a caring manner that acts as an antidote to the traumatic experience.
Summary Of The Change Process
How does EFT get people to soften and shift their emotional positions?
Establishment of a secure, trusting alliance with the therapist.
Therapist’s ability to prompt clients to explore and experience their feelings underlying the distress.
Therapist’s ability to validate the clients real, unmet needs underlying their emotions.
Therapist’s ability to help clients reframe their emotional experiences into new interactions, leading to the development of secure attachment bonds.
The EFT Process is effective at getting distressed, apprehensive, closed-off, aggressive, overwhelmed and withdrawn clients to “soften,” to allow themselves to become vulnerable and ultimately to be able to experience their emotions and express their needs.
The transition from hostility to vulnerability enables clients to reach out and begin to communicate with each other in ways they have not been able to do before.
A crucial difficulty in accomplishing this is that distressed clients are naturally going to be resistant to wanting to open up and share their feelings. This is a common challenge faced by therapists employing any method of talk therapy.
In EFT sessions, the therapist facilitates the eventual softening experience with clients by utilizing key perspectives and methods that build trust and security, and that encourage the clients to tell their story.
It is often not difficult to get clients to speak their mind about what they’re upset about, so the EFT therapist will employ the process of enacting and allow one of the clients (usually a dominating partner) to start out by saying everything they can about what they feel is upsetting them, or what they feel the problem is.
Instead of letting the other partner respond right away, the therapist will stay with this partner and ask them to walk through their experience. The therapist will provide validation as this partner tells their story, and will help to construct a narrative of their point of view so they can feel like they are being heard and understood. In order to prevent the other partner from feeling unheard, the therapist will routinely reference their needs and give verbal reassurance that they will soon have a chance to share their feelings.
This allows one partner at a time to feel like they can take their time to unpack how they’re really feeling underneath the distressed interaction, and to identify what their needs are that aren’t being met.
Empathic attunement, empathetic conjecture, evocative responding, reflecting underlying emotions, and reframing are five important ways that the therapist will continue to engage with clients in a way that reinforces trust and brings them closer to exploring and experiencing emotions.
It is the heightening step of the EFT process that provides the most in-depth emotional experiences. This step primes the softening event. By restructuring these vivid experiences and interactions, the therapist is able to help the clients engage with each other in new ways and use these experiences to shift their positions from distress to attunement. This is where the softening event unfolds.
From there, the therapist continues to work with the clients to review the progress they’ve made, to consolidate a new narrative of their relationship, and to integrate their new-found attunement into secure attachment.
The Key EFT Perspectives And Methods For Facilitating Change
Establishing a strong therapeutic alliance that provides a feeling of safety, validation and trust with the clients.
Understanding that the goal is to establish secure emotional bonds that satisfy attachment needs, not simply to negotiate a compromise to end an argument.
Enacting: Allowing each partner, in turn, to talk about what they feel is causing the distress. This helps the therapist create a narrative of what the distress looks like from both perspectives.
Validating: Consistently providing validation as clients express their perspectives, feelings and needs.
Providing encouraging attunement with clients when they try to withdraw.
Providing affirming attunement to clients when they are expressive.
Providing calming attunement when they are attempting to be dominating.
This maintains the secure alliance and allows clients to feel confident and comfortable with opening up and expressing themselves.
Identifying the negative cycle: This provides a clear definition of the pattern of distress that both partners are experiencing.
Presenting the negative interaction cycle as the core of the problem.
Disarms blame.
Helps clients feel more comfortable exploring the issues that initiated and maintain the cycle.
Provides a common goal to resolve together.
Empathic Attunement: Therapist demonstrates that they are listening carefully and are genuinely interested in understanding the client’s personal experiences.
Simple, affirming expressions and attuned body language.
Leaning in to what the client is expressing.
Helps clients to feel that the therapist is tracking their expressions.
Evocative Responding: Therapist relays back and expands upon implicit elements of the client’s experience.
Helps to bring attention to unexplored nuances of emotions and needs.
Therapist will ask questions like, “What’s happening right now when you said ‘I feel like nothing I ever do is ever good enough’? What’s that feeling like?”
Reflecting Underlying Emotions: Therapist offers reflections that draw upon emotions not immediately clear to the client(s).
