treating attachment injured couples with emotionally focused therapy - a case study approach

Emotionally Focused TherapyNaaman et al.

Case Study

Treating Attachment Injured Couples WithEmotionally Focused Therapy:

A Case Study Approach

Sandra Naaman, James D. Pappas, Judy Makinen, Dino Zuccarini,and Susan Johnson–Douglas

This paper compared the attachment injury resolution process in two distressedcouples undergoing ten sessions of Emotional Focused Therapy (EFT), ashort-term empirically validated treatment for relational distress. An attachmentinjury is a newly coined clinical construct that denotes a specific type of betrayalwithin the couple’s relationship. The incident is so potent that it calls into questionassumptions about the safety of the relationship. The task analytic method wasused to examine the pathways of change as related to attachment injury of eachcouple. Several outcome and process measures were employed in order to differen-tiate the therapeutic process between the resolved versus non–resolved couple. Re-sults indicated that the couple who resolved their identified attachment injury atthe outset of therapy adhered to the attachment injury resolution model, while thenon–resolved couple showed marked deviations from the expected pathways ofchange. Findings suggest that the resolved couple tended to show more differentia-tion of interactional positions and greater levels of experiencing throughout thetherapeutic process in relation to the non–resolved couple. It is recommended thatfurther research is necessary to examine the clinical utility of the attachment injuryresolution model in the context of a larger number of case studies.

INTRODUCTION

Many couples enter therapy in order torestore levels of trust and satisfaction in theirrelationships, specifically issues regardingemotional–relational connections with theirsignificant other. One short–term treatmentmodality, developed by Johnson and

Greenberg (1985), which helps couples workthrough their emotional–relational distress, isEmotionally Focused Therapy (EFT). Thistherapeutic intervention is grounded in JohnBowlby’s (1969) theory of attachment, whichcontends that individuals have a tendency toforge and maintain strong affectional bondsto particular persons (e.g., emotional attach-

Psychiatry 68(1) Spring 2005 55

Sandra Naaman, and Dino Zuccarini, are PhD Candidates in the Department of Psychology at theUniversity of Ottawa, along with Judy Makinen, PhD, and Susan Johnson-Douglas, Ed.D. James D.Pappas, PhD, is at Luther College at the University of Regina in Saskatchewan.

Address correspondence to Sandra Naaman, University of Ottawa, Department of Psychology, 120University Private, Suite 405D, Ottawa, Ontario K1N 6N5; E-mail: [email protected]

ment between child and the primary caregiver,such as the mother). Moreover, the quality ofthese early bonds is regarded to play a pivotalrole in the overall well-being of the individual,since infant–caregiver relationships providethe bases by which the child forms healthy ornon–healthy (e.g., lovable, trustworthy,avoidant, and anxious) interpersonalrelationships with others later on in life.

Consequently, antecedent emo-tional–relational connections develop into at-tachment needs (e.g., security, trust, support,and safety) that contribute to the developmentof the self–concept or self–image which,formed during childhood, have long–term im-plications in the quality of adulthood relation-ships. For example, if a child receives love, ac-ceptance, and trust growing up, according toBowlby (1973), the child will develop what iscalled a secure attachment and, as such, willexpect this emotional–relational connectionfrom others as a basis of survival or a mannerby which to explore and understand theworld. Accordingly, EFT builds on Bowlby’stheory that conceptualizes adult love as an at-tachment bond with an irreplaceableother—the primary caregiver is irreplaceableand is the one who fostered an emotional con-nection or attachment pattern that is difficultto be replaced by another, namely, the currentpartner (Johnson, 1996).

It is the purpose of this paper to explorethese notions based on two clinical case stud-ies of couples that have sustained an attach-ment injury. The concept of an attachment in-jury was recently coined from clinicalobservation (Johnson, Makinen, & Millikin,2001) and is used to describe any incidentwhere an individual’s partner is perceived tobe inaccessible or unresponsive in a criticalmoment, especially when attachment needsare particularly salient. This is a clinically sig-nificant phenomenon in that it results in a tearin the fabric of, or disconnection in, the at-tachment bond creating negative interactionalcycles that perpetuate relational distress.

Furthermore, this study investigateshow an attachment–injured couple resolvestheir injury based on specific in–session infor-mation about how change happens. The prac-

tical utility of this approach can be used tostrengthen both theory and clinical applica-tions, since models are ameliorated based ontheir therapeutic findings. To understand theconcept of an attachment injury, an overviewof attachment theory is presented, specificallyas it applies to adult love and the repair of dis-tressed adult relationships. In addition, at-tachment injury resolution is conceptualizedand discussed in terms of Bowlby’s attach-ment model as per the two case studies. Thispaper closes with a discussion of the salientfindings germane to each case study.

REVIEW OF THE LITERATURE

Adult Love

Until recently, the field of marital the-ory has suffered from a lack of clear theoreti-cal models explicating the nature of adultlove. Clinically, this translated into a lack of aclear sense of direction as to where a coupleshould be heading in their therapeutic journey(Roberts, 1992; Segraves, 1990). This is to saythat the specific changes necessary for distressrecovery were simply unclear, opaque, and thefactors accounting for resilience in relation-ships were unknown. In response to this theo-retical lacuna, attachment theory, as outlinedby Bowlby (1969; 1988), has gained wide-spread popularity in providing a rich theoreti-cal framework for conceptualizing adult inti-macy. Attachment theory, in fact, isconsidered to be the most cogent theoreticalmodel for understanding adult relationships(Hazan & Shaver, 1987; Johnson, 1996).

Accordingly, the attachment model ofadult intimacy views love as a bond, which is atripartite mechanism consisting of behavioral,cognitive, and emotional elements that inter-act in synchrony to optimize survival. As witha parent–child relationship, the behavioralcomponent of the adult bond involves a set ofactions designed to create and manage prox-imity to the attachment figure. Since proxim-ity to an attachment figure must by definitioninvolve a reference to the self, the cognitivecomponent of the adult bond comprises that

56 Emotionally Focused Therapy

element. More specifically, every individualhas a working model of both self and otherthat contains information about one’s lov-ability and the other’s accessibility. Togetherthese two information–containing units orschemes determine one’s attachment style.The term working model was initially used byBowlby (1973; 1980) to describe the internalrepresentations that individuals develop ofthe world and of significant people within it,including the self.

As with a parent–child relationship, themost basic elements of an adult–adult love rela-tionship are those of emotional accessibilityand responsiveness. On the one hand, when at-tachment security is threatened—that is, whenan individual perceives her attachment figureto be inaccessible or unresponsive—a set of at-tachment behaviors are then activated towardsthe goal of re–instilling the attachment bond.On the other hand, if these attachment behav-iors fail to evoke the desired response from theattachment figure, a predictable sequence of re-sponses ensues, such as angry protest, clinging,despair, and finally detachment (Bowlby,1969). Adult bond disruption is followed by asimilar set of predictable responses, namely,protest, despair, and detachment (Sperling &Berman, 1994). Differences betweenchild–parent attachment bonds and those ofadult–adult attachment bonds have been out-lined by Weiss (1982), who maintains thatadult attachment is between peers whereaschild–parent attachment is between caregiverand care–seeker, thus hierarchical in nature. Itshould be noted that adult attachment rela-tionships are not as susceptible to being over-whelmed by other behavioral systems, giventhat adults possess coping mechanisms to dealwith stressful situations. Lastly, adultattachment relationships typically include asexual component.

In view of these notions, an attachmentstyle can be conceptualized as one’s behav-ioral response to both perceived and actualdistress, in addition to the separation fromand re–union to an attachment figure(Sperling & Berman, 1994). Based on the ex-tant literature of adult attachment, four styleshave been identified, which include secure,

preoccupied, dismissive, and fearful avoidant(Bartholomew & Horowitz, 1991). Accord-ing to Hazan and Shaver (1987), these stylesmay also be viewed as information-processingmechanisms that filter information from theenvironment to answer two basic questions:1) “Am I worthy of love and care?” and 2)“Can I count on others in times of dis-tress/need?” There is a finite number of an-swer combinations to these two basic ques-tions, thus giving rise to four attachmentstyles. Attachment styles are long-standingpatterns of expectations or strategies thathave developed as a result of past relation-ships (Hazan & Shaver, 1987; Kobak &Hazan, 1991; Simpson & Rholes, 1998;Sperl ing & Berman, 1994; Weiss &Sheldon–Keller, 1994).

