A Case Study
In everyone’s life there are critical moments, specific situations or crisis that can be identified. It is crucial in these situations, to get appropriate support. Every human being needs to share these experiences with other people. In order for them to solve their problems they must seek appropriate advices and help. Sharing problems and getting professional support is something relatively novel. In the past, people only had available the supportive listening of family, friends and in some cases their spiritual guides. However, in our modernity, with the complexity of everyday life, getting support to solve crisis has become more and more a professional demand. Nowadays people seek advices to solve their problems from organizations, looking for the expertise of counselors, social workers, therapists and a range of professionals specifically trained to give this support. Fortunately, individuals have available a broad range of services, such as individual, group and couple counseling programs. There is also available theories and researches, focused and developed on light of providing better support and intervention during those critical moments of ones’ individual life.
The aim of this paper is twofold. Firstly it is intended to examine the theoretical approach of Emotionally Focused Therapy (EFT) mainly using the work of Susan M. Johnson. This theory presents an analysis of the Attachment Approach applied to direct practice in family and couple therapy. Using a case study, this paper will presented how these elements of EFT have a profound impact in analyzing and solving the problem. The importance of the work of EFT is to show how emotions provide an important basis for human behavior. As Susan& Greenberg note, emotions “amplify the effects of motives on behavior” (Greenberg, & Johnson, 1988). EFT offers both general strategies and specific techniques for helping clients build stronger, more supportive relational bonds. The second aim of this paper is to analyze the application of EFT to the case study. In this part, I will be doing an analysis of the case under the light of ‘appropriate intervention skills’ that EFT theory explains.
This paper will be divided in three sections. In the first section, the definition of Emotionally Focused Therapy to the direct practice that mainly suggested by Susan M. Johnson and Leslie S.Greenberg will be presented. The second section contains the process of change in EFT that has been illustrated into three stages and nine steps. In this part I will try to apply skills of direct practice by applying appropriate intervention skills to the specific case study, concluding with the summary of how the case is solved with the appropriate counseling intervention and the application of the principles of the EFT. In the third section I will present a question to discuss as a beginning EFT therapist, followed by a description of my learning in completing this case study.
Definition of Emotionally Focused Therapy
EFT is based on the Attachment theory, which states that one of the most primary human needs is to have a secure emotional connection, an attachment, with those who are closest to them. This theory argues that needs and fears of loss and isolation that accompany theses needs are the main cause of couples and family distress. However, this attachment will not be accepted in many ways in western societies, which encourage dependency and the concepts of separateness and self-sufficiency. As Susan noted in her book, Hold Me Tight, when she was trying to publish her views about attachment, most of her colleagues argued that healthy adults are self-sufficient and only dysfunctional people need or depend on others. They called those people enmeshed, codependent, merged and fused (Johnson, 2008). In contrast, as it has been cited in the book Attachment Processes in Couple and Family Therapy, Mackay and John Bawlby state the necessity of emotional accessibility and responsiveness for soothing interactions is necessary in all attachment relationships ( Johnson, & Whiffen, 2003). Susan suggests that attachment behavior, which is aimed at maintaining closeness and contact with other people, is particularly significant in couples therapy (Greenberg, & Johnson, 1988). She also argues that while attachment needs are an essential aspect of adulthood and form the core of the emotional bond in close relationships, distress and anxiety will be increased if the partner is emotionally inaccessible. In another study, Bowlby also emphasizes that when attachment behaviors achieve their aim and the bond is secured, then stress is lessened, otherwise, hopelessness and withdrawal will ensue (Bowlby, 1973). Attachment theory suggests that our partner is our shelter in life and that when this person is emotionally unresponsive or unavailable, we will feel alone and helpless (Susan, 2008). In other words, whenever we lose emotional connection with our partner, we will loss our sense of security. Therefore, in order to keep the emotional connection, promote closeness and enjoy the sense of security, couples should learn effective and open communication of emotions. As it is cited in the book Attachment processes in Couple and Family therapy, attachment security has been associated with greater relationship satisfaction and better communication, both verbal and non verbal( Johnson, & Whiffen, 2003) . Buber also pointed out the need of the human for connectedness and also the importance of the emotional bond which will be fulfilled between the couples by