Applying Emotionally Focused Therapy to
Distressed Lesbian Couple
Emotionally focused therapy integrates concepts from systemic therapy, humanistic and experiential approaches, and attachment theory. It is useful for working with couples who are insecurely attached and suffering from emotional distancing and an inability to support one another. This case provides an overview of the approach and applies it to the case of an emotionally distressed lesbian couple in which one partner is struggling against coming out to her family, causing her partner to doubt her love and commitment to the relationship. Through the application of the EFT process, both partners are able to become vulnerable, express their underlying primary emotions, and articulate their needs, thus leading to a more secure attachment. This enables them to re-examine their presenting problem in a more mutually-supportive, less conflicted manner.
Emotionally focused therapy (EFT), developed by Susan M. Johnson and Leslie S. Greenberg, is an integrative approach to couples therapy that combines elements of humanistic or experiential and systemic approaches (Johnson & Greenberg, 1987), as well as borrowing from concepts associated with attachment theory (Bradley & Johnson, 2005). This approach simultaneously focuses on the inner experience of emotions (the intrapsychic) and the external experience of the interactional process between partners (the interpersonal) (Greenberg, Ford, Alden, & Johnson, 1993).
Goals of Therapy
Specifically, EFT attempts to uncover and acknowledge feelings and needs that have been denied, suppressed, or disowned, and through the expression of these feelings and needs, EFT also leads distressed partners to shifting their perspective about each other and their relationship. The founders, Johnson and Greenberg (1987), distilled this into the following:
The goal of therapy is then to access, express, and reprocess the emotional responses underlying each partner’s interactional positions and thereby facilitate a shift in these interactional positions toward accessibility and responsiveness. This then results in a more secure and satisfying bond. (p. 552)
Identification of Client & Etiology of Problem
In this model, the client is identified as the relationship, although it does leave room for working with each partner individually (Bradley & Johnson, 2005). The partners who are manifesting dysfunctional interactional patterns are not labeled or viewed as pathological in EFT; rather, they are viewed as being stuck and relying on past adaptive reactions that are simply no longer useful (Johnson & Greenberg, 1987). The partners are “viewed as struggling with problems arising from a particular social context” (Bradley & Johnson, 2005, p. 182). The distress that couples experience is basically understood as “a natural reaction to a lack of security in attachment relationships” (Margulies, 2009, “Overview Emotionally Focused Couples Therapy,” para. 2). Goldman and Greenberg (1992) said that the existence of unmet adult needs and the repression of feelings leads to the maladaptive psychological symptoms seen in couples.
This model is non-pathologizing and strength-based. The therapist sees the clients as simply being stuck in negative interactional patterns and unable to express primary emotions and needs, which leads them to be less securely attached to one another than they may wish. Rather than probing the client’s past and family-of-origin issues and woundings, the EFT therapist focuses on validating each partner’s current feelings, experiences, and needs, and encourages them to open up and share and be vulnerable with their partner. They have everything within them to deepen their bond; the therapist simply guides them to accessing those resources (Johnson & Greenman, 2006)
Role of the Therapist
EFT practitioners believe that people can heal themselves, and so they don’t put themselves in positions of power or authority over their clients (Niolon, 2009). “Clients are seen as the experts on their experience” (Bradley & Johnson, 2005, p. 182). However, the role of the therapist is somewhat directive in that the therapist guides the partners in identifying and accessing repressed emotions, and helps the partners to shift their interactional sequences, both of which lead to the creation of a more secure bond (Jorgenson & Frye, 2007). Johnson and Greenberg (1987) described the therapist’s role as validating, heightening, and expanding “whatever is poignant in each client’s experience” (p. 552), to help each member of the couple to empathize, accept, and validate the emotional experience of his or her partner.
Target of Therapeutic Intervention
The main target of change or intervention in EFT is the emotional response of each of the partners (Johnson & Greenberg, 1987). This approach delineates two categories of emotion: primary and secondary. Secondary emotions are reactive and what can be seen on the surface, such as anger, jealousy, resentment, and derive from the deeper, primary emotions, such as sadness, hurt, fear, shame, and loneliness (Jorgenson & Frye, 2007). “Primary emotions generally draw partners closer. Secondary emotions tend to push partners away” (Jorgenson & Frye, 2007, p. 12). Greenberg, James, and Conry (1988) found, in an early study of EFT, that “the expression, in a vivid manner, of underlying biologically adaptive primary feelings creates interactional change” (p. 20).
