critical incidents that help and hinder learning emotionally focused therapy for couples copy

8/3/2019 Critical Incidents That Help and Hinder Learning Emotionally Focused Therapy for Couples Copy

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Critical Incidents that Helpand Hinder Learning EmotionallyFocused Therapy for Couples

Danielle DuplassieChuck MackneeMeris W illiams

ABSTRACT. The study's purpose was to identify and categorize thefactors that helped or hindered therapists' ability to learn and implementEmotionally Focused Therapy (EFT) for Couples. Fourteen therapistswere interviewed using the Critical Incident Technique and asked to de-scribe experiences that had helped or hindered their learning process. Atotal of 532 critical incidents were documented, which were sorted into10 "helpful" and 8 "hindering" categories. Among the helpful factorswere exposure to and discussion of EFT concepts, the use of an onlinelistserv, and personal "fit" with model. Hindering factors included thera-

Danielle Duplassie, MA, is affiliated with the Department of Educational andCounseling Psychology and Special Education, University of British Columbia, Van-couver, British Columbia.Chuck Macknee, PhD, is affiliated with the Department of Psychology, TrinityWestern University, Lan|ley, British Columbia.Meris Williams, MA, is affiliated with the Department of Educational and Counsel-ing Psychology and Special Education, University of British Columbia, Vancouver,British Columbia.Address correspondence to: Danielle Duplassie at Department of Educational andCounseling Psychology and Special Education, 2125 Main M all, Scarfe Building, Uni-versity of British Colum bia, Vancouver, BC, Canada, V6T 1Z4 (E-mail: [email protected]).This paper is revised from the first author's thesis, submitted for partial fulfillmentfor the degree of Master of Arts in the Graduate Program in Counseling Psychology atTrinity Western U niversity, Langley, BC.Joumal of Couple & Relationship Therapy, Vol. 7(1) 2008


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JOURNAL OF COUPLE & RELATIONSHIP THERAPYpist anxiety about implementing EFT effectively, countertransferencereactions, and the therapist's personal distractions and limitations. Im-plications of the results for training EFT therapists are discussed, doi:doi: 10.1080/15332690802129689 [Article copies available for a fee from TheHaworth Document Delivery Service: l-800-HAWORTH. E-mail address: Website: 2008 by The Haw orth Press. All rights reserved.]

KEYWORDS. Therapist training. Emotionally Focused Therapy (EFT)for Couples, critical incidentTwo major goals of marital therapy are to help couples alleviate rela-tional distress and develop closer relationships. Currently, there is anincreased demand for efficacious psychotherapy (The University of York,1999), which has been informed by the argument that "unless re-search-based evidence and guidance is incorporated into practice, ef-forts to improve the quality of care [for clients] will be wasted" (p. 1). Anumber of empirically supported therapeutic interventions have been

designed to achieve the goals of marital therapy. However, a therapeuticintervention is only as effective as the therapist who delivers it.One model of marital therapy. Emotionally Focused Couples Ther-apy (EFT; Johnson & Greenberg, 1985), has demonstrated strong empi-rical support (e.g., Dandeneau & Johnson, 1994; Johnson, Maddeaux, &Blouin, 1998; Johnson & Greenberg, 1988; Walker, Johnson, M anion,& Cloutier, 1996). EFTT views relationships from an attachment per-spective, which has been described as "the most promising theory ofadult love" (Johnson, Hunsley, Greenberg, & Schindler, 1999, p. 68).The goals of EFT are to increase awareness of oneself and one's partner,heighten emotional intimacy, and create new, positive interaction cy-cles that help couples cope effectively with conflict.EFT for Couples has been shown to be efficacious with a variety ofpopulations. An early study demonstrated that EFT reduced relationaldistress among 14 couples (Johnson & Greenberg, 1985). Walker andcolleagues (1996) found that, for couples with chronically ill children,the EFT approach was helpful in increasing marital accord (which wasmaintained for at least 5 months after therapy). Using a randomized de-sign, Dandeneau and Johnson (1994) compared EFT with Cognitive