The working models that form the basisof these attachment styles, however, are notimmune to change; rather, exposure to new re-lationship experiences do have the power to al-ter an attachment style. This fluidity is for obvi-ous survival reasons in that they are more thanjust serving as expectations for relationships.For example, Bretherton (1990) contends thatattachment styles are ways of processing at-tachment information. A securely attached in-dividual generally holds a positive view of bothher– or himself such that the self is regarded tobe worthy of love and others, which are viewedas reliable and can be counted on in times ofdistress or need (Bartholomew & Horowitz,1991). In the event of threat to the attachmentbond, securely attached individuals respondwith resourceful flexibility (Johnson &Greenberg, 1994), which indicates a healthylevel of resilience.

Conversely, individuals whose experi-ences are characterized by a predominantsense of unworthiness, juxtaposed against apositive view of others, are referred to as hav-ing a preoccupied attachment style(Bartholomew & Horowitz, 1991). Those in-dividuals, believing they are somehow defi-cient, will tend to cling to their partners, con-t inuously demanding reassurance.Interestingly, dismissive individuals hold apositive view of their sense of self, but a nega-tive view of others (Bartholomew &

Naaman et al. 57

Horowitz, 1991; Main & Goldwyn, 1985).The consequence of this combination is thatindividuals who strive to protect the selfagainst potential disappointment tend toavoid close relationships altogether, which,subsequently, creates an illusion of invulnera-bility (Henry & Benjamin, 1996). Lastly, fear-ful avoidant individuals are those who haveboth a negative view of their sense of self andothers. In anticipation of rejection or betrayal,these types of individuals, like the dismissivetype, will not risk involvement with others(Bartholomew & Horowitz, 1991).

Hitherto, securely attached individualshave been shown to experience better adjust-ment and higher levels of satisfaction in theiradult relationships (Collins & Reed, 1990). Be-ing able to experience higher levels of intimacyand trust, securely attached individuals are alsoless prone to hypervigilance, jealousy, and fearof abandonment (Hazan & Shaver, 1987). Theremaining three attachment styles can be con-sidered variations of a general category of inse-cure attachment. According to Simpson,Rholes, and Nelligan (1992), insecurely at-tached individuals have been shown to exhibita predictable set of emotional and behavioralresponses that render relationship repair in thecontext of marital therapy rather difficult.

Based on this review of the extant litera-ture, attachment theory provides one of themost conducive frameworks for clinically un-derstanding adult love relationships. More-over, this perspective focuses the therapist’sattention on attachment needs, fears, andlongings, since it emphasizes on the adaptiveneeds for contact and proximity to an attach-ment figure. Furthermore, it explains the sig-nificance of loss of connection and trust in arelationship. Additionally, attachment theoryhas contributed to further understanding thesignificance of impasses in therapy—and re-cently, the application of Bowlby’s theory tothe concept of an attachment injury and theprocess of change in couples therapy.

Emotionally Focused Therapy (EFT)

According to Johnson (1996) andGreenberg and Johnson (1988), EFT is con-

sidered to be an effective short–term approachto modifying distressed couples constricted in-teraction patterns and emotional responses.Drawing on attachment theory for under-standing adult love, EFT addresses the role ofaffect in intimate relationships and in modify-ing those relationships. Dialectically, thistherapeutic approach is a synthesis of experi-ential and systemic approaches to psychother-apy. In support of its therapeutic efficacy, re-search by Gottman (1994) has found thatmarital distress is a result of partners beingstuck in certain absorbing states of negativeemotion that give rise to rigid interactional cy-cles, which in turn leads to maintainingaversive emotional states. Consistently, re-search by Johnson (1996) suggests that dis-tressed couples are readily identifiable both bytheir rigidly structured interactional patternsand their intense negative affect.

Understandings of this nature indicatethat the essence of EFT is geared towardshelping distressed couples reprocess theiremotional responses and, in doing so, adoptproductive and healthier interactional posi-tions. This is achieved by allowing couples toelicit and expand—work through—their coreemotional experiences that give rise to theirinteractional positions and then to effectuatea shift in these interactional positions. Ger-mane to this process is that emotional re-sponses and interactional positions are recip-rocally determined—that is, they are bothequally addressed in therapy (Johnson, 1996).Consequently, the salient goal of the thera-peutic process is to foster a secure emotionalbond between partners, which has beenshown to be powerfully associated with physi-cal and psychoemotional well-being, with re-silience in the face of stress and trauma, andwith optimal personality development(Burman and Margolin, 1992).

Furthermore, research by Baucom,Shoham, Mueser, Daiuto, and Stickle (1998)and Johnson, Hunsley, Greenberg, andSchindler (1999) provide empirical support tomaintain the validity of EFT in successfullytreating distressed relationships. This hasbeen found, for example, in terms of treat-ment effect size of 1.3 (Johnson et al., 1999),


rate of recovery (70–75% of couples recov-ered from distress), and evidence of long–termeffectiveness after relatively short–term treat-ment (Gordon-Walker et al. 1996; Walker &Manion, 1998) as well as success in creatingand maintaining secure bonds and helpingcouples whose relational distress is further ex-acerbated by additional problems, such as de-pression, post–traumatic stress disorder(PTSD), and chronic physical illness (Johnson& Williams–Keeler, 1998).

Change Events in EFT

Embedded in the couples therapeuticjourney are three discernible process shifts,which include cycle de–escalat ion ,withdrawer re–engagement, and blamer soft-ening. Cycle de–escalation constitutes afirst-order change where the couple’sinteractional cycle remains essentially unmod-ified, except for the intensity of the struggle.The second significant change process that oc-curs during couples therapy is that ofwithdrawer re–engagement where the with-drawn partner is not just willing to risk occa-sional engagement with the pursuing partner,but is becoming rather active and engaged inthe relationship. Perceptions of contact, acces-sibility, and responsiveness are redefinedwithin the context of the relationship. As a re-sult, interactional positions shift, whichinvites the couple to engage in a different kindof therapeutic dance.

Furthermore, the therapist, by validat-ing the withdrawn partner’s sense of helpless-ness, primes withdrawal and facilitates ex-pression of specific needs and wants.Consequently, the pursuing partner experi-ences the other differently and this in turn pro-motes a new interactional position where thepursuing critical partner becomes less critical.At this point, the therapist guides this partnerthrough a softening, which is a critical changeevent in EFT and is considered to be highlypredictive of change (Johnson & Greenberg,1988). Johnson and Greenberg (1995) de-scribed the softening process as “a watershedfor the relationship and a powerful attach-ment event that initiates a new sense safety,

trust and contact in the relationship” (p. 139).This softening process represents a shift in thedirection of increased accessibility and re-sponsiveness such that, essentially, both part-ners become able to respond to the other in anaccepting manner in the context of a high levelof experiencing. According to Greenberg andJohnson (1988), softening is the most criticaland difficult task to accomplish within EFT,especially for a novice therapist.

Based on clinical observations of dis-tressed couples during EFT, Johnson,Makinen, & Millikin (2001) provide the fol-lowing sequence of events to indicate whatmay transpire during such a therapeutic pro-cess. Once a couple has de–escalated, and themore withdrawn the partner became relativeto her or his accessibility, any attempts by thetherapist at inviting the pursuing partner torisk confiding or self–disclosing has the ten-dency to be met with an explosion of an emo-tionally laden event by the latter. Regardlessof whether or not this event is mentioned atthe start of therapy, its re–emergence at thisstage has a significantly different quality inthat it is described in life and death terms and,more often than not, in the language oftrauma. Moreover, talking about the incidenttends to evoke compelling, constricted emo-tional responses, and rigid interaction pat-terns, such as attacking or stonewalling. Fail-ure on the therapist’s part to find ways aroundthis clinical impasse or any attempts atmoving the couple into the re–engagementphase tends to be futile.

Attachment Injury

An attachment injury or attachmentcrime was not formally defined as a theoreti-cal concept nor integrated in the attachmentframework until recently (Johnson, Makinen,& Millikin, 2001). Conceptually, attachmentinjury arose from the clinical observations ofthose couples whose initial level of distressameliorated, but no actual recovery was made(Greenberg & Johnson, 1988; Johnson,1996). Notwithstanding, Johnson (1996)proposed that the distress experienced bysome couples can often be traced back to a

Naaman et al. 59

specific critical event that occurred in the rela-tionship. For example, during that particularincident, a partner will typically experience astrong sense of betrayal either due to the inac-cessibility or unresponsiveness of the otherpartner. As such, an attachment injury can belinked to an action of betrayal during amoment of exigency in a couple’s relationship.

