Treating Traumatized Couples Using Emotionally Focused Therapy
University of Wisconsin – Stout
The Nature of Trauma
Using Emotionally Focused Therapy to treat traumatized couples can be an effective approach to dealing with relationship distress. Couples may experience trauma in variety of ways including relational trauma, such as a miscarriage, combat, and childhood sexual abuse. Trauma is defined as an experience involving an event or series of events that “involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others [in which] the person’s response involved intense fear, helplessness or horror” (American Psychiatric Association, 2000, 463). Resulting from that sort of experience, an individual may develop Acute Stress Disorder, Posttraumatic Stress Disorder (PTSD), or possibly, Borderline Personality Disorder (BPD) (Johnson, 2002). The symptoms of these disorders include a re-experiencing of the event or events in PTSD and Acute Stress Disorder and a disorganization of emotional and cognitive responses in all disorders.
When clients have experienced trauma, they adapt to cope with it. Their adaptation may come across as pathological and often does cause pathogenic distress following removal from the original trauma. However, it is important for clinicians to recognize and affirm the ultimately adaptive responses to trauma clients develop. If an individual who experienced persistent chronic sexual abuse did not physically numb him or herself upon the initiation of sexual experience, he or she would have not psychically survived. If an individual returned from combat had not developed a hypervigilant nervous system, they too, would not have survived. Working with couples in which one has experienced trauma is the experience of teaching the world’s greatest bear hunters how to survive in the city. Working with couples who have experienced trauma involves not only affirming the adaptations they have each developed to deal with their traumas, but also reminding individuals that they are out of the woods, that combat and sexual abuse are over. The goal of Emotionally Focused Therapy is moving the relationship to a point where each partner leans and defends each other from previous bears (Johnson, 2005).
Mentioning the importance of moving from past bears, it is important to note that emotionally focused therapy is counterindicated in situations where trauma is currently being enacted, similar to physical or sexual violence in the home. More often than not, couples that participate in therapy to deal with trauma will likely have already completed some individual therapy. In situations where the traumatized partner has not already completed some individual therapy, enlisting the help of an individual therapist is often helpful. Susan Johnson, one of the creators of Emotionally Focused Therapy (2005) speaks of the importance of “keeping the relationship as the client” (204) which emphasizes the importance of giving the traumatized individual the space to process their experience effectively.
Emotionally Focused Therapy is the reprocessing and reframing of emotions to repair attachment injuries. Individuals are born with an innate drive for attachment (Rholes 2004). Harry Harlow found this to be true even across species with his baby monkey experiment. When offered milk from a cold, mechanical arm or comfort from a soft and warm body, the infants nearly universally craved touch over sustenance. Mary Ainsworth also explored the attachment patterns of infants with her “strange situation.” When toddlers were put in a room with their mothers, they had a variety of reactions to their mothers’ brief absence from the room. They either seemed to either refer to their mother as a safe point of reference, someone of little consequence, or the whole and depth of their beings. Ainsworth coined the use of “secure attachment” to describe those infants who cried briefly when their mothers left and looked to their mother for soothing upon her return. It is in very early childhood that people learn whether or not the world is safe and whether or not people are dependable (Santrock, 2005). Those attachment patterns seem to continue into adulthood and generally seem to be fairly stable (Rholes, 2004).
Exceptions to this rule occur when individuals experience traumatizing effects later on in life than infancy or toddlerhood. For instance, when an individual enters combat it is often the first time that they graphically face death. When trauma is of human-design like rape or torture, individuals are much more likely to demonstrate symptomlogy in line with PTSD or BPD. These individuals may be emotionally reactive, withdrawn, hypervigilant to perceived rejection or struggle intensely with maintaining positive relationships. This is where couples therapy enters the picture. One member of the couple becomes the sick one and the other member becomes an extreme – either the essential caretaker or the dreaded enemy. While the traumatized individual is dealing with their mental illness, the other is dealing with being an archetype. Neither one of those positions is a particularly comfortable place. However, it is the love for each other and the striving to be able to reach out, touch, and lean on and into the other that compels proactive couples to a therapist.
Knowing Attachment through Emotions
The guideposts to attachment are emotions. It is through recognizing the secondary emotions hidden beneath the significantly safer primary emotions that couples can recognize each others vulnerabilities and see that they are not trying to exploit each others wounds. An example of a primary and secondary emotional interaction would be one in which a first partner berates the other partner for not calling to say that they were going to be late. The primary emotion in that action is anger. If the partner yelled out of fear that something had happened to the late partner, than the secondary emotion would be fear (Johnson, 2004). When working with couples and emotions, it may prove effective to remember that in the scientific and modernistic thinking the majority of Americans ascribe to, emotions are not a factor worth mentioning. Behaviors are the only thing measurable, and thus the only thing that matters. When speaking of using emotions as the basis of therapy some clients may question. It is important to not only allow this questioning, but also encourage it. In the EFT model, the therapist is a “process consultant,” not expert and throughout therapy the therapist should be coming back to the to the couple to be sure that their conceptualizations of the client experience fit (Johnson, 2004). Additionally, emotions may feel like a very unsafe ground for clients to tread upon. Historically, many traumatized couples have seen emotion used as justification for violent or abusive acts. Along with being a “process consultant” (Johnson, 2004, 11) therapists need to move at the pace of the client. Affirm their judgment and sense of safety, while taking note of the therapeutic alliance and challenging them to stay with an emotion or experience so that it can be adequately reprocessed.