the genuine dialogue (Buber, 1958). He then characterized the genuine dialogue as having qualities of presence, in which people make themselves present to each other, and inclusion, which is the process of letting another in on one’s inner thoughts and feelings, and finally mutuality, in which both parties will be engage in the process. Moreover Susan (Greenberg, & Johnson, 1988) and other scholars (Ekman, 1972; Mehrabian, 1972; Tabatabaei, 2003; Scherer, 1986) also emphasize the importance of the nonverbal emotional conversation occurring between the partners which must be observed and listened to by the therapist in couples therapy. These nonverbal communication styles convey different emotional states that influence interaction. As Susan noted, “nonverbal emotional expressions are clearly a visible and observable signal associated with an emotional state and is generally not under control” (Greenberg, & Johnson, 1988). However, some studies suggest that emotions provide an important basis for human behavior and that they play a potentially adaptive role in human relationships (Greenberg, & Johnson, 1988). Therefore, we can say that in order to make the therapeutical change, it would be useful to clinically differentiate between classes of emotional expression. Susan divided these emotions into four main categories (Greenberg, & Johnson, 1988). The first category, which are biologically based categories, are referred to as adaptive primary emotions. The second category is referred to as the secondary emotion and the third category as the instrumental emotions; both of which are more culturally based categories. The fourth and final category is maladaptive primary emotions, in which biological and cultural factors interact. Primary emotions as opposed to secondary emotions are often not fully in awareness. They convey biologically adaptive information that aids in unified action, problem solving and constructive interaction. Those feelings are a rich source of information that should be probed in the therapy. Even though secondary emotional reactions are often available to consciousness and often take the form of defensive coping strategies, they have been suggested to be bypassed in therapy.
Applying EFT Techniques through the case Study
Stage 1: Cycle De-escalation
Steps 1 to 4: Through the first session of therapy, as it has been suggested in the book Becoming an emotionally focused couple therapist (Johnson, Bradley, Furrow, Lee, & Palmer, 2005), I was trying to make a connection with both partners and to build an alliance with them in which each partner felt safe, understood and accepted. I also tried to reflect, validate, reframe and evocatively respond to them by listening to their stories and by trying to understand how their relationship evolved and why they sought out therapy at this time. Through the first session I found that Irene and Arman were a young couple in their 20’s. They have found each other through the internet and have decided to get married after one year of dating. Studying their family histories it was made clear to me that Irene is a pure Canadian girl who is the middle child in her family of six children. Her parents got divorced when she was 10. She stated that she felt a kind of closeness with her mom but also stated that her mother was often busy and was not available for her all the time. She has never had a good relationship with her dad due to his nastiness and meanness. In contrast, Arman is a Lebanese guy who was born in Canada. He still, however, respects and practices his Lebanese culture. He is the eldest son of a family of three and as he stated he was closest to his mother who had been at home and always was available to him. However this close relationship sometimes gives him a felling of childish and inadequacy as an adult, particularly during his teenage years when he was often bullied by his classmates as being a momma’s boy. He respects his mother and admires her for her management of the family without a man. His father was very responsible for taking care of his family; however he was working away from home most of the time. His parents, as he stated, never fought and have had a very good marriage, and as he claims he couldn’t remember a bitter time between them. He also respects his cultural values and tries to practice them. For instance based on his cultural values boys and girls have to live in their parents’ house first after getting married, before moving to their own house. With regards to Irene I found that she has a history of panic attacks that let her to seek individual therapy. However, Arman has had no experience with neither, individual nor couple therapy. Irene also has been given medication by her physician for her anxiety. The couple were motivated to try therapy on the advice of Irene’s individual therapist while she found that they have conflict and were not getting along with each other. Arman states that he cannot tolerate the way Irene talks to him when she gets angry and anxious. He states that in those situations “I feel unworthy and inadequate”. Irene, on the other hand, indicated that when an issue comes up that makes her anxious, she tries to talk about it with Arman, while he would either make a joke, turn aside by changing the subject, or leaves her alone. Irene said, “it is just like he is ignoring me”, “he can hardly hear me”, “his responses make me angry and frustrated.” She also stated that his reactions make her become discouraged and give up on the issue until the next conflict arises.
