DIAGNOSIS: Relationship Distress With Spouse or Intimate Partner
2015 EST Status: Treatment pending re-evaluation
Very strong: High-quality evidence that treatment improves symptoms and functional outcomes at post-treatment and follow-up; little risk of harm; requires reasonable amount of resources; effective in non-research settings
Strong: Moderate- to high-quality evidence that treatment improves symptoms OR functional outcomes; not a high risk of harm; reasonable use of resources
Weak: Low or very low-quality evidence that treatment produces clinically meaningful effects on symptoms or functional outcomes; Gains from the treatment may not warrant resources involved
Insufficient Evidence: No meta-analytic study could be identified
Insufficient Evidence: Existing meta-analyses are not of sufficient quality
Treatment pending re-evaluation
1998 EST Status: Strong Research Support
Strong: Support from two well-designed studies conducted by independent investigators.
Modest: Support from one well-designed study or several adequately designed studies.
Controversial: Conflicting results, or claims regarding mechanisms are unsupported.
Strength of Research Support
- Basic premise: Emotionally Focused Therapy for Couples (EFT) is attachment based and conceptualizes the negative, rigid interaction patterns and absorbing negative affect that typify distress in couple relationships in terms of emotional disconnection and insecure attachment. Change in EFT is presumed to occur, not from insight, catharsis, or improved skills per se, but from the formulation and expression of new emotional experience that transforms the nature of the interactional drama, particularly as it pertains to attachment needs and emotions.
- Essence of therapy: EFT draws on humanistic and systemic principles to help create a more secure attachment bond in a relationship. This model integrates the intrapsychic perspective afforded by experiential approaches with an interpersonal systemic perspective to help distressed partners shape emotional accessibility, responsiveness, and engagement—the key elements of attachment security. The process of EFT involves three stages. The first stage, cycle de-escalation, helps the couple understand how their negative interactions drive a self-reinforcing cycle of distress. At the end of this stage, the couple has internalized that the problem is their self-reinforcing cycle associated with attachment disruptions leading to reframing the problem as their negative cycle. The second stage, restructuring interactions, involves the shaping of new core emotional experiences, and new interactions that lead to a more secure connection. Partners are encouraged to explore and share their attachment vulnerabilities and needs with their partner in session, in focused, structured enactments. These events create new constructive cycles of contact and caring, fostering secure attachment. The third stage of EFT, consolidation, involves helping couples use their more secure attachment bond and improved relationship functioning to solve problems in their everyday lives and create a story of resilience and mastery in their relationship. EFT couples therapy also uses the same 5-step process as EFT individual and family therapies to foster change.
- Length: EFT is a brief short-term therapy that typically takes between 8 to 20 sessions to move a couple through the three stages. As a rule of thumb the first stage, de-escalation, generally requires 75% of the total number of sessions for a couple to de-escalate their emotional distress when triggered and reliably create emotional safety outside of the therapy office. Once that occurs, the second stage, deeply connecting/bonding, utilizes all but a few of the remaining sessions set aside for the final stage – consolidating gains. A variety of confounding variables can increase the number of sessions needed.
Editors:Robert Alan, PhD; Don Zeidlhack, PsyD
Note: The resources provided below are intended to supplement not replace foundational training in mental health treatment and evidence-based practice
Treatment Manuals / Outlines
Books Available for Purchase Through External Sites
- Attachment Theory in Practice: Emotionally Focused Therapy (EFT) with Individuals, Couples, and Families (Johnson, 2019)
Training Materials and Workshops
- More information on the following workshops is available by following the link to the International Center for Emotionally Focused Therapy and looking under the Therapist Resources section:
- Externships – Four days of basic training in EFT. Locations around the world.
- Core Skills – Advanced training in EFT. Locations around the world.
- Master Classes – Specialized topical training. Locations around the world.
- Special Topics in EFT – Locations around the world.
- Individual or Group Supervision in EFT – Available around the world.
