The evolution of couple therapy

It is the British Psychological Society's Year of Relationships. Surely the time to write to my colleagues in the UK (the country of my birth) about the changes occurring here in North America in our understanding of, and ability to affect, close relationships – especially adult love relationships. As a result of these changes couple therapy is truly coming of age. It is no longer individual therapy in double focus or a subset of family work. It is becoming recognised as a powerful intervention that offers not just a more satisfying relationship, but a context for enhanced individual growth and a way to impact family life for the better. This comes at a time when we are really starting to grasp the crucial role the quality of our closest relationships plays in our physical and mental health. For instance, research tells us that marital interactions can have a profound effect on cardiovascular health (Kiecolt-Glaser & Newton, 2001; Smith & Gallo, 1999) – the songs about breaking hearts may have a point! And in heart disease, social connection is a better predictor of survival than severity of disease or the amount of damage to the heart (Bucher, 1994). The link between marital distress and depression is clear, and the experts in trauma tell us that the best predictor of the effects of trauma is not trauma history but whether we can seek comfort in the arms of another (van der Kolk et al., 1991).

So let's look at the main features of the evolution – perhaps even revolution – of my title, an evolution that has been described in detail in the couple therapy literature (Johnson, 2003).
First, the nature of relationship distress and satisfaction is no longer a matter of abstract theorising or guesswork. We now have 20 years of research, by people such as John Gottman at the University of Seattle, that can tell us what makes a relationship happy or unhappy. The old cliché was that distress was all about conflict and disagreement – so couple therapy should help folks make agreements. But the research tells us that all couples fight, that's not what makes the difference. It is whether couples can accept conflict and repair rifts after conflict that seems to matter. Specifically, it is the capacity to reconnect and emotionally engage that seems to predict what happens in their relationship (Gottman, 1994). Huston and colleagues (2001) found that decreases in emotional expression and responsiveness predicted divorce in new marriages – not conflict. All the new research is pointing the couple therapist in the same clear direction. The offering of soothing responses and the ability to stay emotionally responsive when a partner brings up a concern or a protest seems crucial.

This research also outlines the most common and pernicious dance that undermines this ability to stay close and emotionally connected. Some call it 'Demand–Withdraw', other researchers call it 'Criticize/Complain–Defend/Distance' (Gottman, 1994). This dance, if partners cannot exit from it, seems to take over more and more of the relationship and pave the way to separation. All of this research, and I have mentioned only a tiny part of it, is invaluable in that it tells the couple therapist where to look in the drama of distress and what to change.

The second great factor in the evolution of couple therapy is that, at last, we have a theory of adult love. In the plenary of the American Association of Marriage and Family Therapy in 2000, Carol Anderson noted that the field of couple and family therapy had ventured out 'on a vast and troubled ocean in a very small theoretical boat'. If we have no map to the territory of love, it is hard to help our clients find their way. So it is fortunate indeed that researchers such as Shaver and Hazan (1993) and clinicians such as myself (Johnson & Whiffen, 2003) have rediscovered and developed the work of a prominent English pioneer – John Bowlby – into a theory of adult love. Attachment theory now gives us a clear, in-depth perspective and the first body of rigorous research on adult love. This perspective offers a positive take on human dependency and frames a secure emotional connection to a loved one as a source of resilience and health. Research shows, for example, that those who can turn to and depend on a loved one have a more positive, articulated and coherent sense of self (Mikulincer, 1995). This challenges many of the old ideas about independence, fusion and differentiation. The attachment lens highlights that, from the cradle to the grave, we need the safe haven and secure base that a responsive and accessible loved one offers us.

This perspective both echoes and adds to the new findings on distress and satisfaction referred to above. Seen through this lens, core conflicts in a couple's relationship reflect the security of this emotional bond. Criticisms and complaints are viewed as protests – sometimes hopeful and sometimes desperate – about the responsiveness of the partner to needs for connection and caring. Sexuality is also seen as an attachment behaviour, rather than simply erotic or focused on physiological release.

This theory of love tells us what the key moves and moments are in any love relationship. At key moments when attachment needs and longings run high – moments of transition, uncertainty and fear – we turn to those we love. We know that, as the emotion theorist Schore (1994) puts it, 'proximity to an attachment figure tranquilizes the nervous system'. If partners can make connections at such times, they can deal with any number of differences, disagreements and stressors. The research tells us that securely attached couples experience less conflict and more satisfaction and support in their marriage (Simpson et al., 1996).

This theory also tells us what the goal of couple therapy should be – not just the de-escalation of conflict but the creation of a secure emotional bond. The research on the two kinds of intervention that have been empirically validated suggests that approaches that focus on skills and problem solving and conflict de-escalation (behavioural couple therapy) have a very real problem with relapse, while an approach that focuses on building a secure bond, such as emotionally focused couple therapy (EFT) (Johnson 2004), is better able to induce stable positive change. The evolving body of literature on key emotions and how to use them to create change also helps the couple therapist to address bonding issues and interactions.

