A review of the research during 2010-2019 on evidence-based treatments for couple relationship distress.

The current article presents a review of the published research from 2010 to 2019 on the treatment of couple relationship distress; 37 studies met all criteria for inclusion. Behavioral Couple Therapy, Cognitive Behavioral Couple Therapy, Emotionally Focused Therapy, and Integrative Behavioral Couple Therapy meet criteria as "well-established" approaches, Insight-Oriented Couple Therapy is a "possibly efficacious" approach, and several other others are "experimental" treatments for treating couple relationship distress (Southam-Gerow & Prinstein, 2014). Furthermore, several less-intensive interventions-the Marriage Check-up, OurRelationship, and Hold Me Tight programs-have generated substantial support for their ability to improve relationships and are classified as "well-established" or "probably efficacious" interventions. We recommend that future research focus on expanding the reach of evidence-based interventions across a range of settings and populations, deepening our understanding of the mechanisms of change and underlying factors in the change process across approaches, and improving treatment success through treatment matching and progress monitoring.

Emotionally focused therapy: Attachment, connection, and health.

In this review, we suggest attachment science as a framework for understanding the negative impact of loneliness and social disconnection on mental and physical health and for guiding the interventions of clinicians. We provide an overview of current findings linking loneliness and social isolation to mental health problems such as depression and anxiety, as well as to physical illnesses such as heart disease. We propose emotionally focused therapy for couples, families, and individuals to enhance the quality of people's emotional ties to significant others and their subjective sense of social connectedness. We conclude by suggesting that the strengthening of emotional, interpersonal bonds, which is the primary focus of all forms of emotionally focused therapy, can help restore emotional balance, thereby protecting people from chronic feelings of isolation and the host of health problems that they can cause.

Practicing Emotionally Focused Therapy online: Calling all relationships.

In the midst of a global pandemic, couples are dealing a range of impacts that call for a cohesive unit while the virus frays at the edges of our most important relationships. Emotionally Focused Therapy (EFT) is an evidence-based approach to working with relationships rooted in attachment theory. As a process-oriented psychotherapy, EFT is an ideal approach to working with relationships during this pandemic helping to solidify an "in it together" approach required to survive both as a couple and the pandemic. In this paper, we briefly review the adaptations for moving a couple therapy practice online through an EFT lens, drawing on an EFT macro-intervention called the "Tango" as a focus in this process. We conclude the paper with a case example providing the reader with an illustration of the process and ideas for what to pay attention to when working online with a couple from an EFT perspective.

The Healing Hearts Together Randomized Controlled Trial and the COVID-19 Pandemic: A Tutorial for Transitioning From an In-Person to a Web-Based Intervention.

Supportive couple relationships are associated with reduced risk of chronic illness development, such as cardiovascular disease, as well as improved secondary prevention. Healing Hearts Together (HHT) is an 8-week couples-based intervention designed to improve relationship quality, mental health, quality of life, and cardiovascular health among couples in which one partner has experienced a cardiac event. A randomized controlled trial began in October 2019 to test the efficacy of the in-person, group-based HHT program as compared to usual care. In March of 2020, all recruitment, assessments, and interventions halted due to the COVID-19 pandemic. Guided by optimal virtual care principles, as well as by Hom and colleagues' four-stage framework-consultation, adaptation, pilot-testing, and test launch-this paper is a tutorial for the step-by-step transition planning and implementation of a clinical research intervention from an in-person to a web-based format, using the HHT program as an example. Clinical and research considerations are reviewed, including (1) privacy, (2) therapeutic aspects of the intervention, (3) group cohesion, (4) research ethics, (5) participant recruitment, (6) assessment measures, (7) data collection, and (8) data analyses. This tutorial can assist clinical researchers in transitioning their research programs to a web-based format during the pandemic and beyond.

A pilot multi-centre prospective randomised controlled trial of RECELL for the treatment of venous leg ulcers.