Most importantly, attachment injuriesare to be differentiated from the general levelsof trust inherent in a relationship. The conceptis particularly concerned with a specific inci-dent during which one partner’s attachmentneeds were especially salient and the otherpartner’s were perceived to be either inaccessi-ble or unresponsive. The injurious incident issignificant as it becomes used as the standardagainst the dependability by which the otherpartner is gauged. Clinically, couples thathave sustained an attachment injury will oftenpresent it as the recurring theme of the rela-tionship. Such incidents, in addition to callinginto question the security of the attachmentbond between two intimates, have the poten-tial of unravelling the emotional tie betweenthem and, if not addressed, will often becomechronically recurrent impasses, which preventresolution of significant hurts and betrayals.

Identifying an attachment injury is criti-cal to its working–through and integrationinto the relationship. Some couples may beparticularly insightful into specific incidentsthat have marked the deterioration of levels oftrust and intimacy in their relationship whileothers may not be particularly aware of howsuch events may be blocking accessibility andresponsiveness. More importantly, the degreeto which an event is judged to constitute an at-tachment injury depends solely on the percep-tions of the injured partner rather than onsome external criterion. Even subtle incidents,such as being left out of a family photo may beexperienced as an attachment injury. In thelatter example, a wife had just recently immi-grated with her husband and was inadver-tently left out of a picture taken with his fam-ily. In times of transition (e.g., immigration,retirement, childbirth, miscarriage, or loss),attachment needs tend to be particularly sa-lient. If the other partner is not perceived to be

providing the needed care and support, feel-ings of abandonment ensue. Moreover, ifthese feelings cannot be discussed and dealtwith in the relationship, they remain to under-mine the trust and security of the relationshipand may lead to abandonment or betrayal intimes of change when attachment needs areheightened (e.g., childbirth, cancer diagnosis,and miscarriage) as well as to classicalinfidelity (Johnson & Whiffen, 1999).

An attachment injury has also been lik-ened to, and described as, a relationshiptrauma (Johnson, Makinen, & Millikin,2001). In fact Johnson (1996; Johnson et al.,2001) contends that injury to the attachmentbond due to unresponsiveness in critical mo-ments may be equated to trauma with a smallt. This analogy between attachment injuryand relationship trauma seems to be especiallyapt, as a traumatic experience induces a basicsense of existential anxiety by shatteringonce–held assumptions. For example, one ofthe most basic assumptions of any relation-ship is the expectation that a partner will beboth accessible and responsive during times ofneed. When an exigency is imminent, attach-ment needs become prominent, which inducereal or perceived threat, danger, loss, or uncer-tainty (Bowlby, 1969). If a partner fails to re-spond with the expected reassurance andcomfort, the entire relationship becomes de-fined as unsafe. This violation calls into ques-tion the significance of oneself to the otherpartner. As previously mentioned, clients willoften describe these incidents in an intenselyemotional manner, and self–worth is oftencalled into question. One client, in particular,stated, “I was just not all that important tohim, I wasn’t precious. My future didn’tmatter.”

In addition to these existential con-cerns, an injured partner may experiencesymptoms consistent with PTSD, namelyre–experiencing hypervigilance and avoid-ance. While these symptoms arise as a naturaland protective self–defense mechanism, theyprevent emotional engagement, which inad-vertently leads to maintaining relational dis-tress. Similar to an attachment injury, there isan integration of the traumatic event during


treatment (see van der Kolk & McFarlane,1996), which acts like a regulation mechanismto help cope and work through painful emo-tional experiences. Most importantly, thetherapeutic relationship fosters the develop-ment of secure bonds or ties that provide posi-tive emotional experiences of belonging andpositive self–worth. In view of these claims, arelationship that offers a safe haven and se-cure base is regarded to be the most basiccondition of healing (Johnson, Makinen, &Millikin, 2001).

METHOD

Participants

Two couples were randomly selectedfrom a pool of research couples who wereoriginally recruited to participate in a largerstudy relating the process of therapy to out-come. Both couples were identified at the out-set of therapy as having endured an attach-ment injury, a recently coined clinical conceptreferring to a particular incident of betrayal inthe couple relationship. Both couples were ini-tially screened using a standardized telephonescreening procedure. The following inclusioncriteria were included as part of the screeningprocedure: must be living together and not inthe process of seeking separation/divorce; ab-sence of any drug/alcohol abuse; have notbeen recipient of any psychiatric treatmentsince the last year; not receiving other psycho-logical treatment during time of therapy; noongoing marital physical abuse; no history ofphysical abuse; and lastly, must identify a spe-cific incident of betrayal (attachment injury)during the intake session. Both couples wereinformed and gave written consent to theaudiotaping of all therapy sessions.

Couple One. Michel (32 years of age)and Maya (24 years of age) have been livingtogether as a couple for one year, and neitherhas been married. They have never enteredany form of marital counselling prior to thisstudy. Michel works as a consultant for ahigh-tech company and Maya is a supervisor;both have completed two years of post–sec-

ondary education and their gross familyincome is $73,000.

Couple Two. Sam (37 years of age) andKate (36 years of age) have been married forfifteen years and have two children; neitherwas married before. They have never enteredany form of marital counselling prior to thisresearch study. Sam works as a tennis coachand Kate works as a teller on a part–time ba-sis. Sam has attained his high school diploma,while Kate has completed three years ofpost–secondary education; their gross familyincome is $45,000.

INSTRUMENTATION

Process Measures

Based on antecedent research (e.g.,Greenberg & Foerster, 1996; Johnson &Greenberg, 1988), the following process mea-sures were selected for their ability to captureclient processes.

The Structural Analysis of Social Be-havior (SASB; Benjamin, 1974). The SASB isa coding system designed to analyze and rateinterpersonal processes. This method of anal-ysis is based on a circumplex model of socialinteractions and is comprised of three grids.The first grid depicts communications inwhich the speaker focuses on the other person.The second grid describes communications inwhich the speaker focuses on self. The thirdgrid has an intrapsychic focus. For the pur-poses of this study, the second grid was used inorder to measure the changing quality of in-teraction between the couple. This grid iscomposed of four quadrants where thespeaker’s utterance is coded as lying on one ofthe quadrants (e.g., affiliative, distant, hostile,or friendly). The SASB, in addition to havingbeen subjected to validation studies, has alsodemonstrated high inter–rater reliability(kappas ranging from 0.61 to 0.79)

The Experiencing Scale (ES; Klein,Mathieu, Kiesler, & Gendlin, 1969). The ES isa 7–point rating scale that measures in–ses-sion level of experiencing and is very sensitiveto changes in the couple’s involvement in ther-

Naaman et al. 61


apy. Moving up the scale, there is a gradualprogression from superficial, interpersonalself–references to simple, limited, orexternalized self–references, to syntheses ofnewly emerged feelings and new awarenessthat leads to problem solving and betterself–understanding. Validity of the Experienc-ing Scale has been demonstrated by correlat-ing with patient variables such asintrospectiveness and cognitive complexity(Klein et al., 1969). The ES also been shown topredict change in client–centered approachesof therapy (Orlinsky & Howard, 1986). Reli-ability of the scale, captured as kappacoefficients, ranges from 0.80 to 0.84.

Outcome Measures

The following self–report instrumentswhere selected on the basis of their theoreti-cal relevance to EFT, their ability to detectqualitative changes in couples with an at-tachment injury, and their ability to predictoutcome in distressed couples based on re-search by Johnson and Talitman (1997) andMillikin (2000).

The Dyadic Adjustment Scale (DAS;Spanier, 1976). The DAS is a 32–item self–re-port rating scale designed to measure the qual-ity of adjustment between married orcohabiting couples. It is currently consideredthe instrument of choice for the assessment ofrelationship adjustment. The scale yields a to-tal adjustment score, as well as scores on foursubscales: Satisfaction (10 items), Consensus(13 items), Cohesion (5 items), andAffectional Expression (4 items). The scaledscore has a theoretical range of 0 to 151. Highscores are indicative of less distress and betteradjustment. Established norms indicate meantotal scale scores of 114.8 for happily marriedcouples and 70.7 for divorced couples.

The distress cut–off point of 97 hasbeen set at one standard deviation (17.8 be-low the mean for the married sample). Anycouple scoring below 97 will be considereddistressed. The average of the individual cou-ple’s scores yields the couple’s mean totalscore. To be included in this study, each cou-ple’s mean total scale score must be less than

97 but not less than 85. The DAS was used inthis study in order to select mild to moderatelydistressed couples, and to ensure that resolv-ing attachment injuries in these couples actu-ally makes a difference in their relationship.