Example: “Of course you close up because this arguing is so painful, so awful that you just close up. Am I getting that right?”
Empathetic Conjecture: Therapist closely follows what the client is expressing, asking questions that clarify and explore the deeper significance of what is being expressed.
Examples:
“You don’t believe it’s possible that anyone could see this part of you and still accept you, is that right?”
“I am getting the idea that underneath your frustration you may feel some sadness. Am I getting that right, that really you are feeling loss and sadness.”
Reframing: Therapist reframes each partner’s behavior in terms of the attachment needs and wants informing each partner’s position in the relationship.
Examples:
“You freeze because you feel like you’re right on the edge of losing her, is that right?”
“You freeze because she matters so much to you, not because you don’t care.”
Heightening: Circling back around to explore the difficult topics brought up in earlier conversations.
Clients are guided, individually, to revisit and explore their feelings and needs more deeply.
Once clients begin to express their emotions, they are asked to communicate their feelings and needs to one another.
Building towards the softening event.
Examples:
“So you want to crawl into a ball, a tight ball, this is painful, so painful, when he says he still loves her, it hurts so deep, it’s so painful, so difficult that you just want to crawl into a tight ball.”
“It seems like this is so hard for you, like climbing a cliff, it's so scary, you’re right on the edge, it’s awful.”
“Can you turn to him and tell him, ‘it’s too hard to ask. It’s too hard to ask you to take my hand?’”
Restructuring: Therapist offers a directive for the couple, which builds on a new emotional experience and seeks a new response to one’s partner. This shift challenges the couple’s old relationship patterns and links the intrapsychic focus of the previous work to an interpersonal action.
This is where the softening event comes to fruition.
Partners experience their emotions vividly with each other, which causes a disruption in the cyclic pattern of distressed interaction.
Examples:
“Can you turn and tell him directly, ‘that really hurt me.’”
“This is the first time you’ve mentioned being ashamed. Could you tell him about that shame?”
“Can you ask him right here, right now for what you need?”
Softening Event Example:
“When I respond like that and yell at you it’s because I’m really feeling alone and I’m afraid that I’m going to be stuck here alone. I’m really trying to say that I need you, and that I want you to be here with me. I want you to be my partner, but I make you feel threatened. I make you feel like you’re not safe, so you try to avoid me and that hurts me even more. It hurts both of us. I really need you. I miss you and I want to feel secure with you. I want you to feel secure with me too.”
*script examples and definitions referenced from “Therapist’s Core Competencies in Utilizing Emotionally Focused Therapy” by Ronald Vogt, PhD. (2014)
Example of an Attachment-injured Couple’s Interactions
From 2006 Resolving Attachment Injuries study:
To illustrate the process of change, a generic example of an
attachment-injured couple (John and Pat) is provided. John and
Pat, both successful professionals, had been married for 30 years
when Pat found out that John had had an affair three years before when
he was away on business.
Pat felt betrayed, and her trust for John was shattered. Over the years, Pat and John never discussed the incident, although John complained that Pat repeatedly reminded
him of his indiscretion. At the intake, Pat presented as angry and
hostile toward John, and he was very defensive. Pat was hyper-
vigilant whenever John went out.
She wanted to know where he was going, whom he was meeting, and when he was coming home. When he was late, she would become distraught, and the cycle
would escalate immediately upon his return. John reported feeling
controlled and refused to comply with her unrealistic demands.
When John was home, he often retreated to his music studio and
listened to music with headphones, which incited Pat’s anger.
Example conversation:
Therapist: You have compartmentalized your feelings, never
talked about your shame because when she got
scared she would remind you of it. Is that it?
John: Yeah, she would get angry, and it was like replay-
ing an old movie. I’d hear it over and over again . . .I couldn’t escape.
I knew that I’d have to deal with it one day, but....
Therapist: So this is new for you to talk about your feelings,
yes?
John: Maybe it’s because I have a really hard time choosing my words and how I would say it.
Therapist: It’s hard to take that in when there is so much
shame and regret about what happened. Can you try ato tell her now?
John (tearfully turning to Pat): I am so, so sorry . . . I’m really sorry. I wasn’t
thinking, and it was a silly, selfish thing to do . . .
without any thought on my part of how it would
affect you.