Venous leg ulcers (VLUs) have a significant impact on approximately 3% of the adult population worldwide, with a mean NHS wound care cost of £7600 per VLU over 12 months. The standard care for VLUs is compression therapy, with a significant number of ulcers failing to heal with this treatment, especially with wound size being a risk factor for non-healing. This multicentre, prospective, randomised trial evaluated the safety and effectiveness of autologous skin cell suspension (ASCS) combined with compression therapy compared with standard compression alone (Control) for the treatment of VLUs. Incidence of complete wound closure at 14 weeks, donor site closure, pain, Health-Related Quality of Life (HRQoL), satisfaction, and safety were assessed in 52 patients. At Week 14, VLUs treated with ASCS + compression had a statistically greater decrease in ulcer area compared with the Control (8.94 cm2 versus 1.23 cm2 , P = .0143). This finding was largely driven by ulcers >10 to 80 cm2 in size, as these ulcers had a higher mean percentage of reepithelialization at 14 weeks (ASCS + compression: 69.97% and Control: 11.07%, P = .0480). Additionally, subjects treated with ASCS + compression experienced a decrease in pain and an increase in HRQoL compared with the Control. This study indicates that application of ASCS + compression accelerates healing in large venous ulcers.

Reducing Caregiver Distress and Cardiovascular Risk: A Focus on Caregiver-Patient Relationship Quality.

Spouses report elevated levels of distress upon assuming a caregiver role; this role and related distress might, ironically, increase the cardiovascular risk of spousal caregivers of patients with cardiovascular disease (CVD). Physiological, behavioural, and emotional factors experienced by caregivers can contribute to enhanced CVD risk. Despite an appreciation of these established associations few approaches have shown effectiveness in reducing a caregiver's stress. It is known that CVD can produce additional strain on a caregiver-patient relationship, in turn accentuating caregiver distress. Poor relationships are known to be a detriment to cardiovascular health and negatively influence behaviours affecting CVD risk and outcomes. In light of these findings, we argue in this nonsystematic narrative review that enhancing caregiver-patient relationship quality in secondary prevention programs might afford an appropriate and timely opportunity to reduce caregiver distress and improve the cardiovascular health of the patient and their spousal caregiver. Evaluations of the effect of couples-based interventions on patient and caregiver CVD risk and health outcomes are required.

Conversations for Connection: An Outcome Assessment of the Hold-Me-Tight Relationship-Education Program, and Recommendations for Improving Future Research Methodology in Relationship Education.

The Hold Me Tight (HMT) program is a new approach to relationship education based on Emotionally-Focused Therapy (Johnson, 2004), an evidence-based approach to couple therapy. In this exploratory longitudinal research, we examined individual growth in relationship satisfaction and trust for partners in 95 couples in 16 HMT groups across four occasions of measurement: Baseline, Pre-Program, Post-Program and at either 3- or 6-month Follow-Up. We found that relationship satisfaction and trust increased during program participation, and declined during follow-up. We believe our findings provide support for the short-term effectiveness of the HMT program, and suggest a longer period of program delivery may result in improved retention of gains. Finally, we present recommendations for improving the design of future longitudinal research in relationship education.

The Impact of Blamer-softening on Romantic Attachment in Emotionally Focused Couples Therapy.

Emotionally Focused Couples Therapy (EFT; Johnson, ) treats relationship distress by targeting couples' relationship-specific attachment insecurity. In this study, we used hierarchical linear modeling (Singer & Willett, ) to examine intercept and slope discontinuities in softened couples' trajectories of change in relationship satisfaction and relationship-specific attachment over the course of therapy from a total sample of 32 couples. Softened couples (n = 16) reported a significant increase in relationship satisfaction and a significant decrease in attachment avoidance at the softening session. Although softened couples displayed an initial increase in relationship-specific attachment anxiety at the softening session, their scores significantly decreased across post-softening sessions. Results demonstrated the importance of the blamer-softening change event in facilitating change in EFT.

Creating relationships that foster resilience in Emotionally Focused Therapy.

Emotionally Focused Therapy for Couples (EFT) is an evidence-based couple therapy based in attachment theory. Research has amassed over the past three decades pointing to the role of relationships in health and and well-being. Affective neuroscience suggests that secure relationships appear to foster adaptive stress co-regulation. The effectiveness of EFT has been demonstrated in couples facing high levels of stress, and has been shown to reduce depressive and post-traumatic stress symptoms. Furthermore, EFT has been shown to help couples regulate their neurophysiological stress response. In this paper we review the literature in attachment, affective neuroscience and EFT and propose that creating secure attachment bonds for couples can help foster resilience.

Two-Year Follow-up Outcomes in Emotionally Focused Couple Therapy: An Investigation of Relationship Satisfaction and Attachment Trajectories.