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Duplassie, Macknee, and Williams 3EFT was effective in advancing marital satisfaction even when admin-istered by novice therapists in a training clinic.Several articles have outlined other possible uses of EFT. It has beensuggested that EFT be used to address couples' sexual issues (MacPhee,Johnson, & Van Der Veer, 1995), the effects of trauma in relationships(e.g., Johnson, 2003a, 2003b; Johnson & Makinen, 2003; Johnson &Williams-Keeler, 1998), and the stress of chronic illness (e.g., Cloutier,Manion, Walker, & Johnson, 2002; Walker, Johnson, Manion, & Cloutier,1996). EFT has also been recommended for family issues (e.g., Dan-koski, 2001; Johnson & Best, 2003; Johnson, Maddeaux, & Blouin,1998; Johnson, 1998), depression (Dessaulles, Johnson, & Denton,2003), and can be integrated with other therapeutic theories or modali-ties (e.g., Vatcher & Bogo, 2001).Although EFT is being used increasingly with couples, only one con-ceptual article to date has addressed the process of becoming an EFTtherapist (Palmer & Johnson, 2002). Palmer and Johnson outlined thecomplexities of EFT and highlighted some of the struggles experiencedby therapists who were learning and implementing the model. Theauthors stated that effective practice of EFT entails both a strong thera-peutic alliance and the therapist's personal belief in the theoretical as-sumptions of EFT. Potential pitfalls included countertransference is-sues (e.g., feeling uncomfortable and not knowing how to respond tointense emotion); an inability to stay with and expand emotional responsesdue to lack of experience with the model; and difficulty implementingsimultaneous interventions. The authors emphasized the importance ofsupervision while learning EFT. Specifically, they recommended thatsupervision incorporate discussions of EFT theory and practice, andprovide a safe place for trainees to explore and reflect upon their ownreactions during the therapy process.

Although Palmer and Johnson (2002) provided a useful first step indescribing the potential challenges experienced by EFT trainees, scantattention has been paid to the factors that influence a trainee's ability tolearn the model. The purpose of the current study was to explore the ex-periences and events that helped or hindered therapists' ability to learnand implement EFT for Couples. An understanding of these factors


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4 JOURNAL OF COUPLE & RELATIONSHIP THERAPYMETHOD

The Critical Incident Technique (CIT; Flanagan, 1954) is a qualita-tive approach that focuses on an individual's personal experience of aparticular phenomenon. It was originally developed to study U.S. AirForce pilots during World War 11. The CIT has been used to investigatea range of phenomena in psychology including the investigation of per-formance in psychology internships (Ross & Altmaier, 1990) and thedevelopment of a list of significant psychotherapist behaviors (Plutnick,Conte, & Karasu, 1994). Over the past 50 years, the CIT has seen in-creasing use and it is currently acknowledged as an effective tool forempirical investigation and exploration (Butterfield, Borgen, Amun-dson, & Maglio, 2005; Chell, 1998; Woolsey, 1986). In the currentstudy, the CIT was employed to investigate the experiences of EFTtherapists regarding what helped or hindered their ability to learn andimplement EFT. The approach entailed interviewing therapists whowere learning EFT and documenting the specific events and/or experi-ences (i.e., critical incidents [CIs]) that they perceived had helped orhindered this process.Participants

Fourteen participants (2 male and 12 female) were recruited viaword-of-mouth and an EFT electronic mailing list. All participants hadcompleted EFT training within the past three years. They ranged in agefrom 26 to 67 years (M = 4\ .6). Their overall clinical experience rangedfrom 2 to 46 years (M = 15.9), and their experience with EFT rangedfrom 6 months to 3 years (M = 1.6 years). Participants were recruitedfrom a variety of geographical areas in North America including theprovinces of Alberta (1 participant), British Columbia (8 participants),Ontario (2 participants), and Quebec (1 participant) in Canada, and thestate of Texas in the United States (2 participants).Procedure