Emotionally Focused Therapy
Reprocessing emotion and trauma through Emotionally Focused Therapy takes place over the course of nine stages. The first three stages are focused on de-escalating the negative cycle. It is easy to think of this relating to deescalating anger within a system, but it also relates to deescalating patterns of withdrawal. It is in this stage that the couples’ therapist begins identifying the secondary emotions beneath the surface and reframing those emotions in terms of attachment. For instance, a therapist may say something along the lines of “You act like a big angry monster, because you are afraid that she has already rejected you.” Next, therapy begins to attempt to shift some of the interactional patterns that contribute to relationship distress. The methodology for doing this is by widening both partners world of experience and acceptance. For both partners this means identifying the attachment needs that they have put behind them previously and owning the underlying emotions. It also means learning to accept their partner’s experience and attempts toward a new interactional pattern. Asking for nurturance is another vital part of this stage of therapy. It means trying new things and feeling safe while doing so. Finally, the last two stages of EFT involve consolidating new responses. It is in this stage that the therapist and couple recognizes the new responses to old problems and recognize the new positions of each other and their attachment behaviors.
Treating Traumatized Couples Using Emotionally Focused Therapy
Moving through these stages with a couple in which one has experience trauma, it is important to be aware of a number of factors. First of all, traumatized couples are typically dealing with higher levels of distress than non-traumatized couples. Secondly, especially with couples for which the attachment wound was of human design, moving slower through therapy may be vital. Holding both the fear of attachment and drive towards and for attachment is the task of the effective EFT therapist (Greenberg, 2008). Finally, it is important that therapist retain an affirming point of view towards the couple and traumatized individual. EFT as a model avoids pathologizing clients because it believes that giving an individual a pathology is not as effective as working with them to find out how they define the criteria, names and codes for their experience (Johnson, 2004). By working from a position in which the therapist learns the client’s language, the therapist not only removes the middleman of explaining a diagnosis, but also focuses attention back on the client’s worldview.
The goal of EFT with traumatized couples is to move the attachment object from the self to the other partner. At the conclusion of effective EFT with traumatized partners, the traumatized partner should be able to wake their partner up in the night with their nightmares and seek nurturance. The partner should be able to provide that nurturance. The partner who has not been actively traumatized should be able to name and communicate their boundaries. He or she should also be able to effectively seek their partner for nurturance and soothing. The traumatized couple will likely deal with the remembrances of the traumatic experience or experiences for the rest of their life. The goal of EFT is to allow them to seek the secure base they lost in their partner.
When treating clients, taking note of efficacy of treatment is an important consideration. Preliminary research shows that using emotionally focused therapy to treat traumatized couples may be effective. At the nine-month follow up for one study, individuals who had received emotionally focused therapy instead of traditional talk therapy were still ranked as satisfied with their service (Paivio, 2004). Using emotional freedom techniques with veterans also seems to have been effective (Church, 2009). Empirical research on using EFT with traumatized couples seems to still be in the beginning stages, excluding Susan Johnson’s own work. Regardless of the lack of empirical evidence, it would seem intuitive that expanding and exploring the emotional world of a couple for whom emotion has been a battleground may prove to be cathartic.
For therapists treating couples dealing with trauma, therapeutic self care becomes of paramount importance. Clinicians who work with hurting clients may find themselves becoming increasingly aware of their own attachment injuries. As a professional, it is vital to maintain active and open lines of supervision and avoid transference and counter transference. Recognize personal limitations and do not let yourself become a bear hunter along with your client. Walk the line between actively empathizing with your clients and professional boundaries with care. When therapists are called to work with traumatized couples, it can be traumatizing. Johnson (2005) wrote that she is typically only able to serve about one third of her client population as traumatized. This guideline would probably be appropriate for other clinicians as well.
In working with couples that have experienced trauma, effective clinicians recognize the adaptive and resilient power of the individuals sitting in front of them. Individuals who have gone through trauma have seen the worst of humanity and lived to tell about it. Their partners have lived through the secondary effects of their lover’s trauma and often done so without the context of a linear explanation for their behaviors. Ultimately, individuals are adaptive. Empower clients to recognize that fact. Do not just empower clients to recognize their own adaptations to terrible situations. Challenge them to see the secondary emotions lying beneath their expressions of anger or apathy and the attachment needs that are waiting to be met. Work with clients so they work towards each other.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC.
- Church, D., Geronilla, L., & Dinter, I. (2009). Psychological symptom change in veterans after six sessions of emotional freedom techniques (EFT): an observational study. The International of Healing and Caring. 9(1).
- Greenberg, L.S. & Goldman, R.N. (2008). Emotionally-focused couples therapy: the dynamics of emotion, love, and power. Washington, DC: American Psychological Association.
- Johnson, S.M. (2004). The practice of emotionally focused couple therapy (2nd edition). New York, NY: Brunner-Routledge.
- Johnson, S.M. (2002). Emotionally focused couple therapy with trauma survivors. New York, NY: The Guilford Press
- Paivia, S.C., & Nieuwenheis, J.A. (2001). Efficacy of emotion focused therapy for adult survivors of child abuse: a preliminary study. Journal of Traumatic Stress. 14(1). 115-133
- Rholes, W.S. &Simpson, J.A. (ed.) (2004) Adult attachment: theory, research, and clinical implications. New York, NY: The Guilford Press.
- Santrock, J.W. (ed.) (2004). Child development (10th ed.) New York, NY: McGraw Hill.