Relationship Trust Scale (RTS; Holmes,Boon, & Adams, 1990). The RTS is a 30–itemself–report inventory. It was specifically de-signed to assess interpersonal trust in marriedor cohabiting couples. This scale consists offive subscales: Responsiveness of Partner (8items), Dependability/Reliability (6 items),Faith in Partner’s Caring (6 items), ConflictEfficacy (5 items), and Dependency Concerns(5 items). The theoretical range of scores is 30to 210. Subscales are summed to provide anoverall score. High scores are indicative of astronger presence of trust between partners. Acouple’s mean score is obtained by averagingthe sum of each partner’s score. This scale wasused to gauge initial levels of trust at therapyinitiation and to examine any change by theend of therapy as a function of attachmentinjury resolution

Revised Adult Attachment Scale (RAAS;Collins, 1990). The RAAS is a shortened ver-sion of the original Adult Attachment Scalethat consists of 18 items to which each partnermust answer independently. It was developedto identify the individual’s attachment styleand was used in this study to capture anychanges in attachment style from pre–treat-ment to post–treatment. Each item asks the re-spondent to rate the extent to which an itemdescribes him/her. A 5–point scale, with 1 (notat all characteristic of me) to 5 (characteristicof me) is used.

Attachment Injury Measure (AIM;Millikin, 2000). The AIM was developed toobtain a written description of the injury aswell as a measure of its severity. The measuresimply asks each partner to describe the na-ture of the attachment injury from his or herpoint of view. It also asks the couple to rate ona severity scale of 1 (not at all severe) to 7 (ex-tremely severe). Successful resolvers tend toreport “moderately” to “extremely severe” atthe beginning of treatment and report below“moderately severe” after treatment.

Post–Session Resolution Questionnaire(PSRQ). The PSQR is an instrument intendedto capture the degree of in–session change per-ceived by the treated couple in question. It hasdemonstrated face validity (Greenberg &Foerster, 1996; Greenberg, Ford, Alden, &Johnson, 1993). It consists of 4 Likert–typescales and evaluates the extent to which a cou-ple feels they have resolved their presenting is-sues. High scores reflect no change, while lowscores reflect large change. This scale was usedto corroborate clinical judgment in selectingthe best sessions for analysis.

Couples Therapy Alliance Scale (CTAS).The CTAS is a qualitative scale used to assess

the presence of an adequate therapeutic alli-ance. Since therapeutic rapport is a basic in-gredient to the success of an intervention, if itwill demonstrate effectiveness, it was impor-tant to rule out inadequate rapport as a poten-tial cause of treatment non–resolution. Thisscale was administered at the end of the thirdsession.

RESEARCH DESIGN

A case study research design was usedto identify and examine the attachment injuryresolution process that emerged from the twocouples based on ten EFT treatment sessions,which utilizes seven stages, as proposed byJohnson, Makinen, & Millikin (2001). Theseven stages, described below, indicate the at-tachment injury resolution process that typi-cally emerges in the second therapeutic stage,changing interactional positions, of EFTtreatment. They are important to address be-cause they tend to block risk–taking and thecreation of trust within the relationship. Foreach session, each of the stages was inter-preted based on Greenberg’s (1984) task ana-lytic method, which analyzes the emotionalnarratives of the couples engaged in conflictresolution or working through unfinished is-sues during the therapeutic process. Taskanalysis is considered a rational–empiricalmethodology used to study processes ofchange within psychotherapeutic contexts.Greenberg and Foerster (1996) describe task

analysis as encompassing two phases: discov-ery followed by verification. In the discoveryphase, the treating clinician identifies a partic-ular recurrent clinical phenomenon (e.g., at-tachment injury) and defines it explicitly, asthe authors have above. After isolating appro-priate measures that mark the event in ques-tion, a set of hypothetical performances aredelineated with the goal of task resolution. Inregard to the present work, the hypotheticalperformances refer to the attachment injuryresolution model. This marks the end of dis-covery phase. This is then followed by theverification phase, which compares actualwith possible performances, validates theproposed model, and finally relates theprocess to outcome.

Before discussing the seven stages ofEFT, it is necessary to present an overview ofthe three therapeutic phases and their accom-panying nine steps, since they are germane tothe systematic observations.

The Three Therapeutic Phases of EFT

The first therapeutic phase is CycleDe–escalation. Step one includes assessment,which involves the creation of an alliance be-tween couple and therapist. The core issuesare uncovered and explicated in attachmentterms. Step two involves the negativeinteractional cycle, in its entirety, and is iden-tified with the couple. Attachment insecurityand the maintenance of relational distress areaccounted for by the negative interactional cy-cle. Step three includes the denied or unac-knowledged emotions giving rise tointeractional positions. In Step four, the pre-senting problem is reframed in terms of theinteractional cycle, underlying emotions, andattachment needs.

The second therapeutic phase is Chang-ing Interactional Positions. Step five suggeststhat previously disowned needs and aspects ofself are identified and integrated into relation-ship interactions. Step six involves acceptanceof each partner’s experience and new moreflexible interactional patterns are promoted.In Step seven, expression of attachment needs

Naaman et al. 63

and wants are facilitated, thus creatingemotional engagement.

The third therapeutic phase is Consoli-dation and Integration. Step eight addressesprevious relational problems via new solu-tions at which the couple have arrivedthrough the therapeutic journey. Step nineconsiders the couple’s new positions andhealthier cycles of attachment behavior.

The Attachment Injury ResolutionModel According to EFT: SevenStages

During Stage one of EFT, the couplemoves into the de–escalation phase. As thetherapist encourages the injured and criticalpartner to risk connecting with the now avail-able offending partner, the former begins tovividly describe a specific incident duringwhich she or he experienced a violation oftrust that shifted her or his belief in the offend-ing partner’s trustworthiness and the securityof the whole relationship. The specific injuryis described in an intensely emotional manner.The offending partner who was briefly emo-tionally available will move back in self–pro-tection as the injured partner describes the in-jury. The offending partner may discount,minimize or deny altogether the hurtful inci-dent. On the Structured Analysis of Social Be-havior Scale (SASB), the injured and offendingpartner are expected to lie on the hostile quad-rant and distant quadrant respectively. Thelevel of experiencing is expected to be low, atStage two or three.

With the attachment injury still at thesurface, at Stage two, the therapist helps theinjured partner stay in touch with it for thepurpose of further articulating its attachmentsignificance. With the therapist’s validation,secondary emotions of anger and rage gradu-ally differentiate into those of hurt, fear, andshame. The impact of the injury and its ac-companying emotions are related back to thepresent negative interactional cycle. For in-stance, an injured partner may say, “I feel sohelpless, I just scream and swear to show himthat I matter and that he can’t just pretendthat everything is okay.” During this step, the

level of experiencing of the injured partnerwill typically be deeper and a less hostilestance will be taken.

During Stage three, the offending part-ner, with the support of the therapist, hearsthe pain of the injured partner. Having articu-lated the impact of the injury in attachmentterms, the offending partner slowly movesforward. The injured partner’s reaction is nolonger viewed as a reflection of the offendingpartner’s inadequacies, but rather as her or hisimportance to the injured partner. The offend-ing partner, now less defensive, acknowledgesthe injured partner’s pain and describes howthe incident evolved for her or him. The levelof experiencing continues to increase gradu-ally to Stage four or five for the injured part-ner and the offending partner adopts anaffiliative stance.

At Stage four, the emotional climate be-tween the two partners continues to be mild.The injured partner completes articulation ofthe injury in an integrated fashion such thatthe injured partner from a position of vulnera-bility expresses grief at the broken trust andfear of loss of the attachment bond. The in-jured partner may adopt a distant position (asmeasured by the SASB) and the level of experi-encing continues to deepen to stage five.

Having witnessed the vulnerability ofthe injured partner, during Stage five, the of-fending partner feels safer to move forwardand acknowledge responsibility for her or hisshare in the attachment injury. Emotions ofregret, remorse, and empathy are observedand an apology should be forthcoming. Theoffending partner’s utterances are affiliativein nature and there is continued deepened ex-periencing. With a re–engaged partner, atStage six, the injured partner risks asking forthe reassurance and comfort that was unex-pressed at the time of the injurious incident.The level of experiencing reaches a peak atStage six for the injured and offending part-ner. On the SASB, the injured partner has a re-sponse of friendly and the offending partnerhas a response of affiliative.

Finally, at Stage seven, the offendingpartner responds in a caring and protectiveway, which restores previous relationship


trust levels and heals the rift in the fabric of theattachment bond. Both partners are now en-couraged by the therapist to construct col-laboratively a new narrative of the event. Themanner by which the offending partner cameto respond the way she or he did during the in-jurious event needs to be integrated in the nar-rative in order to be acceptable to the injuredpartner.

PROCEDURE

Pre–Treatment Procedure

At the initiation of therapy, the re-searcher administered the Demographic DataQuestionnaire, Attachment Injury Measure(AIM), Dyadic Adjustment Scale (DAS), andthe Relationship Trust Scale (RTS).