Each participant was interviewed once, in person, using a semi-struc-tured format. The average length of the interviews was approximately45 minutes. Participants were asked to recall specific events and experi-


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Duplassie, Macknee, and Williams 5transcribed by the first author. Subsequently, CIs were extracted fromthe transcribed accounts. Following Woolsey's (1986) analysis, the CIswere extracted if they demonstrated clear context, specificity, and out-come. They were then recorded onto separate pieces of paper and cate-gorized according to the type of event/experience, the source andcontext of the event/experience, and the outcome (i.e., helped or hin-dered the learning and implementation of EFT). In keeping withFlanagan's (1954) method of categorization, 15% of the CIs were setaside for a validity check. In a CIT study, validity refers to whether thecategories correctly capture the real meaning of the stories and incidentsshared by the participants (i.e. the categories' "trueness"). The validityof categories can also be gauged by assessing the results in relation tothe findings of previous research (Woolsey, 1986), which will be ad-dressed in the Discussion. A reliability check (i.e., inter-rater agree-ment) was also conducted in which an independent sorter categorized arandom sample of 80 items into the established categories. Anderssonand Nilsson (1964) recommend a minimum of 75% inter-rateragreement.

RESULTSA total of 532 CIs were extracted from the transcribed audiotapes.The firstauthor sorted the CIs by similarity into a set of categories as perFlanagan (1954) and Woolsey (1986). These categories underwent sev-eral modifications until all CIs were sorted. A final scheme of 18 cate-gories accommodated all 532 CIs. Of the 18 categories, 10 representedfactors that were helpful to the therapist's ability to learn and implement

EFT for Couples and 8 categories represented factors that were unhelp-ful in this regard.Category Descriptions and Characteristics

HelpfulFactors. Table 1 summarizes the 10 categories (comprised of238 incidents) that represented factors that were helpful for therapistslearning and implementing EFT for Couples. Appearing in the table arecategory descriptions, the number of CIs in the category and the inci-dence rate, the number of participants who provided CIs and the inci-


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6 JOURNAL OF COUPLE & RELATIONSHIP THERAPY

TABLE 1. Category Descriptions and Characteristics-Heipful Factors in LearningEFT

1

2

3

4

5

6

7

a

9

10

CategotYNameDiscussing/Consultingwiih EFTPractitionersPersonalAgreementwitli TheoryReading lorDirection andtoUnderstandAudio/VisualExposure

PracticingEFTInterventions

Confirmationof Model inWork will!Clients

UsingPersonalResources

Confirmationol Model inTherapists'Ow nRelationship

EFTFramework/Steps

Access to

CategoryDescriptionDiscussion of thetheory/ practice of EFTwith other practitionersand receiving feedbackThe m odel "clicked*with the therapist'spersonality, values,theoreticai orientationThe therapist m advarious materials (e,g,,articles, books. E Rtraining manual)The therapist wa tchedvideo tapes and iiveEFT therapy sessions,or listened toaudiotapes.

The therapist practicedEFT interventions withdifferent clients andsituations

The therapist realizedthat the model "fit" withclients' experiencesand change processes

The therapist usedpersonal resources(e,g,, being genuine intherapy, self-reassurance) todecrease anxietyTl o therapist rea lizedhow the model appliedin his/her ownrelationships

The steps andstructure of EFTprovided the therapistwith direction in termsof defining therapeuticgoats and conductingtherapy sessionsThe therapist had