One of the most important tasks for the EFT therapist is the establishment and maintenance of a strong therapeutic alliance with both partners of the relationship, so as to create an environment where it is safe for them to reveal primary emotions, to ask for their needs to be met, and to reveal their vulnerabilities. Niolon (2009) gave the following tips for building this strong alliance: be genuine and transparent; be trustworthy; believe and convey the belief that the clients are strong, willing and able to face and overcome problems; continuously monitor the alliance; and admit mistakes. Once a strong alliance has been established, then the therapist can proceed through the nine steps of the EFT process, which are divided into three phases or stages.
Stages of Therapy & Common Interventions
Stage or Phase 1 consists of the first four steps in the EFT change process and is aimed at de-escalating the negative interactional cycle between the partners. These steps consist of assessment of the conflict issues; identification of the negative interactional cycle; discovery of the underlying, primary emotions embedded in each partner’s interactional position; and reframing the problem in terms of the underlying emotions, attachment needs, and attachment issues. Stage 2 is designed to restructure the partners’ interactional positions and includes steps five through seven: helping the clients identify with their disowned feelings and needs and integrating these into the relationship interactions; promoting acceptance in the other partner of the first partner’s new emotional experience and interactional position; assisting the couple to express their wants and needs to each other, promoting deeper bonding experiences and strengthening the attachment between them. Stage 3 is about consolidation and integration, and it is in this stage that the couple is supportively encouraged to revisit problems and discover new solutions through step 8, and then new interactional positions and cycles of attachment behavior are consolidated and integrated in the work of step 9 (Bradley & Johnson, 2005; Jorgenson & Frye, 2007).
In Stage 1, EFT therapists use interventions such as reflective statements; validation; evocative questions (such as “what’s happening now for you, as I say that?”); and heightening, which expands the emotional experience, sometimes using metaphors to help the client more fully engage with his or her expressed emotion or uncover a repressed emotion (Niolon, 2009). Jorgenson and Frye (2007) described evocative responding as “questions and prompts that call up emotion through open questions about stimuli, bodily responses, desires, meanings, or action tendencies” (p. 45). They also described heightening more fully, by saying this is where the therapist can “expand and intensify emotional experience using repetition, images, metaphors, focusing, or enactments” (p. 46). Another technique that can be used during this stage is empathic conjecture or interpretation, where the therapist reaches below the client’s expressed description of his or her experience and infers about the deeper meaning or emotional experience (Jorgenson & Frye, 2007).
Stage 2 interventions include tracking, reframing or restructuring, and helping the partner to understand and express their emotions while helping their mate to truly hear and understand these expressions (Niolon, 2009). Tracking includes reflecting and replaying of interactions and helps the therapist show the clients more clearly how their interactional patterns evolve and play out (Jorgenson & Frye, 2007). Reframing involves proposing a new perspective on one partner’s behaviors, to take into account the underlying feelings and needs. This often leads to a “softening” of the other partner, where they feel more drawn to this softer, more vulnerable side of their mate (Bradley & Johnson, 2005). Jorgensen and Frye (2007) stated that reframing “shifts the meaning of specific responses, clarifies their attachment significance, and fosters more positive perceptions of the partner” (p. 49).
In the third stage, the therapist steps back from being as directive and allows the couple to re-engage with their problems from this new perspective of each other and their strengthened attachment bond. Bradley and Johnson (2005) described this phase as one in which the therapist might review the couple’s accomplishments, to show how different and more positive their interactional cycles have become. The therapist praises them and helps them write a new narrative about how they managed to create a stronger bond between them.
Theory of Change Process
“The process of change involves the synthesizing of new emotional responses and the enacting of new interactions rather than the learning of new skills or the attainment of insight” (Johnson & Greenberg, 1987, p. 554). The change process can be broken down into two components: in the first, the “expression of feelings leads to change in interpersonal perception” (Greenberg, James, & Conry, 1988, p. 20); and in the second, “the expression of underlying feelings leads to change in the interaction” (p. 21).