Following these observations I asked them to give me an example of this situation in their relationship. Upon this Irene started to illustrate the problem which occurred a few days ago and forced them to see a counselor. The issue was about Arman’s mother interfering with their wedding plans.
Irene: “I was so frustrated and anxious about his mother’s advices that she gives us all the time regarding how we should plan our wedding. She likes to control us in all aspects of our lives. I tried to talk to Arman about this subject but he just shut me out. He completely ignores me, just as if he has not heard me.”
Arman: “And you came after me and yelled at me several times and disrespected my mom.”
Irene: “No, I did not. I just wanted you to hear me, to listen to me and to understand how I feel lonely when you shut me out and leave me alone, when you take your mom’s side.”
Arman: I did not leave you alone. I did not take my mom’s side. I just wanted to let you get a bit calmer, to reduce your anxiousness, to bring your voice down. I don’t like to argue. I don’t like you to disrespect and humiliate me or other people.”
Here I tried to track his emotional experience by reflecting his feeling of inadequacy. Thus I stated the following:
Therapist: “It seems that you feel humiliated.”
Arman: Yes, yes, you are absolutely right. I don’t like to be humiliated. I am mature enough to make any decision by myself. And then she comes and wants to prove that I can’t stand by myself.”
Therapist: “And what is that like for you?”
The goal here is to understand his experience and also get a sense of the cycle.
Arman: “I just try to keep my distance from her in order to reduce the level of conflict. You know what? I need some space.”
To track the cycle, then I turned to Irene and asked her the following:
Therapist: “Ok Irene, what happened next?”
Irene: “He shut the door and went to his mom’s house. Then I called him to talk to him but he did not answer me.”
In order to show my empathic reflection, I implied the following:
Therapist: “And that must be hard for you, right?”
Irene: It is so hard. I always have to go after him while he leaves me alone. I am the one who tries to talk to him, to explain to him while he is ignoring me.”
In order to continue tracing the cycle I added the following:
Therapist: “Then it is like you are always dealing with it?”
Arman: “No, it is not true. You can’t even imagine what it’s like when she gets angry, she is another person. I hate it. I don’t like this side of her.”
Therapist: “So, let me understand this cycle. When a situation comes up where you feel humiliated, Arman, you get tense and Irene, your approach him to talk to him angrily and disrespectfully. That’s when you, Arman, try to leave her alone. Is this right?”
Arman: “But she really humiliates and insults my family and I.”
Therapist: “And when you get upset, what do you do?”
Arman: “I try to get myself out of that situation. I go somewhere I feel more comfortable.”
Therapist: “You go off on your own, right?”
Arman: “That is the only way I can prevent a big conflict from occurring. Isn’t it?”
Therapist: “That feels like that is the only thing you can do, leave the scene, and get comfort at your mom’s house. Ok, Irene, what is that like for you?”
Irene: “For me? Who cares about me? I am on my own. I have always been on my own.”
Then in steps 3 & 4, as Susan suggested, I tried to access the unacknowledged emotions underlying interactional positions and also reframing the problem in terms of the negative cycle, the underlying emotions, and attachment needs (Johnson, 2004). The goal of these two steps of therapy is to help couples tune in to the music of the dance by listening to their primary emotions (Johnson, Bradley, Furrow, Lee, & Palmer, 2005). In fact in these two steps, I helped the couple understand their problem by realizing the pattern of their relationship cycle that is influenced by emotional response’s of each of them and also their attachment needs. As Susan noted, if therapy stops here, the assumption is that the couple will tend to relapse (Johnson, & Whiffen, 1999). Using these steps, I then helped Arman & Irene to see the cycle of negative interactions that has ruined their relationship. Irene sees Arman as selfish and withdrawn while Arman finds Irene bossy, disrespectful and judgmental. The more this cycle continues in their relationship, the more physical and emotional distance occurs between the couple. In the fifth session, when the cycle had already been identified for the couple, I tried to refer to their cycle as the enemy that takes over the couple’s relationship as opposed to the relationship itself (Johnson, Bradley, Furrow, Lee, & Palmer, 2005). In these steps couple’s responses tend to be less reactive and more flexible, however the organization of the dance between them has not changed (Johnson, & Whiffen, 1999). The couple came to the fifth session while they both felt disappointed.