Clfreq,;IR52;22%36;15%

34;14%

34;14%

19;a%

ia;6%

15;6%

13;5%

12;5%

5:2%

Participantfreq,; IR

13; 93%

12; 88%

14; 100%

12; 88 %

8; 57%

9; 64%

8; 57%

8; 57 %

8; 57%

2; 14%

Sample ;Cis i1 wili be getting together with people, doing a lot of italking, brainstoniting,,. Collaborating, networking i[works], 1I really believe in [the theory], 1 reaiiy think thiat it's got ;great poten tial,, ,it's what's needed specifically for our jway of interacting and our attachmen t issues and al) of ithat, 1 think it can be very powe riui, ;1 think looking at [the book] and going to eac li one of jthe steps and seeing, for instance, in the [training] ibinde r-it had different types of ways to ask questions; idifferent things that we could expect to happen and jthat was helpfu l, i1 vtfatched my last two tapes with a ciient, and then I :watched Sue's first and third teaching tapes. And I'm igoing to do that again and again because i see what 1 idid and 1 see what she does and I can get clearer and |clearer about,.,


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Duplassie, Macknee, and Williams 7TABLE 2. Category Descriptions and Characteristics-Hindering Factors inLearning EFT

#1

2

3

4

5

6

7

8

Note.

CategoryNameLack ofExperioncowith Model

Lack ofDiscussion/Consultation

Feelings o fAnxietyand/orPressureaboutEmployingEFT ProperlyPersonalReactions toCliontsand/orCounter-transferencePersonalDistractionsand/orLimitationsLack ofBelief in theModel/TheorVInsuffldentAudio and/orVisualModoting

EmotionaiConceptsDifficult toImplementwfth SomeCulturosand/orClients

CategoryDescriptionB IO therapist's lack ofexperience with EFTresults Ina lack ofconfidence,'stucknoss," and/orinability to graspconcepts/skillsA tack of opportunitiesfor the therapist todiscuss EFT theoryand practice withothersThe Iherepist'sfeelings of anxietyabout employing theEFT model correctly,and in response toclients' expectationsof the therapistThe therapist'sresponse to intenseemolion and/or thetriggering of his/herown Issues in thetherapy processThe therapist'spersonal limitations,indudingintra personal,interpersonai, andlogistical constraintsThe therapist's lack ofpersonal beliel tn theEFT theory/modelThe therapist'sinsufficient exposureto nKxJeling (iive,audioorvidoo}byother EFTprat::titioner8 and/ortrainers, and desire tosee a visual d iagramto explain the EFTprocessThe therapist'sdifficulty inimplementing themodel with certainclients, pariiailarlythose who do notconnect withemotional tanquaqe.

Cl freq.;iR

78; 27%

69; 23%

36; 12%

36; 12%

34; 12%

14; 5%

14:5%

13; 4%

IR = Incidence Rate. C l ^ Crit icul Incident.

Participantfreq.; iR14; 100%

14; 100%

13; 93%

12: B6%

11;7fl%

5; 36%

8:57%

5:36%

SampleCIS[A] hindrance would be my lack of experience. I'm fairiynew to all of this and i haven't had a lot of experiencewith therapy, in generai, iet alone couples therapy.

What 1 need is to have supervision...that gives mefeedback on, 'This is where you should be moving; thisis what youshould be saying; ttiis is where you shouldnnove; you're getting bogged down in content here;you're movinq too quickly here,"[A] huge hindrance is my ovm anxiety. You know, i'm inthe middie of a session and my couple starts freakingout at each other and I'm so caught up in the detailsthat I don't know where 1 am with the model, or whereI'm going, or what the goat is.

i think 1 become a bit afraid [of the anger). The anger, 1think tfiat has to do wllh my own personal discomfofiwittv-J guess it's pjirtiy being triggered in some things inmyseif-my own story.

[A) hindrance has been finances. You know, it costsmoney for supervision and., .training. That makes Itdifficult when I'm on a limited income.

1 know that 1 resist pure model-l have a hard time"following recipes when I'm cooking'-l like to throw thisIn and try this.Although the videos are helpfui, the videos that SueJohnson has put out, they're atso a bit of a hindrancebecause you have a 7&-minute session condensed into15 minutes. So 1 guess 1 don't know how a wholesession is supposed to kx)k.