Assessment in EFT
During the initial assessment phase (step 1 of stage 1), the therapist looks for the cycles of interaction, the attachment insecurities, and the buried needs and feelings of each partner. This is also the point where the therapist determines whether this couple is actually a good candidate for EFT (Bradley & Johnson, 2005). The factors that indicate EFT might be a good match for any particular couple include low sexual affection, high levels of negative affect, and lower levels of emotional engagement (Niolon, 2009). EFT is contraindicated for couples who have ongoing abuse or violence, or situations of emotional divorce, where one partner has already made the decision to leave the relationship (Johnson & Greenberg, 1987). In short, any condition “under which the experience or expression of vulnerability is not likely to be adaptive or respected” (Johnson & Greenberg, 1987, p. 554) is not a good fit for EFT.
Case Study of Distressed Lesbian Couple
Jackie and Collette are a lesbian couple who have been in relationship for approximately six months. They have been cohabiting for the last three months. They are presenting with complaints of arguments and declining satisfaction in their sexual interactions. Both Jackie and Collette are Anglo-American and come from similar socioeconomic backgrounds. Currently, Jackie maintains a decent income as a freelance graphic designer, while Collette is re-entering the job force after having been a stay-at-home wife and mother for 15 years.
Jackie, 44, has been “out” as a lesbian for her entire adult life, and has been internally aware of her orientation since her teenage years. Collette, on the other hand, has just come out to herself at 37. However, she identifies as bisexual, rather than lesbian, and “surprisingly” fell in love with Jackie after her heterosexual marriage with Frank fell apart.
Jackie and Collette met in their neighborhood tennis club, which Collette joined after her divorce as a way to get out and meet new people. She and Jackie hit it off and started spending a lot of time together, which gradually became intimate. Jackie was very supportive of Collette’s coming-out process, but has had some difficulty accepting Collette’s desire to keep their relationship secret. Collette is not ready to come out to her ex-husband and children, even though she thinks her teenage daughter suspects. Collette also has a pre-adolescent son. Her ex-husband has custody of both children, and Collette has visitation rights. She worries that if he finds out Jackie is anything more than a roommate, that she’ll lose all contact with her children.
Jackie is also a bit dismayed at Collette’s insistence that she’s bisexual. “Some partners who enter a same-sex relationship directly out of a heterosexual marriage may have mixed feelings about being with another woman. Some partners self-identify as bisexual, and this can frustrate a feminist partner who proudly identifies as lesbian” (Alonzo, 2005, p, 380).
Jackie’s family of origin is now mostly supportive, although her father still doesn’t “get it,” according to Jackie. But he now accepts her, even if he doesn’t understand her. Collette’s family of origin are devout Christians who “don’t believe in homosexuality” and so she is also hesitant to reveal her new relationship to them. In fact, Collette has kept her newfound orientation a secret from all of her family and the friends she had while married. The only person from her life before Jackie that Collette has come out to is her best friend from high school, who lives in another state, but who had been her confidante throughout her marriage and subsequent divorce. Kort (2008) stated that partners in different stages of the coming out process can often experience feeling misunderstood by each other, and this discrepancy can lead to conflict.
They describe their current situation as tense, because both have been snapping at each other for seemingly small issues. They’re also finding it difficult to be intimate with one another, stating that “either we’re always tired or always fighting.” Jackie seems to be the less engaged partner, sitting with crossed arms and often staring off into space, while Collette leans forward in her chair and maintains almost constant eye contact, except for frequent glances toward Jackie.
Jackie and Collette are in different stages of lesbian identity acquisition and different life stages. And although their childhoods were similar in many ways, their adult experiences and relationships have been quite different. They state that they had begun talking about planning a commitment ceremony, but then the problems seemed to get worse, and both dropped the topic. Both express an interest in resolving their current issues and re-exploring the possibility of making a longer-term, more formal commitment to one another. Jackie and Collette meet the criteria for being a good fit for EFT: they are committed to their relationship and neither seem to be on the verge of leaving; they have low sexual affection, high levels of negative affect, and lower levels of emotional engagement. Additionally, there does not seem to be violence or abuse of any kind present (Niolon, 2009).
Both Jackie and Collette are operating from some assumptions, some based on their past history, some culturally conditioned, about what their relationship should be like. They both also seem to be suppressing some intense emotion, only allowing secondary emotions of anger and irritation to be openly expressed to one another. It is likely, too, that buried in the assumptions and masked by the secondary emotions of anger, that both Collette and Jackie have some unmet needs they don’t even know how to articulate. There may be some internalized homophobic and/or heterosexist influences at play, as well. They are a prime candidate for lesbian-aware emotionally focused therapy. It will be important to be sensitive to the very real dangers associated with Collette’s public identity and coming-out process, especially in regards to her parental rights (Dudley, 2002). With careful guidance through the EFT process with a therapist aware and accepting of the challenges associated with lesbian relationships, this couple will learn how to communicate more effectively and create a stronger bond, allowing them to negotiate and weather their challenges together.
