A. Emotion-focused family therapy
The experiential models of family therapy developed from the phenomenological theories, highlighting the immediacy of the therapeutic encounter, “in the present” emotional processing, addressing emotional suppression, getting in touch with one’s inner world, and increasing awareness of vulnerabilities. The experiential models are less systemic in nature, don’t reflect a strict theoretical standpoint, and emphasize different aspects than the other family therapies based on cognitive and behavioral approaches or social constructivist theory. In their humanistic aspect, the experiential models propose a customized approach to the needs and specific goals of the client, auto-determination and self-fulfillment. In the mid-1980s, Susan Johnson and Leslie Greenberg developed a new experiential approach, the emotionally focused couple therapy (EFCT), having roots in the attachment theory and combining affective expression and relational availability with the attachment responses. These two authors are notable for their efforts to research the principles of the emotionally focused couple therapy and demonstrate its effectiveness (Goldberg & Goldberg, 2012).
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To date, research has established that EFCT has one of the strongest empirical support of all family therapies, which fulfills and sometimes exceeds the guidelines for an evidence-based couple therapy (Wiebe & Johnson, 2016). Founders of the EFCT advance the idea that EFCT offers an original perspective to the family and couple therapy, based on new scientific findings (Johnson & Wittenborg, 2012). Basically, the emotionally focused couple therapy (EFCT) is a process integrating humanistic and existential principles (client-centered, free will, eliciting empathic responses), Gestalt therapy (increasing awareness through present emotional experience), Satir’s congruent communication, and Bowlby’s attachment theory with application to adult couples. Therapist’s role in the EFCT is to facilitate emotional communication and processing between the clients who learn how to recognize dysfunctional patterns and what triggers in them emotional reactivity. Clients are guided and encouraged to explore their emotional responses in the moment, which leads them to become comfortable in understanding and accepting vulnerabilities, respond compassionately to each other, and change inflexible behaviors (Goldberg & Goldberg, 2012). Process of change in EFCT takes place in three stages which include de-escalating negative cycles, changing relational attitudes, by getting involved the withdrawn partners and softening those who criticize, and consolidation and integration of positive outcomes (Johnson & Boisvert, 2002).
John Bowlby’s attachment theory had an important contribution to the development of EFCT. Bowlby described how early interactions with caregivers shape the quality of future relationships (Holmes, 2014). The emotionally focused couples therapy applies these concepts to distressed adult couple relationships, in the context of attachment anxiety and attachment avoidance (Johnson, 2004). People experiencing attachment anxiety or attachment anxiety are more likely to express emotional hyperactivation, be involved in troubled or distrustful relationships and affairs, blaming the partners for relationship difficulties, avoiding intimacy or have unfulfilling sexual relations, and withdraw emotionally from the relationship contract. Emotionally focused couples therapy works on the premise that changing these anxious and avoidant attachments into secure attachments will lead couples to more satisfying relationships. In the course of emotionally focused couple therapy, clients identify negative emotional patterns blocking their relationship and then reprocess these barriers to create more secure attachments. In doing this, clients redefine those emotional experiences from a new perspective, getting a new understanding of their own emotional needs and their partners. Thus, new patterns of interaction are formed, based on stronger and more genuine emotional bonds.
Proponents of the EFCT boast compelling evidence in support of the effectiveness of their model, beyond outcomes of any other therapeutic approach, with 86-90% of couples experiencing significant improvements and 70-73% of the couples reporting recovery from distress. Research shows that a general good predictor of successful therapy is a variable called “softening”, which describes the empathic response of partners reaching out one to another as a result of expressions of emotional vulnerability. This is particularly important in resolving relationship conflicts (Meneses & Greenberg, 2011). It is believed that the positive lasting and reliable outcomes are due to EFCT effectively helping couples to form a secure emotional attachment (Johnson & Wittenborg, 2012). It appears that studies show stable relationship improvement and decreases in attachment anxiety. A two-year follow-up of a study of parents with chronically ill children evidenced 38.5% of couples continued to improve on their relationship (Cloutier et al., 2002). Another long-term follow-up study showed that after taking EFCT, couples which experienced “attachment injuries” (infidelity or abandonment at a difficult time) regained trust, reached relationship satisfaction, and forgiveness (Halchuk, Makinen, & Johnson, 2010). Research performed on the EFCT client change process revealed how couples experience forgiveness and reconciliation in therapy. In cases of attachment injuries (hurtful betrayal of relationship), it was found that clients who are deeply engaged with their intrapsychic experience are more likely to reconnect with their partners (Zuccarini, Johnson, Dalgleish, & Makinen, 2013).