Irene: “This weekend we were supposed to spend time together in order to plan our wedding. His mom called him and asked him to go back home to do something, and he just left me alone and went to his mom’s house. Before he left, I tried to talk to him and convince him to stay, because he has already promised me last week, but it did not work and he left me, without even any explanation. He left me alone and slammed the door on his way out.”
Arman: “You didn’t talk to me. You yelled at me. I have not had a good weekend either. I had to go to help my brother, because my mom asked me to do that. I couldn’t say no to her, and I expected you to understand my situation.”
Irene: “All I did was just ask you to stay with me for the weekend. You left me with all the wedding preparations. Alone and by myself.”
Therapist: (validating) “It seems that this incident hurts your feelings Irene; did you get the feeling that you are alone again? That you are on your own?”
Irene: “It is true. I need him to be with me. I feel alone. I always feel that way. In my whole life I have been alone, and even now” (She starts crying) “Nobody cares about me. Nobody loves me.”
Therapist: (Validation) “I can understand that. That must be very hard for you. I could feel your sadness and frustration, feeling lonely your whole life. It must be very frustrating.”
Irene: “When he leaves me after we have argued about something, I get frustrated. I get angry.”
Therapist: “And when he withdraws, goes silent or leaves you alone, you Irene usually go after him, yelling at him?”
Irene: “Yes, he can’t ignore me. He has to listen to me.”
Therapist: “And you show your feelings with anger? By yelling at him, right?”
Irene: “Maybe!”
Arman: “And then the only way that I have is to withdraw even more. Leave the place that makes me nervous and overwhelmed. I just give up.”
Therapist: “So, at this point the cycle kicks in, and you both are left far away from each other with all these emotions that the other doesn’t know about.”
I think here is where the couple should have opened the conversation about their emotions and exchange them with each other:
Irene: “I feel that he is also ignoring me, he doesn’t love me, I am unimportant to everybody, like I was for my mom and dad.”
Arman: “But I do not mean to hurt your felling at all. I just can’t tolerate yelling. I feel humiliated and disrespected.”
By the end of these two steps, the couple was starting to be emotionally engaged with each other. As Susan noted “the couple are engaged in a new kind of dialogue about emotions, attachment issues, cycles, and how these all go together” (Johnson, 2004).
Stage two: Changing Interactional Positions
Steps 5 &6: In these steps I was promoting identification with disowned attachment needs, such as the need for comfort and reassurance, and aspects of self such as a sense of unworthiness and shame. Furthermore I integrated these into relationship interactions and also promoted acceptance of the partners’ new construction of experience and his or her new responses by the other spouse (Johnson, & Whiffen, 1999).
Therapist: “When he leaves you after an argument, what feelings do you have?”
Irene: “I feel he doesn’t love me. He probably is not sure about marrying me. He doesn’t want me. Maybe he loves someone else.”
Arman: “Since our relationship got serious I have never thought about anyone but you. Why would you even think about that?”
Irene: “Because you never asked me to make love. We have been together for more than a year and you have never even asked me to make love, you have never even kissed my lips, not even once.”
Arman: “But you know my cultural restrictions. I explained it to you several times. Didn’t I? I am eager to make love to you as soon as possible. I really love to.”
Therapist: “Could you, Arman, explain a little bit about the impact of your culture in the subject of having intimate relationships with your partner?”
Arman: “I am a Muslim, and in my culture, men and women shouldn’t have intimate relationships before they get officially married. I have already explained it to her and asked her to respect my beliefs.”
Therapist: “What’s happening right now, Irene? You don’t look angry now? What happened to you? How do you feel now?”