Emotionally focused therapy

In an era of significant change many threads come together to form a new whole. The third core feature of this new evolution, I am going to suggest, is the creation of a technology for in-session change that is informed by the basic research on the nature of marital distress and by the attachment theory of love. The forward movement in this area could be seen as exemplified by the development of EFT. This approach, first tested in the early 1980s, is accepted by the American Psychological Association as empirically validated and obtains the most positive results in the couple therapy field. In meta-analyses of several studies, 70–73 per cent of couples were found to have recovered from distress in 10 to 12 sessions of EFT, as measured by the Dyadic Adjustment Scale (Spanier, 1976), and 90 per cent were significantly improved (Johnson et al., 1999). EFT has also been used in many diverse populations, across different social classes and ethnic groups and with clients who also suffer from depression and anxiety (including post-traumatic stress disorder), or who have physical health problems, such as breast cancer and aphasia.

So what does EFT involve? If you were to watch an EFT therapist in a session, you would see them tracking and reflecting key emotional responses and interactional patterns, such as Criticize–Withdraw. The therapist would typically reflect a problematic interaction that leaves both partners alone and unhappy and then help one of the partners expand and deepen his or her emotional response: for example to move from 'irritation' and the need to 'win' an argument to an acknowledgement of 'desperation' and 'loss'. The therapist, who is a process consultant and works collaboratively with clients, then helps this client share the above response with the other partner. The therapist then helps this partner begin to respond or acknowledge his or her difficulties in taking in and responding to this message. So, step by step, the couple gain control of their negative cycle and begin a new set of interactions characterised by accessibility and responsiveness and so a more secure bond. The specific stages and interventions of EFT are laid out in the EFT manual (Johnson, 2004) and all publications on EFT, including chapters with excerpts of therapy, are to be found on the EFT website (see weblinks).

But perhaps most interestingly, if we think about the growth of the field, what is crucial is not just the articulation of a clear set of interventions that use the power of emotion to reshape key interactions between intimates. It is the fact that students of EFT have conducted a number of process studies that outline key events in the change process so that it too becomes a known territory. For example, a key change event in Stage 2 of EFT is termed a 'softening'. This is where a previously critical partner can move into vulnerable emotions and ask for attachment needs to be met in a way that pulls the other partner towards him or her. The steps in this process have been outlined and the key therapist interventions that create successful softenings – and so elicit bonding events that redefine the relationship – have been identified (Bradley & Furrow, 2004). Clinician/researchers have also identified an impasse to the creation of new more trusting interactions – termed an attachment injury – that can block progress in EFT, they have outlined the steps in the process of forgiveness and reconciliation and have shown that this process leads to a more trusting, happy and secure relationship (Johnson et al., 2001).

These three features are just the peaks of the groundswell that signals a new era in couple and family therapy. In a world where many live in a community of two – not in supportive villages or social networks – the development of this field is urgent and necessary. It is also exhilarating. The number one reason that individuals seek psychotherapy in North America is unhappiness in a key relationship. Our ability as psychologists to make sense of, address and impact this unhappiness is growing daily. The ability of the couple therapist to move a couple from mutual blame and alienation, from dialogues like, 'You are an emotional cripple' (says Susan), 'I refuse to talk to you – you are just too difficult' (says Bruce) to dialogues of connection and support is increasing daily. Susan and Bruce in the final stages of therapy are able to have a different kind of dialogue where Susan asks for her needs to be met – 'I need your reassurance and I need you to hold me' – and Bruce can respond. He says, 'I want to hold you – I miss the closeness between us. I shut down when I get feeling helpless – scared.' This kind of change has many ramifications for mental health and family life. The couple above were struggling with depression in the wife and the husband's coercive negative parenting of adolescent children and chronic illness. A more secure attachment bond enabled this couple to find new and more positive ways to deal with these problems, as well as to create a more satisfying marriage.

Some of the interesting challenges that face the couple therapy field are to look at how culture impacts intervention. For example, we have found that couples from oriental cultures respond well to EFT, but there may be other cultures where its effectiveness is limited. Research into how couple therapy impacts and is impacted by other mental and physical problems is also just beginning. For example, does couple therapy have a place in the treatment of PTSD or in helping people cope with breast cancer? While there are many challenges, the field of couple therapy has come far in the last two decades – and we have only just begun.

– Susan Johnson is Professor of Psychology at the University of Ottawa, Director of the Ottawa Couple and Family Institute, and Research Professor at Alliant University, San Diego. E-mail: [email protected].