Potential Ethical Issues
Of primary importance in working with this couple is maintaining therapeutic objectivity and self-monitoring for heterosexist bias. It is unethical to deny service based on sexual orientation (AAMFT, § 1.1), but it is also unethical to provide services in an area in which competence has not been attained (AAMFT, § 3.6). Gay, lesbian, and bisexual clients look for therapists who won’t judge them for their sexual orientation, who understand the effects of being a stigmatized minority, and who won’t impose heterosexist values on them (Kort, 2008).
Applying EFT to the Case of Jackie and Collette
Stage One: De-escalating the Negative Cycle
It is difficult for a couple to work on their stated problems until they have de-escalated from their habitual negative interactional cycle, which is the goal of the first stage of the EFT process (Bradley & Johnson, 2005; Jorgenson & Frye, 2007). While Jackie and Collette described their story, the therapist empathized with both, in order to create a strong working alliance with both of them individually and as a couple. As the two described their arguments over household duties, the therapist noted that Collette often demanded that Jackie look at her and to answer for her faults (i.e., those chores which she consistently neglected to complete), to which Jackie responded by sighing, rolling her eyes, or gritting her teeth while making the requested eye contact. Collette would then sometimes respond with apologies and pleading. In this first step, the therapist assessed that Collette is insecurely attached, often attempting to make connection with Jackie through coercive anger, followed by seeking and clinging behavior, a classic pattern noted by Johnson and Greenman (2006). The therapist used reflective statements and validated Collette’s need for more connection with her partner, while also validating Jackie’s need to be approached in a different manner, thereby empathizing with both (Greenberg, James, & Conry, 1988).
In step two, the therapist asked the couple to focus on a single point of contention and enact the interactional cycle, so that patterns could be observed and pointed out. Jackie and Collette focused on their argument about coming out to Collette’s parents, wherein Jackie accused Collette of being ashamed of their love, and Collette reacted defensively, accusing Jackie of not being able to understand her position (Dudley, 2002; Kort, 2008). It became clear to the therapist that in this particular argument, the cycle is different than when they’re discussing household duties. In this case, Jackie is the one on the attack, and Collette goes on the defensive. The therapist used heightening and reflective statements to bring to the couple’s attention the quality of their interactions.
When Jackie suggested that Collette is ashamed of their love, the therapist addressed Jackie: “You feel sad that Collette wants to hide your relationship from her family. You worry that she doesn’t truly love you if she can’t be honest about how she feels about you to others.” At this point, Jackie nodded and looked away with tears in her eyes. The therapist then turned to Collette and asked her an evocative question: “What is happening for you inside as you see how Jackie feels?” Collette still reacted defensively, but not as vehemently: “I can see that she’s upset, but I still don’t think she gets how hard this is. How scary it is. She has no idea what I’m going through.” The therapist then reflected this back to Collette and the process moved smoothly into step three (Bradley & Johnson, 2005).
In step three, clients are assisted in accessing the primary unacknowledged emotions underlying each partner’s interactional position. To begin, Jackie was helped to identify her feelings of fear and sadness associated with Collette’s refusal to be open about their relationship. The therapist offered an empathic interpretation (Niolon, 2009; Jorgenson and Frye, 2007) of Jackie’s description of her emotional state: “I wonder if maybe you are worried, too, about how her family will react to the news. Maybe you’re even feeling anxious and just want to get it over with, because you’re scared that you’ll lose Collette in the process. Am I close?” Collette’s feelings of fear with being out were brought to the surface through heightening. She stated, “I’m terrified of losing my children. It’s like being in a boat in the middle of a storm, and I’m desperately trying to shelter them, while the waves are threatening to rip them away from me.” The therapist used this imagery to continue evoking the fear underlying Collette’s angry defensiveness toward Jackie, thereby enabling her to reach a vulnerable state. In the process, Jackie was able to get a clearer understanding of Collette’s resistance to coming out.