Some ciients like having concrete suggestions or theyhave a different way of looking at things. They don'tprefer talidng about their emotional experiences. SoMflth those clients 1 have found it very challenging touso the model.

implementing EFT for Couples. Again, category descriptions are pre-


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8 JOURNAL OF COUPLE & RELATIONSHIP THERAPYReliability and Validity Analyses

In a reliability check, a random sample of 80 CIs (approximately15%) was drawn from the pool of 532. A counseling psychology stu-dent was provided with the title and a brief description of each categoryand was asked to place the 80 CIs into the 18 categories. The level ofagreement was found to be 89%, which exceeds the recommended levelof 75% (Andersson & Nilsson, 1964). A validity check consisted ofplacing another 80 CIs (which were set aside prior to sorting and cate-gorizing) into the 18 categories. This task was completed with no diffi-culty, which suggested a comprehensive category system.DISCUSSION

This study identified 10 categories of events and experiences thathelped therapists learn and implement EFT and 8 categories that hin-dered this process. The categories, as they relate to extant research, aredescribed below within the context of four main themes that emergedacross the categories: (1) Exposure to and Discussion of EFT Concepts,(2) Personal Experiences, (3) Agreement with the EFT Model/Theory,and (4) Framework and Structure of EFT.Theme 1: Exposure to and Discussion of EFT Concepts

Exposure to the EFT model was a major theme across several catego-ries. The categories included in this theme were: D iscussing/Consultingwith EFT Practitioners (1+), Reading for Direction and Understanding(3-I-), Audio/Visual Exposure (4+), Practicing EFT Interventions (5+),Access to Facilities and Clients (10+), Lack of Experience with Model( 1 - ) , Lack of Discussion/Consultation (2-), and Insufficient Audioand/ or Visual Modeling (7). The bracketed information refers to thecategory number and whether the category was helpful (+) or hindering( - ) . Specific helpful components included the therapist's reading of re-sources related to EFT and/or attachment theory; watching live therapysessions and/or videos of therapy sessions; discussing cases with col-leagues and supervisors; and practicing the model through role-playsand/or experimentation with clients. When therapists were unable togain sufficient exposure via these methods, they reported a lack of con-fidence in using EFT interventions.


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Duplassie, Macknee, and Williams 9cases) helped counselors develop their counseling skills and deepentheir theoretical understanding. Ray and Altekruse (2000) found thatsupervision in any form could be helpful to practitioners who werelearning therapeutic skills. O'Donovan and Dawe (2002) stated thatclinical practice, training manuals, and exercises designed to developconceptualization skills contributed to skill acquisition. Other research-ers have recommended the use of films to promote the development ofcounseling skills and conceptual understanding (Higgins & Dermer,2001; Toman & Rak, 2000; Tyler & Guth, 1999). Greenberg andGoldman (1988) stressed that "training is most effective when it in-cludes conceptual instruction, experiential learning, [and] skill trainingthat involves modeling and practice" (p. 698). The findings of the cur-rent study corroborate Palmer and Johnson's (2002) opinion that themore experience a therapist acquires, the more he/she will trust the pro-cess of, and feel confident in using, EFT. The literature described aboveunderscores the importance of using multiple strategies to help thera-pists grasp and implement EFT concepts. Insufficient use of a variety ofmethods (e.g., clinical practice, training manuals, supervision) couldcontribute to therapists' lack of learning and growth in developing EFTclinical skills.Kolb's (1984) experiential learning theory (in particular, the grasp-ing and transformational dimensions) may also be useful in situatingthe above findings. Kolb stated that knowledge is created through thetransformation of experience. He posited that learners grasp conceptsand information through concrete experience, abstract conceptualiza-tion (grasping components), reflective observations, and active experi-mentation (transforming components). Applied to the current study,Kolb's model suggests that direct, concrete contact with EFT throughreading and watching therapy sessions helped therapists grasp themodel through tangible means, which then impacted their internal re-flection and experimentation, thereby transforming their practice ofEFT. The process of reflection may have enabled the therapists to con-ceptualize their experience abstractly. For example, many participantsindicated that watching, reading, and/or discussing EFT helped themapply, in a practical manner, conceptual learning to their own clinicalcases. They subsequently experimented with this learning in therapysessions (active experimentation). Some participants explicitly statedthat the more they watched, read, and/or discussed cases and experi-