Irene: “Yes, he explained his restrictions to me, but I don’t know, I feel, I just can’t believe him.”
Therapist: “How about now? Can you believe him?”
Irene: “I guess so. I am not sure, I don’t know. You know it really doesn’t matter if he doesn’t love me; it is just like others who don’t either.”
Irene seems like she is dealing with a dilemma inside of herself that she is fighting with. I tried to help her to realize this dilemma and overcome it.
Therapist: “Is that right? Does it not matter to be important and special to someone? Especially to him, as your husband?”
Irene: “I have never been special to anyone. I just give up. Thinking about this subject makes me angry. I have no more energy to fight for being loved, being important to someone.”
Therapist: “You can’t trust anyone. I understand how difficult it may be for you to be in this situation. While you can’t trust anybody, you love to trust him. You want to prove to yourself that he loves you. Isn’t that right?”
Irene: (crying) “Yes, I think that’s it. I love him and I would love to keep him for myself. I wish I could trust him and his love.”
Therapist: “Can you tell him that you love him this much and you are trying to trust him, that you need his help in this process?”
Then after Irene manifested her feeling to Arman directly, I turned to Arman in order to promote his attachment needs as well.
Therapist: “Arman, what would you like to share as you listen to Irene? How do you feel now?”
Arman: “I feel confused. I don’t know how I should prove myself and my love to her, while I also do not feel satisfied with our relationship.”
Therapist: “Do you really want to know how you can show your love to her? Ask her now?”
Arman: “How can I show you that I really love you? How can you trust me and my love?”
Irene: “I feel so lonely; please don’t ignore me when I need you. Talk to me and let me talk to you. I need you Arman, I need your love and your attention.”
Arman: “But you make me feel overwhelmed when you yell at me.”
By the end of these two steps, I promoted acceptance of Irene and Arman’s new construction of experience and also their new responses to each other.
Step 7: in this step, I facilitated the expression of specific need and wants and the creation of emotional engagement. By the end of this step, the goal is to have Arman as a withdrawn partner reengaged in the relationship and actively state the term of this reengagement and to have Irene as the more blaming partner soften up (Gurman, 2008).Then I will help Arman access his primary emotions that are not usually on a person’s awareness by asking him about his feelings when Irene yells at him and says something about his family.
Therapist: “What do you mean by feeling overwhelmed, Arman?”
Arman: “I mean I can’t tolerate the humiliation anymore. And even though I was born in Canada, I am different from pure Canadian people. And from Irene too. My culture is different and the way that I have grown up is different. Since I remember everybody has always humiliated me. My friends, classmates always said that I am not mature enough to take care of myself. I feel so inadequate, so overwhelmed. Irene always keeps telling me that I am looking at my mom’s mouth, she believes that I can’t make a decision by myself. I feel that everybody including Irene is judging me and criticizing me and my family because we are different from them or because I am not good enough to take care of myself. I don’t know! I am confused! You know, feeling different is not good at all.”
Therapist: “And when Irene yells at you, you prefer to leave the scene, instead of staying there and explain your feeling. Is that right?”
Arman: “Yes, at least this way I will go somewhere that gives me more comfort, like my childhood. I feel safe and secure with my mom and my family because they never yell at me. They understand me and my differences, they never judge me. I have never wanted to hurt Irene though. She is my love.”
Therapist: “How do you feel now Irene?”
Irene: “I feel sad and sorry.”
Therapist: “Could you please tell him how your feeling?”
Irene: “I am sorry Arman, I didn’t know that is how do you feel when I yell, I didn’t know what feelings I spur in you when I talk to you like that, and when I verbally attack your family.”
Therapist: “Arman, what do you want to ask Irene from the bottom of your heart? Could you please say it to her directly?”
Arman: If you stop criticizing me, while I need your understanding and your comfort, then I will have a chance to show my love for you. Please trust me and my love. I am trying to not escape from the situations that bother me, in order to not give you such a bad feeling, such as ‘I will leave you alone for ever or you are not loveable’. It is not true Irene. I need your help to do that.”