Inter–Treatment Procedure

At the end of each therapy session, thePost-Session Resolution Questionnaire(PSRS) was administered. This is a five–pointscale ranging from (1) not at all resolved to (5)fully resolved. This was used to obtain clientand therapist judgments of task resolutionand to objectively isolate each couple’s “bestsession” for examination of the therapist’s in-terventions. By the end of the third session, theCouples Therapy Alliance Scale (CTAS) wasadministered in order to ensure that the qual-ity of the therapeutic alliance was not a con-founding variable in the non–resolutionprocess of change.

In order to track the process of change,the best ten–minute segment of each of the tentherapy sessions was coded using the Struc-tural Analysis of Social Behavior (SASB) andExperience Scale (ES). For each therapy ses-sion, the best ten–minute segment was se-lected from the second half of the session toensure that the therapeutic process was at itspeak level. Each segment was isolated by find-ing a marker as indicated by an emotionallyladen event related to the attachment in-jury—that is, where there is an incongruencybetween expressing and experiencing—and

transcribing the ten–minute therapy segmentfollowing it. Two raters, doctoral students, fa-miliar with EFT and coding procedures codedall sessions independently. The two raterswere not directly involved in the therapyprocess of any of the couples.

For each couple, the best ten–minutesegment of each therapy session was tran-scribed and coded using the SASB and ES. Foreach segment, every utterance from both theinjured and the offending partner was ratedon the Quadrant scale of the SASB. To arriveat one rating for each partner for each session,the modal average of her or his ratings wasused. The same procedure was implementedto arrive at one rating for the level of experi-encing for each partner in every session.

Post–Treatment Procedure

At the completion of therapy, the thera-pist administered the AIM, the DAS, and theRTS. The resolution of an identified attach-ment injury was based on fulfillment of thefollowing criteria: a) judgment of resolutionfrom the couple’s vantage point; b) opinion ofthe therapist; c) degree of improvement on theDAS and RTS measures.

Research Hypothesis

It is hypothesized that the resolved cou-ple, in comparison to the non–resolved cou-ple, will show more variation in terms of theirinteractional positions, as captured by theSASB and will also move towards more expe-riencing as captured by the ES. Resolution ofthe identified attachment injury is expected tofollow the resolution model outlined above.

RESULTS

The following section reports the find-ings that emerged for the two couples, the re-solved and the non–resolved, as interpreted bythe task analysis method and as measured bythe instruments administered. The data is dis-cussed in accordance to inter–rater reliability,narrative and explication of attachment in-

Naaman et al. 65

jury by each partner, process measures, out-come measures, and observed pathways ofchange (in relation to the proposed attach-ment injury resolution model)—hypothesesare mentioned where appropriate.

Inter–Rater Reliability

Inter–rater reliability was high with mi-nor discrepancies between raters. Codings onthe SASB scale were analyzed for convergence,yielding a kappa of 0.78 for couple 1 and akappa of 0.90 for couple 2, with an overallkappa of 0.84. Similarly, raters’ codes on theES yielded kappa’s of 0.85 and 0.90 for couple1 and couple 2, respectively. The overallkappa coefficient for inter–rater reliability onthe ES was 0.87.

The Resolved Couple: Michel andMaya

Narrative of Attachment Injury

The attachment injury identified at theoutset of therapy was an internet relationship.

Michel

Michel, the injured partner, describedthe sustained attachment injury in the follow-ing narrative: “An on–line relationship. Iemailed some URLs to Maya and when I waschecking her email to retrieve the URLs, I sawan email from someone called Dave. I askedher who it was and she said that she didn’tknow him, but then I found numerous e–mailsfrom him for the last four months. She contin-ued to lie for three days until I told her that Isaw all the emails from Dave.”

Maya

Maya, the offending partner, describedthe incident as follows: “I spent a lot of timeon the computer and whenever we had a prob-lem, I felt lonely. I really didn’t have manyfriends around here so I got in the habit ofchatting on the computer and I started becom-ing addicted. After a while I became close toone guy. I was afraid that Michel would

know, so I lied about it. When he found out,Michel thought that I cheated on him, but Ionly needed someone to talk to when I wasdown.”

Explication of Attachment InjuryWhen asked to indicate the level of se-

verity at a subjective level, on a scale of 1 or se-vere and 5 or negligible, Michel rated the se-verity of the attachment injury as 1 or severe,while Maya rated it as 4 or considerable.However, during the initiation of therapy,Michel felt that overall he could trust his part-ner while Maya indicated that she could nottrust her partner. Nonetheless, both partnersbelieved, to a moderate extent, that the issuecould be resolved and the trust in therelationship could be improved.

Process Measures

In terms of attachment styles, as mea-sured by the Revised Adult Attachment Scale(RAAS), Michel and Maya endorsed answersindicative of dismissive and fearful avoidantstyles, respectively, consistent with hypothesis6. On the DAS, Maya’s score was 91 whileMichel’s was 84, and both partners’ averagescore was 87.5, ten points below the cut–offfor distressed couples. On the RTS, Micheland Maya obtained scores of 117 and 151,respectively.

Outcome Measures

The therapeutic process adhered sub-stantially to the attachment injury resolutionmodel proposed earlier. The SASB and EScodings are graphed below (see Figures 1a and1b) to illustrate the entire process of changethroughout the ten sessions. Figure 1a illus-trates how this couple’s interactional posi-tions showed the expected changes associatedwith the proposed attachment injury resolu-tion model. This couple showed a gradual in-crease in the level of experiencing from the be-ginning of session 3 to session10; session 3marked the de–escalation phase and ispre–requisite to attachment injury resolution.The peak level of experiencing by the lastsession was at stage 6 for this couple.


Naaman et al. 67

Observed Pathways of Change

During the first therapy session, the as-sessment phase, the couple’s dispositionalpresence was emotionally laden with hostilityand lack of empathy, and since they were re-luctant to reveal this affect, they coped byovertly behaving in a shallow or superficialdemeanour (i.e., emotional distant behaviorindicative of a flattened affective tone). Thisincongruency between affect and behaviormarked the first process in the pathways ofchange, since the content and manner ex-pressed the extent to which the injury affectedtheir relational quality. At the beginning ofsession two, the level of experiencing was stillquite shallow—a distant and detached stancetowards each other, as indicated by a lack ofemotional communication. However, pro-gressively throughout the second session, thetherapist succeeded in de–escalating this cycleby uncovering and explicating the emotion-ally laden issues associated with antecedentattachment needs stemming from their child-hood working models (e.g., lack of respon-siveness of Maya’s father which led to apattern of investing in multiple relationshipssimultaneously).

By session three, a classic with-draw–pursue was observed by the couple’sdispositional presence whereby each experi-enced the relational distress between them andbegan to slowly and intermittently accessthese emotions by brief expressions (i.e.,started to slowly open up to authentically ex-periencing their attachment insecurities,which indicates the building of an emotionalconnection). This working–through processindicated the efficacy of the therapeutic alli-ance (i .e . , safety and trust lowersintrapersonal and interpersonal resistance),which was maintained during sessions fourand five. Moreover, this therapeutic processallowed Maya to begin to identify her nega-tive interactional cycle where she spoke abouther underlying emotions and attachmentneeds by acknowledging her insecurities andemotionally distant behavior as a way to pro-tect her sense of self from shame and the fearthat she be exposed to Michel. She feared that

if she really exposed herself to him, if he reallyknew what she was about, he would leave her.

During sessions four and five, thisinteractional cycle led Michel, despite beingthe injured partner, to take a risk in communi-cating his painful emotions to Maya, whichallowed him to reconnect to his denied emo-tions, and, thus, to Maya. For example,Michel said to the therapist, “I do want our re-lationship to work, but it is hard when she’sdistant.” This transaction gave way for Mayato express her anger, shame, and fear throughemotional outbursts, which carried the mes-sage that she may not be enough to satisfyMichel’s needs or what he expects from her ina relationship. “You are a great personMichel, but everything I say . . . I mean . . . Ipersonally think that I am not good enoughfor you . . . I am not asking you to leave, I’mjust afraid that you’ll give up, that’s what I’mafraid of . . . maybe you should be withsomeone your level.”

Consequently, this opening up— wherehe witnessed Maya speaking from such a vul-nerable place—led Michel to be forthcomingwith reassurance. Michel responded by sayingthat “It makes me sad that she feels this way,she said that she didn’t care about looks, Iguess it happened after her last relationshipwhen her ex cheated on her, and so she pushesme away all the time.” This interactional cyclewas maintained throughout session five andpropagated a pattern of releasing unacknowl-edged emotions to the point where de–escala-tion was attained—each became affiliative to-wards the other, and both entered deeperlevels of experiencing their emotions, bythemselves and with one another.