The fourth step of the process is about reframing the problem in terms of the underlying emotions, attachment needs, and attachment issues that have been revealed by the previous steps. The therapist helped the couple to reframe their problem (Niolon, 2009; Jorgenson and Frye, 2007) within the context of societal issues regarding homophobia and the dangers associated with being out (Dudley, 2002; Kort, 2008). This helped Jackie and Collette to begin to externalize their problem, which helped them see that their negative interaction pattern, resulting from the pressures associated with living in a stigmatized relationship, leads to the opposite of what they ultimately want (disconnected from each other, rather than supporting one another) (Bradley & Johnson, 2005).
Stage Two – Restructuring Interactional Positions
Step five involves helping the clients identify with their disowned feelings and needs and integrating these into the relationship interactions. Starting with the less engaged partner, Jackie, the therapist focused more deeply on and used heightening statements (Bradley & Johnson, 2005) to evoke her sadness and her beliefs about herself in relationship, thus bringing to the surface her deep fears about not being good enough, and her resistance to her own internalized homophobia (Kort, 2008). Jackie was able to express, first to the therapist and then, with the therapist’s encouragement and guidance, to Collette, her need for reassurance from Collette that she truly does love her and will not let her family’s potential disapproval drive them apart.
With Collette, the therapist will help her deepen her understanding of her own fears and worries about her relationship, and how others will perceive her (however, work with Collette through steps 5-7 will occur after these steps have been completed with Jackie as the focus).
The therapist used evocative questioning paired with reframing in step six to promote Collette’s acceptance of Jackie’s new emotional experience and interactional position (Jorgenson and Frye, 2007). Collette was asked, “What’s it like for you to hear that Jackie doesn’t feel like she’s good enough for you? What’s going on for you as you see her tears while she talks about being so deeply in love with you that she’s willing to face the fear of losing you?” The therapist observed a shift in Collette’s stance toward Jackie, in which she shifted her body toward Jackie and reached a hand over and rested it on her partner’s thigh, signaling the beginning of a softening event (Bradley & Johnson, 2005). The therapist guided Collette in processing her reactions to what Jackie revealed, and helped her to feel more compassion for Jackie’s position.
Step seven focuses on assisting the couple to express their wants and needs to each other. In this case, Collette was encouraged to reach out to Jackie from a compassionate stance, while Jackie was encouraged to verbalize her needs for support, connection, and acceptance. This step naturally follows the “softening” (Bradley & Johnson, 2005) that is a result of the interventions associated with the previous step. When Jackie was finally able to frame her need for reassurance into a direct request for such from Collette, Collette responded by saying “Of course I love you. I love you so much that I don’t want to complicate our lives with the drama of coming out to my family. You are more important to me than the family I was born to, and I desperately want to protect our relationship and our family.”
After going back and processing steps five through seven with the focus on Collette, she was able to make her own request of Jackie: “What I need is your patience and understanding, and maybe even your help, while I figure out how to protect my children and my relationship with you.” By this point, Jackie had also softened while listening to Collette’s fears about losing her children and their relationship. The therapist validated Collette’s fears about custody (Kort, 2008). Through becoming vulnerable with each other, expressing their deeper, primary emotions of fear and sadness, and articulating their basic needs for support from one another, Collette and Jackie have achieved a more stable, secure bond and deeper attachment.
Stage Three – Consolidation and Integration
In step eight, the therapist encouraged the couple to revisit their problems and discover new solutions. In this case, once Jackie and Collette experienced a de-escalation of their conflict (stage one) and learned to be vulnerable with and support one another (stage two), they were now ready to revisit the problem of Collette’s hesitancy to come out to her parents. Through this new understanding of each other and the strengthened attachment bond, Jackie and Collette were able to discuss the issue in a less volatile way, opening the door for new creative solutions to emerge to assuage both partners’ problems with the issue (Bradley & Johnson, 2005). Collette requested that they put aside some money to secure the services of a lawyer versed in custody law and same-sex relationships. Jackie readily agreed, and additionally suggested that they continue in therapy to learn how to approach the coming-out process with Collette’s family.
Step nine is about consolidating and integrating the new cycles of behavior and attachment gained through the therapeutic process. The therapist supported the couple’s advances in positive interactions and complimented them on their strengths and their willingness to endure the scary process of revealing themselves so deeply. The therapist also helped them to re-write their relationship narrative to reflect their newfound attachment and ability to rise above their old negative interaction patterns (Bradley & Johnson, 2005).
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