Burgess Moser et al. (2016) conducted research to verify changes in relation-specific attachment in the process of EFCT and the results showed decrease in attachment anxiety and avoidance, with a move toward a more secure bond. Another study measuring relationship functioning and relation-specific attachment levels pre- and post-therapy found that attachment anxiety decreased because of EFCT, with further improvements throughout follow-up, although it was not the same with the attachment avoidance. The relation-specific attachment avoidance was found to be lower throughout follow-up compared to pre-therapy (Wiebe et al., 2017). However, a new study is challenging empirical evidence supporting the assertion that EFCT facilitates changes in attachment for clients involved in EFCT. Researchers examined 461 couples in an eight-session EFCT and found relative constant attachment anxiety and avoidance scores throughout therapy. These seem to be in line with previous studies showing that we cannot be definitive and conclude that therapy can change attachment (Benson et al., 2013; Seedall & Wampler, 2013; Johnson et al., 2016).
Emotionally focused therapy with couples (EFCT) was found effective in treatment of various couple populations from different cultures, sexual orientations, or spiritual beliefs (Johnson, Bradley, & Furrow, 2011; Furrow, Johnson, Bradley, & Amodeo, 2011). Effectiveness of EFCT was demonstrated in practice with couples facing relationship distress because of partners struggling with depression, both men and women (Dessaulles, Johnson, & Denton, 2003; Wittenborg, Culpepper, & Liu, 2012), military relationships of those affected by PTSD (Blow, Curtis, Wittenborg, & Gurman, 2015), survivors of childhood abuse (Dalton, Greenman, Classe, & Johnson, 2013), couples with family members diagnosed with chronic illness, terminal illness, neurodegenerative, or other medical conditions (Walker, Johnson, Manion, & Cloutier, 1996; Tie & Poulsen, 2013; Ghedin et al., 2017; Fitzgerald & Thomas, 2012). EFCT was applied successfully in cases of couples having one partner struggling with sexual addiction (Love, Moore, & Stanish, 2016), improving sexual relationships of couples during and after cancer (Grayer, 2016), or increasing sexual satisfaction of infertile couples with marital conflicts (Soleimani et al., 2015). “Hold Me Tight” is a relationship enhancement psychoeducational program for couples based on the principles of EFCT. Program’s effectiveness was demonstrated by improving intimate relationship, relationship satisfaction, emotional bond, forgiveness, and behavioral functioning (Khan, 2018; Conradi, Dingemanse, Noordhof, Finkenauer, & Kamphuis, 2018). Emotion-focused family therapy (EFFT) has wide applications. For example, when used in a children’s mental health center, EFFT did augment the effects of solution-focused therapy (Efron, 2004), enhanced best practices in treatment of eating disorders in case of children and adolescents (Robinson, Dolhanty, & Greenberg, 2013), and provided a successful two-day intervention strategy in helping families with members experiencing eating disorders (Robinson et al., 2016).
B. Solution-focused family therapy
Solution-focused therapy (SFT) was developed in the 1980’s by researchers at the Brief Family Therapy Center in Milwaukee, Wisconsin, influenced by the activity of the Mental Research Institute in Palo Alto, California and the work of Milton Erickson who stressed the importance of utilizing client’s resourcefulness (Gurman, 2008). Solution-focused brief therapy (SFBT) is a postmodern model based on a social constructivist approach and the power of language to create solutions and effect change by helping the client to describe life in new perspectives (Miller, 1997). SFBT is a strength-based approach highlighting client’s goals, creativity, hope, and gradual improvement, with the therapist acting as a skilled facilitator engaging the client with interactive solution-focused questions: the miracle question, exception question, pretreatment question, scaling question, or coping questions. De Jong and Berg (2008) outlined five stages of therapy: defining the issue, identifying clear goals, exploring exceptions, end-of-session feedback, and scaling progress. SFBT is also hope-focused. Clients are responsible to develop well defined goals and encouraged to have hopeful expectations that they hold the solution to their problem (de Shazer, 1985).