However, this deepening of affect re-leased somatic pains (e.g., chest pains) andpsychological distress (e.g., anxiety), whichMichel attributed to suppressing his anger atMaya’s uncaring attitude towards him. Thissession marked the first step in the proposedmodel of attachment injury resolution. De-spite the risk he took to connect with Maya,Michel became doubtful as to her trustworthi-ness as he articulated the attachment injury,which continued to be high, specifically atstage five as depicted on Figure 1b. In light of


these circumstances, the therapist, throughsupportive encouragement, guided Michel tostay in the moment and in touch with his feel-ings of anger and rage that eventually differ-entiated into hurt and fear of relationship loss.“So, from what you just said, I hear a lot ofhurt from your broken trust and feeling thatshe can look at another man, despite her lovefor you ." Michel’s self–observation of hostileemotions lasted throughout session 6, whichset the stage for Michel to distance himselffrom Maya during sessions seven and eight.This distancing stance revealed that Michelwas processing his attachment injury andneeded time to reflect and work through hispainful emotions, which, incidentally, led toMaya to come to terms with how her actionsinjured Michel, specifically in his perceptionof the relationship.

Having now witnessed Michel’s vulner-ability, Maya became emotionally expressiveand acknowledged her responsibility in howshe dealt with the relationship. This emotionalcatharsis revealed how her previous relation-ship had conditioned her to feel untrustwor-thy and lacking of self–worth, which, conse-quently led her to express regret and offerMichel an apology for what had transpired.Notwithstanding, Maya came to experiencedoubt as to whether Michel believed her ornot, which prompted the therapist to keepMaya in the moment of the experience andguided her to feel, rather than cognitively pro-cess the event, and requested that she askMichel whether he believed her. Throughnon–verbal behavior, Michel acknowledgedwith a nod, and stated that he did believe her.As a consequence to this reciprocal acknowl-edgment, Maya’s emotional expressions weretainted with shame, and to avoid her revertingto a distancing behavior, the therapist keptMaya emotionally engaged in her experience.This therapeutic move helped Maya to main-tain an affiliative stance (see Figure 1a) for thelast four sessions, despite her insecurity andMichel’s initially distant stance. The couplecontinued to engage with each other in amanner reflective of deep experiencing, andby session 9, Michel had moved to a friendlierstance.

By the end of session ten, the couplereached a plateau in terms of level of experi-encing, and both were relating to each other inaffiliative ways. Session ten entailed consoli-dation of new interactional positions as a re-sult of the new experiences that were fosteredby the positive cycles and awareness of pres-ent feelings and internal processes. At the finalsession, it was judged by both the couple andthe therapist that successful resolution of theattachment injury had taken place. This wasconsistent with results from the pre–treatmentand post–treatment measures of the DAS andRTS scales. At therapy termination, bothMichel and Maya indicated that they weretrusting of each other. Their average score onthe DAS has increased 16.5 points (more thanone standard deviation) compared topre–treatment. On the RTS, Michel andMaya’s scores increased to 124 and 149points, respectively, and their combined aver-age score on the RTS had increased, thoughinsubstantially (2.5 points). The modal aver-age for each partner’s rating at each sessiondepicts the expected process of change accord-ing to the proposed model of attachment in-jury resolution (see Figure 1). The modal aver-age for each partner’s rating at each sessionillustrates the gradual deepening of experienc-ing throughout therapy, consistent with theproposed attachment injury resolution model(see Figure 1b).

The Non–Resolved Couple: Sam andKate

Narrative of Attachment Injury

The attachment injury identified at theoutset of therapy was a sexual affair.

Sam

Sam, the offending partner, describedthe sustained attachment injury: “The inci-dent occurred in May 1996, Kate walked inon myself and her friend engaging in sexual re-lations. I was away from home when it oc-curred and when we did return home, wetalked about it, hoping to resolve it ourselves,but it is a continuous source of stress in our

Naaman et al. 69

marriage. I have put it behind me, as there isno longer any involvement with this woman.”

Kate

Kate, the injured partner, described theinjurious incident as follows: “On a businesstrip on which I accompanied my husband, Ifound him with my best friend in her bedroomin the middle of foreplay. At first I tried to ig-nore my husband when he came running afterme; he wouldn’t let me just go. He needed toapologize. After I came home, I felt that Ineeded to prove something and I call it angrysex.”

Explication of Attachment Injury

On the Attachment Injury Measure(AIM), both Mike and Kate categorized thesustained attachment injury as severe. Mike,however, felt that the issue could be resolvedconsiderably in therapy and that subsequentlytrust levels could improve. Kate, the injuredpartner, held that belief too, but only to amoderate degree. Sam and Kate tend to havedismissive and pre–occupied attachmentstyles, respectively, as determined by their re-sponse patterns on the attachment stylequestionnaire (Collins, 1996).

Process Measures

On the RAAS, Sam and Kate endorseddismissive and pre–occupied styles respec-tively. On the DAS, both partners’ averagescore was 87.5, which is substantially belowthe cut–off point for distressed couple. Sam’soverall score on the DAS was lower thanKate’s, 84 and 92. On the RTS, Sam and Kateobtained scores of 141 and 114, respectively.At the outset of therapy, Sam, the offendingpartner, felt that overall he could trust Kate,while the opposite was the case for Kate, theinjured partner.

Outcome Measures

The therapeutic process of this couplelooked very different from the hypothesizedmodel of attachment injury resolution model

proposed earlier. The SASB and ES codingsare graphed below (see Figures 2a and 2b) toillustrate the entire process of changethroughout the ten sessions. Figure 2a illus-trates how this couple’s interactional posi-tions showed rigidity and lack of differentia-tion throughout the ten sessions and theexpected changes associated with the pro-posed attachment injury resolution model.Figure 2b illustrates relatively lower levels ofemotional experiencing compared to the hy-pothesized model. Specifically, this coupleshowed a gradual increase in the level of expe-riencing from the beginning of session three tosession ten; session three marked the de–esca-lation phase and is pre–requisite to attach-ment injury resolution. The peak level ofexperiencing by the last session was at stage 6for this couple.

Observed Pathways of Change

From the onset of the first session oftherapy, the dispositional presence of this cou-ple was that of a classical pursue–withdraw,where Kate, the injured partner, showed a dis-paraging and blaming attitude towards Sam,the offending partner, who defended by with-drawing and distancing himself from Kate’ssubjugation. This rigid interactional disposi-tion, as depicted in Figure 2a, remained con-stant for the first four sessions, as measured bythe SASB, where Kate remained hostile andovertly aggressive, while Sam maintained anisolated and reserved demeanor to containKate’s negative affect. Despite these patternsof exchange, both partners gradually pro-gressed, and shifted from expressing imper-sonal statements (i.e., affect laden and uncon-genial) to personal statements (i.e., affectexpressive and emotive), as depicted in Figure2b.

By session five, however, the couple hadde–escalated, specifically Kate, who movedfrom a hostile to a distant stance, similar toSam’s dispositional attitude (see Figure 2a).This dispositional style, consequently, createda calm interpersonal emotional climate thatenabled the therapist to guide Sam to partici-pate in the expression of his feelings, since the


Naaman et al. 71

environment was now much safer, which low-ered his levels of resistance and increased hissense of safety. This emotional de–escalationallowed Kate to experience a deepening of af-fect, as compared to previous sessions. In thissession, she reflected on how she was express-ing and experiencing her painful emotions(i.e., venting through hostile criticizing).

In light of this forward move to de–es-calation, an impasse developed between thecouple following session five that was broughtto attention during session six. Kate was of-fended when Sam went on a business trip witha woman she disliked. Sam had forgotten tomention the trip to Kate, given that it was un-important to him as a collegial relationship.Although Kate initially claimed that she be-lieved it was a platonic relationship, the eventdid trigger the attachment injury by re–awak-ening her attachment fears as indicated by herdeepened level of experiencing her feelings(see Figure 2b). Just as the couple had man-aged to de–escalate in the previous session,Kate reverted back to her hostile attitude, al-most in an unspoken attempt to conceal hervulnerability and unwillingness to ever trusther partner again. Sam, in response to Kate’shostility maintained his usual distance (seeFigure 2a). Note that after de–escalation, cou-ples typically move into the second stage oftreatment. However, with this couple, theirinteractional pattern or cycle seemed sodeeply entrenched (possibly as a function ofthe long duration of time since the occurrenceof the attachment injury) that maintainingde–escalation or a first-order changepresented as very challenging.