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10 JOURNAL OF COUPLE & RELATIONSHIP THERAPYpostulates that some learners grasp information more easily through so-cial stimuli. Such stimuli include working in pairs or groups, and/or un-der the supervision of an authority figure. All participants in the currentstudy identified the need to consult with others through peer consulta-tion and/or supervision with an EFT trainer. Participants who had op-portunities to receive peer supervision with colleagues or EFT trainersindicated that such contact facilitated their understanding of the EFTmodel and helped them implement it with greater ease in therapy ses-sions. Participants who reported insufficient opportunities to receive su-pervision associated this insufficiency with a lack of confidence andskill in using EFT. This finding provides support for Palmer and John-son's (2002) view that supervision is of crucial importance for EFTpractitioners-in-training. It may also be important that therapists receivesupervision and support after their initial EFT training, which couldfurther enhance their ability to learn and implement the model.

Several therapists referred to the helpfulness of an electronic mailinglist. CIs referring to the list were placed into the Discussing/Consultingwith EFT Practitioners category. The Internet has been identified as auseful tool for consultation among counselors and therapists. For exam-ple, in their investigation of e-mail supervision, Graf and Stebnicki(2002) found that e-mail supervision, combined with group and individ-ual supervision, helped therapists-in-training develop their skills.Each of the findings described above was experiential in nature. Thatis, the forms of exposure to EFT described by participants were "hands-on" interactions (e.g., direct contact with clients, reading, receiving su-pervision, watching live therapy sessions). Therefore, EFT trainers maywant to ensure that a variety of "hands on" learning activities are incor-porated into training activities. It may also be important to consider thatthe experiential nature of EFT may draw specific types of learners (e.g.,those who enjoy social stimuli and learn through experience).Theme 2: Personal Experiences

All participants in the study referred to personal experiences, whichsuggested the importance of the self in learning and implementing EFTskills and interventions. The categories included in this theme were: Us-ing Personal Resources (7-I-), Personal Reactions to Clients and/orCountertransference (4), and Personal Distractions and/or Limita-


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Duplassie, Macknee, and Williams 11mission to bring parts of their personal experiences into the therapy pro-cess, which helped them learn and implement the model with ease.Participants noted that implementing the EFT model without the anxi-ety of delivering it the "proper way" enabled them to be more fully pres-ent, which, in turn, permitted them to model genuineness to their clients.They reported that when their performance anxiety abated, they learnedthe model more easily. Similarly, Strupp and colleagues (1988) arguedthat skill acquisition involves personal involvement with clients andthat the more a therapist is able to bring him/herself into the process, themore competent he/she becomes. They argued that efficacy is notstrictly dependent on the use of techniques and/or specific interven-tions, and that therapists will learn more effectively when performanceanxiety is not present.In terms of hindering factors, participants indicated that personaland/or countertransference reactions were not helpful in the process oflearning and implementing EFT. For example, participants felt hin-dered when they did not know how to cope with a client's emotional re-sponses or when they felt uncomfortable about those responses due totheir own difficult emotional experiences. In their study of hinderingphenomena in group supervision, Enyedy and colleagues (2003) foundthat supervisees were hindered in their ability to learn group therapyskills when they experienced personal reactions to group members,co-therapists, and supervisors. In a study investigating trainees' per-spectives on learning empathic communication, Nerdrum and Ronnestad(2002) noted that empathic interventions led to more involvement on thepart of the therapist, which could prove challenging for the therapistwhen the client expressed a highly negative emotion. The participants inthat study reported that such clients contributed to strains and chal-lenges for the therapist while the therapist learned empathic inter-ventions. However, participants indicated that such challenges were ne-cessary for their overall learning. Palmer and Johnson (2002) also statedthat therapists who experienced countertransference and/or personal re-actions during therapy had difficulty implementing EFT interventions.The current study, using therapists' own perspectives, supports and ex-pands upon this idea.In the research literature, there has been scant attention given to thetherapist's own personal distractions or limitations. In the current study,the CIs included in the Personal Distractions and/or Limitations cate-