Pat: Well . . . I accept your apology.
John (sobbing): Because I do love you so very much, and I do want
to grow old with you.
Pat: I can’t believe how I feel . . . since we’ve been
coming here. It is in the past, and I don’t carry it
with me anymore. My life doesn’t revolve around it
anymore. I don’t get up in the morning and think
about it. I am sad to hear that you are dealing with
it more now than before. I don’t want you to worry
about it.
Therapist: It saddens you to hear that he still carries this?
Pat: Uh hmm . . . because it is gone for me, I have
forgiven him. It is in the past. It is not even an issue
anymore. I will never again . . . I know . . . that I
will never worry about it. I just miss you. I need
you in my life. I too want to grow old with you.
John: It has helped talking about the affair and hearing
how you felt. When you told me how you felt
before, all I heard was your anger, which is now
gone. This makes such a big difference when we
talk now.
EFIT & EFFT: Emotionally Focused Therapy For Individuals And Families
We’ve primarily used examples of couples therapy (EFCT) in this exploration of EFT, but the same clinical process has been adapted as highly successful interventions for individuals and families alike.
Because this methodology is centered around attachment needs and emotional bonds, it lends itself easily to help families identify and reprocess distressed interaction patterns into secure attachments, much in the same manner that it works with couples.
Our individual, intrapersonal, relationships with ourselves are also deeply influenced by our attachment needs. Attachment theory suggests that the degree to which one is able to meet their emotional bonding needs in childhood, adolescence, and adulthood has an impact on a person’s sense of self-image, self-esteem, and ability to maintain interpersonal relationships. In essence, EFT views a person’s relationship with themselves as being built upon the same foundation of needs and emotions as couples and family structures are.
In the EFIT, EFFT and EFCT Processes:
EFIT: Individuals explore distress stemming from traumas that have damaged their attachment experiences and work to establish secure attachment bonds with themselves and/or imagined others (i.e., unavailable parental figures, peers).
EFFT: Families explore and establish a number of simultaneous attachment bonds between adult partners and between parents/caregivers and children.
EFCT: Couples explore how their behaviors affect their ability to establish a secure bond with one another. Additionally, in therapy, individual partners may discover that their problematic emotional responses in the relationship stem from attachment injuries earlier in their own life.
Summary
Sue Johnson views relationships as being like a dance, with music and tempo, improvisation, risk, needs and, most importantly, feeling.
“Love is a constant process of tuning in, connecting, missing and misreading cues, disconnecting, repairing, and finding deeper connection. It is a dance of meeting and parting and finding each other again. Minute to minute and day to day.” - Sue Johnson, Love Sense, (2013)
In this metaphor, Sue suggests you can’t learn how to dance just by memorizing the steps— you have to become attuned to your partner.
Attunement is crucial in the dances taking place in all of our relationships, whether it is with our co-workers, friends, family members, significant others, or even with ourselves.
When we experience distress in our relationships it is, most often, because the dance has gotten out of attunement (or because it has never reached attunement). Attunement is all about being aware of, and responsive to, the deeper emotional needs of ourselves and others.
When we fail to maintain attunement with our own needs or to the needs of others in our lives, negative patterns of interaction and behavior often emerge. These negative patterns often cause additional negative reactions, eventually creating a pattern of distress.
The EFT Process views relationships through a “lens of attachment science.” The principles of attachment science serve as a map to help the trained therapist observe and identify a client’s presenting patterns of distressed behavior, identify and experience the emotions connected to underlying unmet attachment needs, and to reprocess these emotions into new, healthy and secure attachment bonds.
Just as a good dance instructor helps their student learn to dance by helping them develop familiarity with their movements and understand they aren’t making mistakes because they’re inherently flawed, the EFT therapist also allows their clients to experience their emotions in order to become familiar with their own, and each others’, needs. The EFT therapist also helps the clients understand that it is the underlying cycle of negative interaction that is the problem, which allows the clients to feel like a successful outcome is attainable and worth the effort.
Clinicians and researchers have been building upon these ideas for the last 35+ years, and they continue to be considered a gold-standard in clinical couples therapy today.