As it has been argued in studies of Kobak, Ruckdeschel & Hzan, 1994 and cited by Susan (Johnson, 2004), in step 7, partners will be able to present their specific requests in a way that pulls the spouse toward them and also maximizes the possibility that this spouse will be able to respond to them.
Therapist: “How do you feel Irene? Please tell him what it is that you want from him.”
Irene: “It is hard to say that, you know Arman, I want to be held. I need you to be close to me. I want you to trust me and look at me like you look at your family who come from the same culture. Don’t look at me like an other. I need your love. Please show me that I am special to you. Arman, I know that I need to change my reactions when I feel lonely, in order to do that I need your help. Be with me and hold me tight.”
These steps as we have seen through the above dialogs created new and positive cycles. They also developed engagement that Arman & Irene would encourage themselves to use instead of their old negative cycles. As Lebow noted, however, this stage-change event, is one of the more difficult tasks in EFT, and may result in the therapist becoming stuck (Lebow, 2005).
Stage 3: Consolidation and Integration
Steps 8 & 9: In these final phases of EFT I helped couples find new solutions to their old problem (step 8) and consolidate their new interaction cycles and integrate them into their everyday lives (step 9) (Lebow, 2005). In fact my goal in these steps was to identify and support healthy patterns of interaction. As it has been discussed by Susan the role of therapists in these steps is to validate the new emotions and responses that the couple share and enact (Johnson, 2004). In these steps, particularly in step 9, I tried to give a summary of my understanding about their new interactions and pass it on to them. I also suggested to them some new interaction methods instead of their old ones.
Therapist: “You know Arman, I really congratulate you. You have been able to find and identify the impulse that forces you to withdraw from the situations that bother you and also for sharing and reaching for Irene.
Arman: “Thank you for helping us. By using the advice you gave us in our last session we now can almost overcome our problems as long as we stay emotionally open to each other. Since the last session, I have never left Irene. Even when a distress occurs, we sit together and help each other to find our primary emotion that has caused this problem. We are now able to identify our relationship’s negative cycle.”
Therapist: “And how about you Irene? Do you feel better now?”
Irene: “Yes, of course. And, since our last session, I have never yelled at him. Rather, I tried to get more familiar with his culture by being more close to his family. I feel now that Arman really loves me. By the way, regarding our old problem, I mean our wedding plan and his mom’s issue; as you suggested, we divided our wedding plan into several tasks and asked his mom to take care of some of them. Particularly, those that are more related to his cultural issues.”
Section Three: Presenting a question & Description of my learning in completing this case study
* I would like to ask a question that will possibly stick with me as a beginning EFT therapist. As we know cultural beliefs may have harmful effects on couples’ relationships, particularly when those beliefs are different between them. The question which arises is whether or not this issue might affect the process of change in the therapy. If so, as an EFT therapist how should we deal with it?
* Before I tried to complete this case study, I was under the strong impression that reading and studying the materials that have been written to illustrate this new approach of couple and family therapy is good enough in order to be a good EFT therapist. However, completing this case study by making a dialogue which was in accordance with the EFT’s theory, taught me the language of EFT and attachment more clearly. Furthermore this made a notable impact on my understanding of the EFT method. Where I put the theory into the intervention process and made a related conversation, it gave me a better understanding of EFT in practice. I am now sure that if I have a chance to practice these techniques in real situations they will make a huge difference. Now I completely agree with the notion that Emotionally Focused Therapy is an experiential therapy and learning EFT is an experiential process. Through the first stage, I tried to trace the couple communication patterns, by recognizing the trigger points, exploring and understanding the basis for the triggers, recognizing trigger points, unlatching from rigid unhealthy patterns of behavior, diffusing conflict, and also by helping them recognize that their partner is not the enemy; the two of them are struggling together. In Stage 2, I tried to build on the platform of connection I have already established in the first stage of therapy. I helped the couple develop new ways of expressing themselves that don’t evoke their triggers and set off the old negative patterns. And finally in stage 3, I strengthened their new patterns of communication by applying them to previously unresolved issues.
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