Box: Typical Emotionally Focused Therapy interventions

Describing the negative cycle
Therapist: So – as far as I can see you are caught in a trap – both of you – You, Tom, say you feel 'hammered' and so you withdraw to protect yourself. And you, Maria, say you are 'alone' and 'dismissed' so you yell louder and protest his distance. The more he shuts down – the more you bang on the door – and you are both stuck and feeling – what did you say? – 'desperate'. Is that it? This dance is the enemy in your relationship – it has you stuck. It is the cycle that you have to help each other step out of.
Using reflection, process questions and heightening to expand emotion
Therapist: Can we stay here a moment? You used the word 'irritated' – and it was after she noted that you disappointed her 'again' last night. What happened to you when you use that word? Can you help me understand it? – Is it an anger? – What would you like to do when you feel this way?
Client: Don't know – I guess I feel like its like – what is the point?
Therapist: You throw up your hands – so it is like – this is pointless – there is no use – I will never please her – maybe better to give up. I have failed before I start?
Client: Yes – that is it – helpless – I am damned no matter what – I want to hide away.
Creating enactments of new responses after emotion has been expanded
Therapist: So you are saying – I do run and hide – I do withdraw – that is part of our dance – the one we are stuck in. I just feel so discouraged and helpless – I can never please you – is that it?
The client agrees.
Therapist: So can you turn and tell her please – I give up – I felt helpless with you – like I can never make it.
Can you tell her this directly?
The therapist will then stay with the client and help him and his partner process and discuss what this interaction, which is very different from their usual pattern, brings up in them. Sometimes clients can only tell their partner that the message is 'too hard' to say directly to this partner – but this is still a new level of interaction.  

Discuss and debate

What do you believe is the main factor or key kind of interaction that shapes adult love relationships as satisfying or distressed? How does it fit with the research described above?
Do you believe that there are common elements across cultures that couple therapy as a modality can address? Could our need for secure connection – what Bowlby calls 'effective dependency' – be one of these factors?
How do you usually deal with emotion in couple therapy? Do you use it to create positive change?
When should couple therapy be used in conjunction with individual therapy, or even instead of individual therapy?
Have your say on these or other issues this article raises. Write to our Letters page on [email protected] or at the Leicester address – 500 words or less, please. Or you can contribute to our online forum on this or any other topic – go to www.thepsychologist.org.uk and follow the links.

References

Bradley, B. & Furrow, J. (2004). Toward a mini-theory of the blamer softening event: Tracking the moment-to-moment process. Journal of Marital and Family Therapy, 30, 233–246.
Bucher, H. (1994). Social support and progress following first myocardial infarction. Journal of Internal Medicine, 9, 409–417.
Gottman, J. (1994). What predicts divorce? Hillsdale, NJ: Lawrence Erlbaum.
Huston, T., Cauglin, J., Houts, R., Smith, S. & George, L. (2001). The connubial crucible: Newlywed years as predictors of marital delight, distress and divorce. Journal of Personality and Social Psychology, 80, 237–252.
Johnson, S.M. (2003). The revolution in couple therapy. Journal of Marital and Family Therapy, 29, 365–384.
Johnson, S.M. (2004). The practice of emotionally focused couple therapy (2nd edn). New York: Brunner-Routledge.
Johnson, S.M., Hunsley, J., Greenberg, l. & Schindler, D. (1999). Emotionally focused couples therapy: Status and challenges. Clinical Psychology: Science and Practice, 6, 67–79.
Johnson, S.M., Makinen, J. & Millikin, J. (2001). Attachment injuries in couple relationships: A new perspective on impasses in couples therapy. Journal of Marital and Family Therapy, 27, 145–156.
Johnson, S.M. & Whiffen, V. (Eds.) (2003). Attachment processes in couple and family therapy. New York: Guilford.
Kiecolt-Glaser, J.K. & Newton, T.L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503.
Mikulincer, M. (1995). Attachment style and the mental representation of self. Journal of Personality and Social Psychology, 69, 1203–1215.
Schore, A. (1994). Affect regulation and the organization of self. Hillsdale, NJ: Lawrence Erlbaum.
Shaver, P. & Hazan, C. (1993). Adult romantic attachment: Theory and evidence. In D. Perlman & W. Jones (Eds.) Advances in personal relationships, Vol 4, (pp.29–70). London: Jessica Kingsley.
Simpson, J., Rholes, W. & Phillips, D. (1996). Conflict in close relationships. An attachment perspective. Journal of Personality and Social Psychology, 61, 61–69.
Smith, T.W. & Gallo, L.C. (1999). Hostility and cardiovascular reactivity during marital interaction. Psychosomatic Medicine, 61, 436–453.
Spanier, G. (1976). Measuring dyadic adjustment. Journal of Marriage and the Family, 38, 15–28.
van der Kolk, B., Perry C. & Herman, J.L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665–1671.

Weblinks

Emotionally focused therapy:
www.eft.ca
The Gottman Institute: www.gottman.com