Sessions six and seven represented a re-gression in the service of attachment injury;that is, revisiting previous dispositional pat-terns of rigidity as observed in earlier sessions.In an attempt to resolve this impasse, the ther-apist began to reinitiate the de–escalation pro-cess in order to move the couple into the sec-ond stage of therapy, which was establishedduring the end of session eight; however, bothmaintained distant attitudes towards eachother. During session eight, Kate continued todifferentiate her feelings of anger, her resent-ment at not being able to go back to work, and

the sacrifices she had to make for her family.Some of her anger was differentiated into feel-ings of aloneness, especially when she first hadtheir children. Sam responded in a manner re-flective of his continued distant attitude,specifically at a lower experiential level ascompared to Kate.

It is important to note that up until ses-sion nine, there had not been any mention ofthe attachment injury because the emotionalclimate of the relationship was quite volatile.However, during session nine, an interestingshift occurred. Sam adopted a friendly stancefor the first time since the beginning of ther-apy (see Figure 2a) and began exploring hisfeelings. He felt somewhat safer, given Kate’sattenuated hostile attitude, which in turn low-ered his levels of resistance. Although Kate ar-ticulated the attachment injury—the af-fair—she remained distant, as did Sam, whichindicated that they were not ready to processthis affect nor deal with it at this time. DespiteSam’s friendliness (withdrawer engagement)in session nine, it failed to create a change inKate’s stance (softening). Since she was stillquite distant, Sam regressed back to his for-mer detached stance largely due to lack ofsafety. No further mention was made of theattachment injury, and the final session wasmarked by a sudden decrease in the level ofexperiencing for both partners.

At the termination of therapy, bothSam and Kate felt that they had made somegains in learning to express their emotions anddisconnections between each other; however,resolution of the identified attachment injurydid not take place. In view of this, Sam still feltthat he could trust Kate, while Kate could notsay the same for Sam. Their pattern of re-sponses thus did not change from the onset oftherapy to the outset. In addition to this thera-peutic observation, indication of non–resolu-tion was suggested by the pre–treatment mea-sures (DAS and RTS average scores for thiscouple were 88 and 127.5 points, respec-tively), when compared to the post–treatmentmeasures (DAS and RTS average scores were79.5 and 130.5, respectively). In terms of thiscouple’s resolution process in relation to theproposed model, none of the seven tasks were


accomplished. The proposed model specifiesthat resolution takes place during the secondstage of treatment in EFT. It was evident thatthis couple experienced great difficulty even inmaintaining de–escalation, let alone movinginto the second stage of treatment.

DISCUSSION

This study used the case study approachto uncover the session–to–session changes intwo couples with sustained attachment inju-ries that were undergoing EFT. The first cou-ple was successful at arriving in a resolutionwhile the second couple was unsuccessful,based on their perceptions and objective mea-sures. Considering this, the following dis-cusses the empirical findings of the results pereach couple’s therapeutic process.

First Couple

The process of change for the first cou-ple adhered to the proposed model of attach-ment injury resolution, where the injuredpartner was initially hostile and blaming to-wards the withdrawn, offending partner. Asde–escalation occurred, the emotional climateattenuated until the attachment injury wasre–awakened and the emotional intensity in-creased once again. Moreover, the couplemanaged to de–escalate and then successfullymove into the second stage of treatment, acritical step toward starting to emotionallyprocess the attachment injury. The seven stepsproposed in the model as they pertain to theresolution process are:

1. Injured partner expressed violationof trust.

2. Injured partner articulated meaningof experience at an emotionallydeepened level.

3. Offending partner became less de-fensive.

4. Grief was expressed by the injuredpartner, from a position of vulnera-bility.

5. The offending partner moved for-

ward and acknowledgedresponsibility for her share in theinjury.

6. The injured partner risked askingfor the reassurance that was unex-pressed at the time of the injury.

7. The offending partner responded ina caring and protective way.

It is important to note that the injuredpartner expressed full responsibility for the in-jurious event and several statements of remorsewere made. With appropriate therapist inter-ventions, a softening was elicited. Specific in-terventions included following the patient’s af-fect and heightening experience in order todifferentiate secondary emotion (e.g., anger)into more primary ones (e.g., hurt or fear).

Second Couple

The process of change for the secondcouple did not adhere to the proposed modelof attachment injury resolution, since theywere entrenched in a vicious cycle of volatil-ity—negative interactional cycle—based onthe period of time it took for them to de–esca-late. This was largely due to the fact thatde–escalating this couple was a challenge inand of itself. For example, a subtle event (hus-band’s business trip) was powerful enough todisplace the equilibrium created in the de–es-calation stage. Moreover, despite thewithdrawer–engagement process, the injuredpartner refused to risk exposing any vulnera-bility or expressing any need, which inadver-tently led to a therapeutic impasse. The in-jured partner made clear statements about herunwillingness to trust, unless her partner wasto prove himself to her over time. Conse-quently, none of the steps of the model wereobservable with this couples’ change process.

Differences Between the Couples

Recency of the Attachment Injury

Some differences observed between thetwo couples may have factored into the finaloutcome of therapy. A major difference be-

Naaman et al. 73

tween the two couples was that of the recency ofthe attachment injury. While the first couple hadexperienced a rift in their emotional tie relativelyrecently (a few weeks prior to therapy initia-tion), the second couple had spent several yearsenduring a weak interpersonal bond as a resultof the major injury sustained. Relatively recentattachment injuries may prove to be good prog-nostic indicators of the therapy outcome. Itseems plausible to hypothesize that the longer acouple spends together interacting in a negativestyle resulting from an attachment injury, themore likely the interactional patterns and emo-tional experiences become entrenched. If the in-jurious incident is potent enough to alter the at-tachment style and the ways of relating betweenpartners consequently change, therapy may alsoprove to be more therapeutically challenging.Conversely, those couples who present with re-cent attachment injuries may be more respon-sive to change in a shorter period of time. Fur-ther research is needed comparing couples withrecent versus older sustained attachmentinjuries to compare their amenability totherapeutic change.

Style of Attachment

In the first couple, the reported attach-ment styles of the injured and offending part-ners were dismissive and fearful avoidant, re-spectively. At termination and as a result ofsuccessful resolution, both partners ratedthemselves as securely attached. This outcomewas somewhat unexpected, given the resis-tance of a dismissive–fearful avoidant combi-nation—Johnson and Simms (2000) havefound that a fearful attachment style is difficultto change in the context of therapy. In contrastto the first couple, the injured and the offend-ing partners of the second couple endorsedanxiously preoccupied and dismissive styles ofattachment, respectively. These attachmentstyles remained constant throughout thecourse of therapy and where both partners per-ceived themselves to be relating in the samefashion. It may be the case that attachment in-juries sustained in the context of particularcombinations of attachment styles prove to beresistant to working through and integration.

For example, with the first couple, the injuredpartner adopted a fearful avoidant stance,where she would take one step forward fol-lowed by one step back. When her avoidantpartner re–engaged, she felt it was safe to ex-press remorse for her behavior. It is the au-thors’ contention, however, that withdrawerre–engagement was facilitated, because of thecalm emotional milieu of the relationship, sincethere was no hostility between partners. How-ever, this was not the case with the second cou-ple, as exemplified by the injured partner whoremained adamant in her goal to control andpunish her partner for making her feel insecure,and, as such, manifested a level of hostility thatprecluded his willingness to engage. Accord-ingly, couples with different attachment stylecombinations may be studied to further refineunderstanding of such therapeutic limitations.

Gender of Injured Partner

Another difference that emerged acrossthe two couples was gender of the injuredpartner. In the first couple, the injured partnerwas the male, while in the second it was the fe-male. Past research has maintained thatwomen tend to be the “emotional managers”in relationships (Fincham, Beach, & Nelson,1985). It could be that the gender of the in-jured partner juxtaposed on a particular at-tachment style combination may prove to beless amenable to short-term couples therapy,in which case, further research is required tosubstantiate the reasons.

CONCLUSION

While attachment injury has beenshown to be a clinically useful construct in ad-dressing many forms of both overt and covertexperiences of betrayal and loss of trust, thoseunprocessed injurious events carried overfrom past relationships, whether from child-hood trauma or from adulthood, have yet tobe addressed from an attachment frameworkand integrated into this therapeutic approach.Qualitative differentiation of the attachmentinjury concept may be a fruitful endeavor tohelp tailor appropriate intervention. Al-


Naaman et al. 75

though there is support both quantitativelyand qualitatively for the attachment injuryresolution model, as evidenced by the resolv-ers’ change process in comparison to theirnon–resolving counterparts, further researchis needed to compare a larger pool of couplesto determine whether or not non–resolvedcouples ever succeed in moving beyond de–es-calation or at least maintaining it for morethan one session. Although broad generaliza-tions cannot be made at this time, preliminary

evidence suggests that couples who resolvetheir attachment injury work through their re-lational rift in a certain predictable pattern, asdelineated by the model. Differentiation ofinteractional positions as well as deeper levelsof experiencing seem to be paramount toresolution of the injurious event andrestoration of the couple’s emotional bond.