Language utilized in formulation of questions is such paramount that can lead to effective therapeutic change. A cross-cultural study showed significant increase in self-efficacy, goal orientation, and action steps, with significant decrease of negative affect when clients were asked solution-focused as opposed to problem-focused questions (Neipp, Beyebach, Nuñez, & Martínez-González, 2016). Utilizing solution-focused questions and avoiding problem-focused questions during the intake procedures can influence the information that the clients present at the interview and even produce pre-treatment change (Richmond, Jordan, Bischof, & Sauer, 2014). In a qualitative study, it was observed that after clients report no improvement in previous therapy sessions, focusing on the positive as opposed to negative topics in the follow-up conversations can be helpful (Sanchez-Prada & Meyebach, 2014). SFBT’s therapeutic techniques have been the subject of many studies. McKeel (2012) did a review on the process change research and found that solution-focused conversation, presuppositional questions, and instillation of hope and positive expectations are precursors of change. Another systematic review published in 2016 examined the process research of SFBT and found strong scientific support for SFBT practice, especially for SFBT techniques combined: strength and resources, future-oriented, and multiple techniques. The review supports previous studies showing the uniqueness of language-oriented techniques of SFBT, which are distinct from other strategies, like MI or CBT (Franklin, Zhang, Froerer, & Johnson 2017).
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A review of the literature between 1990 and 2010 revealed that SFBT was tentatively effective as an early intervention in families with children having internalizing and externalizing behavior issues. Most of the well-evidenced studies came from USA, UK, Australia, Canada, Cyprus, Lithuania, Norway, Romania, Sweden, Hong Kong, and Korea. SFBT was often used in combination with other approaches. Only five high-quality studies were identified, which does not represent an enough strong evidence base. Some of the studies dealt with the therapeutic process rather than the results. It was suggested that more controlled studies are needed (Bond, Woods, Humphrey, Symes, & Green, 2013).
Since both SFBT and experiential family therapy are strength-based approaches, they can be integrated successfully, or at least some of the techniques. For example, solution-based family sculpting can facilitate the client to move from words to images, thus expanding the repertoire of possible solutions (Reiter, 2016). SFBT and Motivational Interviewing (MI) are utilized extensively in medical therapy. Because of the similarities of these approaches, evidence was established for effective integration of SFBT and MI in helping patients deal with ambivalence in a solution-oriented medical treatment setting (Stermensky & Brown, 2014).
C. Compare EFCT and SFBT
Emotions are not neglected in SFBT. Although SFBT does not appear to deal with emotions, attachment, or self-concept, de Shazer, founder of SFT, asserts that helping clients to create new emotion rules to follow can enhance the solution-building process (Miller & de Shazer, 2000). One way of doing this is by utilizing enactments, which can lead clients to construct new emotions and access more exceptions (Seedall, 2009). From a contextual and social constructivist perspective, positive emotions like hope, happiness, joy, gratitude, faith, courage, trust, pride, and interest can play an important role in the SFBT process of change by making clients to remember and keep those feelings connected to the context of the conversation (Kim & Franklin, 2015).
There are some commonalities between EFCT and SFBT. Both models are relatively short-term, strength-based, and looking for the reduction of presenting problem behavior, they are client-centered, less directive, and respectful. EFCT and SFBT increase couple resourcefulness by improving communication style, problem-solving skills, and coping skills. Clients experience improvement in fulfillment of psychological needs, intimacy, trust, and ability to interact successfully with social systems. EFCT and SFBT have strong support for their efficacy and even inexperienced therapists can manage to apply their principles and obtain positive results. Although SFBT is not interested in increasing awareness and insight into presenting problem or weaknesses, both therapies lead to new perceptions and new meanings that can facilitate change. EFCT and SFBT are theory-based models, relatively structured, using specific techniques which are applied systematically, as a series of therapeutic tasks.
There are also notable differences between EFCT and SFBT. EFCT is based in the humanistic-existential tradition, insight-, in-the-moment-, vulnerabilities-, and problem-oriented. SFBT is a postmodern, social constructivist approach, future-, solution-, hope-, and strength-oriented. In EFCT, clients discover meaning or co-create meaning mostly in session; through various tasks and homework, SFBT is looking to disrupt the patterns outside of the therapy. EFCT is paying attention to the emotional process, whereas SFBT is paying attention to the linguistic discourse to resolve the presenting problem and not working through the underlying emotional issues. In EFCT, clients pursue mediating, process goals, as opposed to SFBT, where clients set clearly defined goals aimed at solving the presenting problem. SFBT relies minimally on theory, is not interested in conceptualizing the abnormal, and has no theory to describe difficulties in a relation, while EFCT is strongly founded in the attachment theory. EFCT helps by increasing emotional awareness, meaning and attribution, SFBT focuses on behavioral change. EFCT elicits an empathetic response leading to an increased sense of safety, SFBT seeks exceptions to change stuck interactions.
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