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riers, lack of time and/or financial resources, an insufficient number cli-ents with whom to utilize the model, personal life stress, lack of officespace, and difficulty integrating the model into their existing theoreticalorientation) made it challenging for them to focus on their learning pro-cess, and contributed to their inability to fully grasp and/or implementEFT interventions.The above findings suggest that the incorporation of training activi-ties that address the personal experiences of EFT trainees (e.g., how atherapist might bring parts of his/her experience into the therapy pro-cess; how to cope with countertransference issues, distractions, and per-ceived limitations) could assist trainees in learning and implementingthe EFT model.Theme 3: Agreement with the EFT Model/Theory

The categories included in this theme were: Personal Agreementwith Theory (2+), Confirmation of Model in Work with Clients (6+),Confirmation of Model in Therapists' Own Relationships (8->-), Lack ofBelief in the Model/Theory (6), and Emotional Concepts Difficult toImplement with Some Cultures and/or Clients (8). Participants re-ported that, as they began to perceive the model and theory of EFT oper-ating in "real life," they were increasingly able to agree with, believe,and invest in the principles of the model. That is, therapists came to be-lieve in the EFT model/theory, in part, due to witnessing its applicabil-ity and "fit" with their own, and their clients', lives and relationships.These findings support Palmer and Johnson's (2002) assertion that,"becoming an EFT therapist will be less of a challenge if the therapist'sgeneral perspective on relationship problems and therapeutic change isconsonant with, or at least not contrary to, the assumptions of EFT"(p. 3). Moreover, they suggested that EFT would be difficult to learn ifthe principles of the model did not fit with the personal style of the ther-apist.Nerdrum and Ronnestad (2002) found that observing clients' experi-ences helped the therapist learn therapeutic interventions. For example,the therapist participants in their study reported that their observation ofthe effects of empathic communication on clients helped the therapistsacquire a more complete understanding of therapeutic m echanisms. Theauthors also found that therapists' own experiences of being a client in


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Duplassie, Macknee, and Williams 13Skovholt and McCarthy (1988) found that clients were able to contrib-ute to the therapist's skill development through their reactions to, andsuccesses and failures with, clinical interventions. The authors reportedthat undergoing personal therapy aided therapists in their skill develop-ment because it increased their understanding of what was helpful intheir own therapeutic process. The findings of the current study suggestthat EFT trainees could benefit from ongoing opportunities to assesswhether EFT "fits" with their own beliefs about relationships as well asthe ability of EFT to explain, and assist with, their clients' relationshipchallenges.Theme 4: Framework and Structure of EFT

The categories included in this theme were: EFT Framework/Steps(9+) and Feelings of Anxiety and/or Pressure about Employing EFTProperly ( 3 - ) . Several participants reported that the framework andsteps of EFT Jiad facilitated their learning because they enjoyed struc-ture. Moreover, participants reported being able to refer to the frame-work for direction, which enabled them to "locate" their work withclients in the EFT process. However, the framework was anxiety pro-voking for other participants. For example, it was reported to inhibitlearning when the steps were followed inflexibly. One potential reasonfor this anxiety may be EFT's status as an evidence-based treatment(i.e., participants may have felt obligated to adhere strictly to the empiri-cally supported format). One participant commented, "I know it's beencarefully documented and very carefully written about and researched.But it seems to me that it would be the most effective and efficient in theform in which it's designed."Reifer (2001) discussed the anxiety felt by beginning therapists in su-pervision. However, such anxiety could manifest in any counselor ortherapist learning a new therapeutic modality. Because most therapistsdesire to facilitate positive change in their clients' lives, professionalsuccess or failure can be viewed as a reflection of the therapist's owncharacter development and functioning (Reifer, 2001). Arkowitz(2001) highlighted perfectionism in trainees, which could also contrib-ute to feelings of anxiety. The author posited that perfectionism could

function as a hindrance to trainees' learning if it contributed to a fear ofmaking mistakes. When the fear of making mistakes arises, "the ability