Emotionally Focused Couple Therapy (EFT; The practice of emotionally focused couple therapy: Creating connection. New York, NY: Brunner-Routledge) is an evidence-based couple therapy that aims to create lasting change for couples (Clinical Psychology: Science and Practice, 6(1), 67-79). Although studies have demonstrated strong results in follow-up (Journal of Marital and Family Therapy, 28(4), 391-398), less is known about relationship functioning across time after therapy has ended. We modelled change in relationship satisfaction and attachment from pre-therapy through 24 months follow-up in 32 couples. HLM results confirmed a significant growth pattern demonstrating increases in relationship satisfaction and secure base behaviour and decreases in relationship specific attachment anxiety over the course of therapy and across follow-up at a decelerated rate. These findings support the theoretical assumption that EFT helps couples engaged in therapy create lasting relationship satisfaction and attachment change.

Predicting Follow-up Outcomes in Emotionally Focused Couple Therapy: The Role of Change in Trust, Relationship-Specific Attachment, and Emotional Engagement.

Emotionally Focused Couple Therapy (EFT), an evidence-based couple therapy (Johnson, Hunsley, Greenberg, & Schindler, 1999), strives to foster lasting change through the creation of secure attachment bonds in distressed couples. Although studies have demonstrated lasting change in follow-up (Wiebe et al., in press), research is needed to investigate predictors of long-term outcomes. Our goal was to investigate predictors of long-term outcomes in relationship satisfaction. Relationship satisfaction was assessed across 24 months in a sample of 32 couples who received an average of 21 EFT sessions. Decreases in attachment avoidance were most predictive of higher relationship satisfaction across follow-up. These findings support the theoretical assumption that EFT helps couples foster lasting change in relationship satisfaction through the facilitation of secure attachment bonds.

A Review of the Research in Emotionally Focused Therapy for Couples.

Emotionally Focused Therapy for Couples (EFT) is a brief evidence-based couple therapy based in attachment theory. Since the development of EFT, efficacy and effectiveness research has accumulated to address a range of couple concerns. EFT meets or exceeds the guidelines for classification as an evidence-based couple therapy outlined for couple and family research. Furthermore, EFT researchers have examined the process of change and predictors of outcome in EFT. Future research in EFT will continue to examine the process of change in EFT and test the efficacy and effectiveness of EFT in new applications and for couples of diverse backgrounds and concerns.

Changes in Relationship-Specific Attachment in Emotionally Focused Couple Therapy.

Emotionally focused couple therapy (EFT; Johnson, The practice of emotionally focused couple therapy (1st/2nd edition). Brunner-Routledge, New York, 2004) is an effective treatment of relationship distress (Johnson et al., Clinical Psychology: Science and Practice, 1999; 6, 67). However, less is known about EFT's impact on couples' relationship-specific attachment bond. Using hierarchical linear modeling with a sample of 32 couples, we examined session-by-session changes in couples' relationship-specific attachment anxiety and avoidance and pre- to posttherapy changes in their relationship-specific attachment behaviors. Couples significantly decreased in relationship-specific attachment avoidance, and those who completed a blamer softening significantly decreased in relationship-specific attachment anxiety. Couples' attachment behavior significantly increased toward security. Finally, session-by-session decreases in relationship-specific attachment anxiety and avoidance were significant associated with increases in relationship satisfaction across sessions. These results provide empirical support for the attachment-based assumptions of EFT. Video abstract accessible by clicking here.

Predicting Change in Marital Satisfaction Throughout Emotionally Focused Couple Therapy.

Emotionally focused couple therapy (EFT) is an empirically validated approach to couple therapy that uses attachment theory to understand the needs and emotions of romantic partners. EFT is recognized as one of the most effective approaches to couple therapy, but to guide therapists in their use of EFT, a theoretically based model to predict change is needed. This study tested such a model by recruiting 32 couples, and 14 therapists who provided approximately 21 sessions of EFT. Couples completed self-report measures of marital satisfaction, attachment security, relationship trust, and emotional control at pre- and posttherapy and after each therapy session. Results of hierarchical linear modeling suggested that individuals higher on self-report attachment anxiety and higher levels of emotional control had greater change in marital satisfaction across EFT sessions. Assessing attachment security at the start of therapy will inform therapists of the emotion regulating strategies used by couples and may help couples achieve positive outcomes from EFT.

Predicting Key Change Events in Emotionally Focused Couple Therapy.