- Attachment Injury Repair Training Program – Online
- Emotionally Focused Therapy Step by Step: a complete online course
- The Emotionally Focused Casebook: New Directions in Treating Couples (Furrow, Johnson, & Bradley, 2011)
- Emotionally Focused Therapy for Couples (Greenberg, L. S., & Johnson, S. M., 1988)
- Becoming an Emotionally Focused Couple Therapist: The Workbook (Johnson, S., et al., 2005)
- Attachment Processes in Couple and Family Therapy (Johnson & Whiffen (Eds.), 2003)
- The Practice of Emotionally Focused Couple Therapy: Creating Connection (2nd ed.) (Johnson, 2004)
- Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds (Johnson, 2002)
- The Heart of the Matter: Emotion in Marital Therapy (Johnson & Greenberg (Eds.), 1994)
- The Practice of Emotionally Focused Marital Therapy: Creating Connection (Johnson, 1996)
Measures, Handouts and Worksheets
- Emotion-Focused Therapy–Therapist Fidelity Scale (EFT-TFS): Conceptual development and content validity (Denton, Johnson, & Burleson, 2009)
- Measuring fidelity in Emotionally Focused Couples Therapy (EFT): A pilot test of the EFT Therapist Fidelity Scale (Sandberg et al., 2015)
- Hold Me Tight: Seven Conversations for a Lifetime of Love (Johnson, 2008)
- Created for Connection: The “Hold Me Tight” Guide for Christian Couples (Johnson & Sanderfer, 2016)
- An Emotionally Focused Workbook for Couples: The Two of Us (Kallos-Lilly & Fitzgerald, 2014)
- Emotionally Focused Couple Therapy for Dummies (Bradley & Furrow, 2013)
- Love Sense: The Revolutionary New Science of Romantic Relationships (Johnson, 2013)
Important Note: The books listed above are based on empirically-supported in-person treatments. They have not necessarily been evaluated empirically either by themselves or in conjunction with in-person treatment. We list them as a resource for clinicians who assign them as an adjunct to conducting in-person treatment.
- Professionally developed training videos demonstrating all aspects of Emotionally Focused Couples Therapy are available by following the link to the International Center For Emotionally Focused Therapy and looking under the “Therapist Resources” section. A sampling of the titles to be find there include:
- Emotionally Focused Therapy Step by Step: a complete online course
- Shaping Secure Connection: Stages 1 & 2 of Emotionally Focused Couple Therapy
- Facing The Dragon Together. EFT with Traumatized Couples
- Predicting key change events in emotionally focused couple therapy (Dalgleish et al., 2015)
- Nurturing connections in the aftermath of childhood trauma: A randomized controlled trial of emotionally focused couple therapy for female survivors of childhood abuse (Dalton et al., 2013)
- Augmenting antidepressant medication treatment of depressed women with emotionally focused therapy for couples: A randomized pilot study (Denton, Wittenborn, & Golden, 2012)
- Emotion-Focused Therapy for couples in the treatment of depression: A pilot study (Dessaulles, Johnson, & Denton, 2003)
- Comparison of integrated systemic and emotionally focused approaches to couples therapy (Goldman & Greenberg, 1992)
- Emotionally focused marital intervention for couples with chronically ill children (Gordon-Walker et al., 1996)
- Effects of a communication training component added to an emotionally focused couples therapy (James, 1991)
- Emotionally focused couples therapy: An outcome study (Johnson & Greenberg, 1985)
- Differential effects of experiential and problem solving interventions in resolving marital conflict (Johnson, & Greenberg, 1985)
- Predictors of success in emotionally focused marital therapy (Johnson, S. M., & Talitman, E., 1997)
- Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy (Johnson et al., 2013)
- Emotionally focused couple therapy for parents raising a child with an autism spectrum disorder: A pilot study (Lee, Furrow, & Bradley, 2017)
- Emotionally focused therapy for couples and childhood sexual abuse survivors (MacIntosh & Johnson, 2008)
- Low sexual desire in women: The effects of marital therapy (McPhee, Johnson, & Van der Veer, 1995)
- Resolving attachment injuries in couples using EFT: Steps toward forgiveness and reconciliation (Makinen, & Johnson, 2006)
- A couples intervention for patients facing advanced cancer and their spouse caregivers: Outcomes of a pilot study (McLean et al., 2008)
- A couple-based intervention for patients and caregivers facing end-stage cancer: Outcomes of a randomized controlled trial (McLean et al., 2013)
- The effectiveness of emotionally focused couples therapy with veterans with PTSD: A pilot study (Weissman et al., 2017)
- Randomized controlled trial of emotionally focused couple therapy compared to treatment as usual for depression: Outcomes and mechanisms of change (Wittenborn et al., 2018)
Meta-analyses and Systematic Reviews
- Emotionally Focused Couples Therapy: A systematic review of its effectiveness over the past 19 years (Beasley & Ager, 2019)
- Emotionally Focused Couples Therapy: Status and challenges (Johnson et al., 1999)
- A review of the research in Emotionally Focused Therapy for couples (Wieve & Johnson, 2016)
- What works for whom: A meta-analytic review of marital and couples therapy in reference to marital distress (Wood et al., 2005)
- Research on the treatment of couple distress (Lebow et al., 2012)
Other Treatment Resources
- The following resources can be found at the International Center for Emotionally Focused Therapy under the “Hold Me Tight” section:
- Hold Me Tight – Relationship education and enhancement program – Online
- Hold Me Tight – Relationship education and enhancement program – Workshops around the world
- Hold Me Tight for Christian Couples – Relationship education and enhancement program – Workshops around the world
- The Hold Me Tight Let Me Go Program For Families With Teens – Workshops around the world
- Emotionally Focused Individual Therapy – DVD
- Emotionally Focused Family Therapy: Restoring Connection and Promoting Resilience (Furrow et al., 2019)