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ful. Others who felt the need to perform EFT "by the book" found it to behindering. Palmer and Johnson (2002) commented:A novice therapist learning the [EFT] model can get caught by thelure of the stages of change and can, as one young male studentdid, become absorbed by what stage his couple was at and howcould hemove them through the steps. His concern with being ableto perform the model successfully and, therefore, have his couplecomplete the nine steps of therapy obscured his vision of what washappening in the moment in the session, (p. 8)

Our study's findings suggest that it may be beneficial for EFT trainingto address the issue of flexibility within the structure and framework ofthe model, with perhaps particular attention paid to trainees' potentialanxieties about delivering EFT "by the book."

CONCLUSIONS AND RECOMMENDATIONS

The objective of this study was to investigate EFT therapists' opin-ions about what helped or hindered their ability to learn and implementthe EFT for Couples model. The perspectives of the participants in thisstudy may be helpful in informing the direction of current and futuretraining for EFT for Couples. The study 's results suggest the followingrecommendations. Trainers are encouraged to review their training ac-tivities to ensure that adequate "hands-on" experiences have been incor-porated (e.g., experimentation with interventions through role plays orwith client actors and then receiving feedback from trainers). In addi-tion, a comprehensive discussion of trainees' personal experienceswhen using EFT, including any countertransference issues, may be use-ful. For exam ple, role plays or worksheets presenting a variety of diffi-cult scenarios likely to evoke a reaction in the therapist could bedeveloped. Group discussions could also be employed to debrief thecomplexities of coping with intense emotion and to identify variousmethods of grounding oneself when personal reactions interfere withthe delivery of EFT.

We also recommend the development of several, centrally-locatedEFT training centers where therapists can observe EFT-trained thera-


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Duplassie, Macknee, and Williams 15individual and/or group supervision with EFT supervisors (and peer su-pervision with colleagues) are also likely to be critical. In this support-ive context, trainees could assess how EFT "fits" with their personalstyle and own beliefs about relationships, as well as with their clients'relationship problems. Moreover, to decrease therapist anxiety, it wouldbe helpful to develop realistic, full-length training videos that couldhelp therapists learn EFT interventions and provide them with the op-portunity to observe how EFT can be implemented during both the in-tense and less intense moments of therapy. In particular, observing theless intense moments of therapy might encourage therapists to exert lesspressure on themselves to "go by the book" because they could see thatEFT does not always unfold in predictable ways. Finally, the use of atraining manual that incorporates a variety of exercises (e.g., role playideas, identifying attachment issues, countertransference issues, tran-scripts) could enhance training by facilitating the discussion and prac-tice of EFT concepts. Such exercises could help trainees acquire adeeper understanding of how to manage difficult situations in therapyand aid in expanding their theoretical understanding of the EFT model.The limitations of the current study included the small number of par-ticipants, which may have decreased the comprehensiveness of the re-sults; the possibility that the lists of helpful and hindering componentswere not exhaustive; the use of retrospective self-report (i.e., partici-pan ts' memories may not have been completely accurate); and the vary-ing amounts of EFT training possessed by participants (e.g., only someparticipants had received further training and consistent supervision af-ter completing the basic 40-hour EFT externship).Future research using a different research method or sample of par-ticipants could help refine and validate the categories that were devel-oped in this study. Investigating whether the "helpful" CIs elicited inthis study contribute to positive clinical outcomes might also prove in-formative. Finally, therapists could be surveyed regarding the helpful-ness of EFT training workshops and materials and asked to makerecommendations for improvement.

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