In emotionally focused couple therapy (EFT), the blamer-softening event helps individuals express and respond to partners' unmet attachment needs. This study examined the impact of this event in relation to attachment at intake and changes in marital satisfaction from pre- to posttherapy. Thirty-two couples were provided an average of 21 sessions of EFT. Hierarchical linear modeling revealed that the occurrence of a softening event significantly predicted increased marital satisfaction. Furthermore, the occurrence of a softening event significantly moderated the relationship between attachment avoidance at intake and change in marital satisfaction from pre- to posttherapy. For couples who had a softening event, partners with higher levels of attachment avoidance were less likely to have positive changes in marital satisfaction.

Soothing the threatened brain: leveraging contact comfort with emotionally focused therapy.

Social relationships are tightly linked to health and well-being. Recent work suggests that social relationships can even serve vital emotion regulation functions by minimizing threat-related neural activity. But relationship distress remains a significant public health problem in North America and elsewhere. A promising approach to helping couples both resolve relationship distress and nurture effective interpersonal functioning is Emotionally Focused Therapy for couples (EFT), a manualized, empirically supported therapy that is strongly focused on repairing adult attachment bonds. We sought to examine a neural index of social emotion regulation as a potential mediator of the effects of EFT. Specifically, we examined the effectiveness of EFT for modifying the social regulation of neural threat responding using an fMRI-based handholding procedure. Results suggest that EFT altered the brain's representation of threat cues in the presence of a romantic partner. EFT-related changes during stranger handholding were also observed, but stranger effects were dependent upon self-reported relationship quality. EFT also appeared to increase threat-related brain activity in regions associated with self-regulation during the no-handholding condition. These findings provide a critical window into the regulatory mechanisms of close relationships in general and EFT in particular.

Process research on Emotionally Focused Therapy (EFT) for couples: linking theory to practice.

The focus of this article is on the link among theory, process, and outcome in the practice of Emotionally Focused Therapy (EFT) for couples. We describe the EFT model of change and the EFT perspective on adult love as the reflection of underlying attachment processes. We outline the manner in which theory and research inform EFT interventions. This leads into a detailed review of the literature on the processes of change in EFT. We highlight the client responses and therapist operations that have emerged from process research and their relation to treatment outcomes. We discuss the implications of this body of research for clinical practice and training.

The brief accessibility, responsiveness, and engagement (BARE) scale: a tool for measuring attachment behavior in couple relationships.

This article describes the purpose, reliability, validity, and potential clinical applications of the brief accessibility, responsiveness, and engagement (BARE) scale. In addition to focusing on the central attachment behaviors of accessibility and responsiveness, this instrument highlights the key role of engagement in couple bonding. The BARE is a short, systemic, self-report measure of attachment behaviors in couple relationships. Both classical testing theory and item response theory were used to test the psychometric properties of the instrument. The BARE demonstrated appropriate reliability and validity while maintaining its brevity and potential usefulness for clinicians and researchers. The BARE also accurately predicted the key relationship outcomes of stability and satisfaction. The data for this study were collected from the RELATE assessment (see www.relate-institute.org).

New research findings on emotionally focused therapy: introduction to special section.

This article introduces the special section "New Research Findings on Emotionally Focused Therapy." Emotionally focused couple therapy researchers have a strong tradition of outcome and process research and this special section presents new findings from three recent studies. The first study furthers the goal of determining the kinds of clients for which EFT is effective (Denton, Wittenborn, & Golden, this issue) and the next two studies (Furrow, Edwards, Choi, & Bradley, this issue; Wittenborn, this issue) focus on the person of the therapist and provide some implications for EFT intervention and training. Together, these three studies provide valuable lessons on how to deepen our knowledge of the application of EFT for different populations and therapists.

United we stand: emotionally focused therapy for couples in the treatment of posttraumatic stress disorder.

We present emotionally focused therapy (EFT) for couples as a viable treatment option for posttraumatic stress disorder (PTSD). We outline the empirical evidence of a link between interpersonal relationships and posttraumatic stress, with an emphasis on social support as a buffer for the development of PTSD symptoms. This leads into a discussion of the usefulness of attachment theory in the conceptualization and treatment of PTSD, followed by a description of the EFT approach and its empirical evidence. We present a clinical case with excerpts from EFT couple therapy sessions in which one partner was diagnosed with PTSD. The article concludes with clinical recommendations for helping people confront and overcome the pain and the fear that PTSD provokes.