REFERENCES

Bartholomew, K., & Horowitz, L.M. (1991).Attachment styles among young adults: A test ofa four–category model. Journal of Personalityand Social Psychology, 61, 226–244.

Baucom, D., Shoham, V., Mueser, K., Daiuto, A.,& Stickle, T. (1998). Empirically supported cou-ples and family interventions for marital distressand adult mental health problems. Journal ofConsulting and Clinical Psychology, 66, 53–88.

Benjamin, L.S. (1974). Structural analysis of so-cial behavior. Psychological Review, 81,392–425.

Bowlby, J. (1969). Attachment and Loss: Vol.1.Attachment. New York: Basic Books.

Bowlby, J. (1973). Attachment and Loss: Vol. 2.Separation: Anxiety and Anger. New York: Ba-sic Books.

Bowlby, J. (1980). Attachment and Loss: Vol. 3.Loss: Sadness and depression. New York: BasicBooks.

Bowlby, J. (1988). A Secure Base. New York:Basic Books.

Bradley, B. (2001). Toward a Mini–Theory ofEFT Behaviors Facilitating a Softening. Unpub-lished doctoral dissertation.

Bretherton, I. (1990). Open communication andinternal working models: Their role in the devel-opment of attachment relationships. In R.Dienstbier & R. Thompson (Eds.) ,Socioemotional development, Nebraska Sympo-sium on Motivation (pp. 57–114). Lincoln: Uni-versity of Nebraska Press.

Burman, B., & Margolin, G. (1992). Analysis of

the association between marital relationshipsand health problems. An interactionalperpective. Psychological Bulletin, 112, 39–63.

Collins, N.L. (1990). Working models of attach-ment: Implications for explanation, emotion,and behavior. Journal of Personality and SocialPsychology, 71, 810–832.

Collins, N.L., & Reed, S.J. (1990). Adult attach-ment, working models and relationship qualityin dating couples. Journal of Personality and So-cial Psychology, 58, 544–663.

Fincham, F.D., Beach, S.R., & Nelson. (1985).Attributions in close relationships. In J.H.Harvey & G. Weary (Eds.), Attribution: BasicIssues and Applications. Orlando, FL: AcademicPress.

Gordon-Walker, J., Johnson, S., Manion, I. &Cloutier, P. (1996). An emotionally focusedmarital intervention for couples with chronicallyill children. Journal of Consulting and ClinicalPsychology, 64, 1029-1036.

Gottman, J. (1994). What Predicts Divorce? TheRelationship Between Marital Processes andMarital Outcomes. Hillsdale, NJ: Erlbaum.

Greenberg, L.S. (1984). Task analysis: The gen-eral approach. In L.N. Rice & L.S. Greenberg(Eds.), Patterns of change: Intensive Analysis ofPsychotherapy Process (pp. 124–148). NewYork: Guilford Press.

Greenberg, L.S., & Foerster, F.S. (1996). Taskanalysis exemplified: The process of resolvingunfinished business. Journal of Consulting andClinical Psychology, 4, 443–446.

Greenberg, L.S., & Johnson, S.M. (1988). Emo-tionally Focused Therapy for Couples. NewYork: Guilford Press.

Greenberg, L.S., Ford, C.L., Alden, L.S., &Johnson, S.M. (1993). In–session change inemotionally focused therapy. Journal of Con-sulting and Clinical Psychology, 61, 78–84.

Hazan, C., & Shaver, P. (1987). Conceptualiz-ing romantic love as an attachment process.Journal of Personality and Social Psychology,52, 511–524.

Hazan, C., Shaver, P.R. (1994). Attachment asan organizational framework for research onclose relationships. Psychological Inquiry. Vol5(1), 1-22.

Holmes, J.G., Boon, S.D., & Adams, S. (1990).The Relationship Trust Scale. Unpublishedmanuscript. University of Waterloo, Waterloo,Canada.

Johnson, S.M. (1996). The Practice of Emotion-ally Focused Marital Therapy: Creating Connec-tions. New York: Brunner/Mazel.

Johnson, S.M., & Greenberg, L.S. (1985). Dif-ferential effects of experiential and prob-lem-solving interventions in resolving maritalconflict. Journal of Consulting and Clinical Psy-chology, 53, 175–181.

Johnson, S.M., & Greenberg, L.S. (1988). Relat-ing process to outcome in marital therapy. Jour-nal of Marital and Family Therapy, 14,175–183.

Johnson, S.M., & Greenberg, L.S. (1995). Theemotionally focused approach to problems inadult attachment. In N.S Jacobson & A.S.Gurman (Eds.), The Clinical Handbook of Mari-tal Therapy, 2d ed. New York: Guilford Press.

Johnson, S., & Simms, A. (2000). Creating se-cure bonds in couples therapy. In T. Levy (Ed.),Handbook of Attachment Interventions (pp.167–191). New York: Academic Press.

Johnson, S.M., & Talitman, E. (1997). Predic-tors of success in emotionally focused maritaltherapy. Journal of Marital and Family Therapy,23, 135–152.

Johnson, S. & Whiffen, V. (1999). Made to mea-sure: Adapting emotionally focused couples’therapy to partners’ attachment styles. ClinicalPsychology: Science & Practice, 6, 366-381.

Johnson, S.M., & Williams–Keeler, L. (1998).Creating healing relationships for couples deal-ing with trauma: The use of emotionally focusedcouples therapy. Journal of Marital and FamilyTherapy, 24, 25–40.

Johnson, S., Makinen, J., & Millikin, J. (2001).Attachment injuries in couple relationships.Journal of Marital and Family Therapy, 27,145–155.

Johnson, S.M., Hunsley, J., Greenberg, L.S., &Schindler, D. (1999). Emotionally focused cou-ples therapy: Status and challenges. Clinical Psy-chology: Science and Practice, 6, 67–79.

Klein, M., Mathieu., P., Kiesler, D., & Gendlin,E. (1969). The Experiencing Scale. Madison:Wisconsin Psychiatric Institute.

Kobak, R. R., & Hazan, C.(1991). Attachmentin marriage: Effects of security and accuracy ofworking models. Journal of Personality and So-cial Psychology, 60, 861–869.

Main, M., & Goldwyn, R. (1985). Adult attach-ment scoring and classification system. Berkeley:University of California Press.

Millikin, J.W. (2000). Resolving attachment in-juries in couples using emotionally focused ther-apy: A process study. Unpublished doctoraldissertation, Virginia Polytechnic Institute andState University.

Roberts, T.W. (1992). Sexual attraction and ro-mantic love: Forgotten variables in marital ther-apy. Journal of Marital and Family Therapy, 18,357–364.

Segraves, R.J. (1990). Theoretical orientationsin the treatment of marital discord. In F.D.Fincham & T.N. Bradbury (Eds.). The Psychol-ogy of Marriage (pp. 281–298). New York:Guilford Press.

Simpson, J. A., Rholes, W., & Nelligan, J.(1992). Support seeking and support givingwithin couples in an anxiety provoking situa-tion: The role of attachment styles. Journal ofPersonality and Social Psychology, 62,434–446.

Simpson, J.A., & Rholes, W.S. (1998). Attach-ment Theory and Close Relationships. NewYork: Guilford Press.

Van der Kolk, B.A., & McFarlane, A.C. (1996).The black hole of trauma. In Traumatic Stress:


The Effects of Overwhelming Experience onMind, Body, and Society (pp. 3–323).NewYork: Guilford Press.

Walker, J. & Manion, I. (1998). A two year fol-low-up on an emotionally focused interventionfor couples with chronically ill children. Unpub-lished manuscript.

Weiss, K.L. (1982). Attachment and adult life. InC.M. Parks and J. Stevenson–Hinde (Eds.), ThePlace of Attachment in Human Behavior. (pp.171–184). New York: Basic Books.

Weiss, K.L., & Sheldon–Keller, A. E. (1994).Patterns of Relating and Adult Attachment Per-spectives. New York: Guilford Press.

Naaman et al. 77

treating attachment injured couples with emotionally focused therapy - a case study approach

Documents

theory of attachment

attachment bond

attachment needs

identified attachment

attachment pattern

secure attachment

attachment injured couples

nonresolved couple