Toward a culturally sensitive application of emotionally focused couples therapy: A qualitative study of therapists' experience using EFT in Spanish-speaking countries/cultures.

The purpose of the current study was to identify specific ways Emotionally Focused Couples Therapy (EFT; S. Johnson) could be adapted to better meet the needs of clients in Spanish-speaking countries throughout Europe and the Americas. The results were drawn from responses to a qualitative questionnaire regarding the experiences of learning and applying EFT; 103 therapists in 12 different countries where Spanish is spoken responded to the survey. Overall, the results suggest that the therapists surveyed consider EFT to be a "good fit" for many Spanish-speaking clients because of its focus on emotion, attachment theory, close interpersonal relationships, and model-specific interventions that match cultural values. Participants suggested a few culture-specific modifications regarding how to access and process emotion with men in therapy, translation of key EFT concepts and phrases into Spanish, and navigating the intersection of two cultural values (respeto and personalismo). Fewer modifications were suggested by therapists as they discussed application of the model than while learning it.

Family Adversity and Relationship Quality for Pacific Islanders and the Mediating Role of Coming to Terms, Self-Esteem, and Depression.

This study investigated the association between family of origin (FOO) adversities and relationship quality for Pacific Islanders as well as the potential intermediary role of coming to terms (CTT), depression, and self-esteem. The sample consisted of 226 self-identified Pacific Islanders who completed the RELATE assessment (see www.relate-institute.org). Results indicated that greater levels of FOO adversity predicted lower levels of CTT. However, higher levels of CTT in turn associated with higher self-esteem, and lower levels of depression. Results also indicated that greater FOO adversity associates with lower relationship quality indirectly. The clinical implications of these findings and directions for future research are discussed.

The Experience of Learning EFT in Spanish-speaking Countries: A Multi-National Replication Study.

This study is a multi-national follow-up to the original (Sandberg and Knestel (2011) Journal of Marital and Family Therapy, 37, 393-410) article on the process of learning Emotionally Focused Couples Therapy (EFT). A total of 102 clinicians from nine Spanish-speaking countries (Mexico, Costa Rica, Guatemala, Spain, Colombia, Argentina, Chile, Ecuador, and El Salvador) participated in the study. A comparison of results across the two studies revealed more similarities than differences. However, a few notable differences emerged from responses to qualitative questions, namely a heightened sense of appreciation for and resonance with the focus on core emotion in EFT and less frequent reports of difficulty learning and adapting to the model among Spanish-speaking therapists. These differences were consistent with common cultural values and forms of expression in Latin America and Spain. Results are discussed in terms of training, supervision, and future research as well.

Short-Term and Long-Term Effects of Training in EFT: A Multinational Study in Spanish-speaking Countries.

This study seeks to validate the cross-cultural effectiveness of emotionally focused couple therapy (EFT) training in a sample of Spanish-speaking clinicians. The 28-hr formalized training for EFT was offered in six different Spanish-speaking countries, covering Europe, North America, Central America, and South America. Two hundred and seven therapists of 14 different Spanish-speaking nationalities completed pre-training assessments, 153 of them completed post-training assessments, and 92 therapists also completed the follow-up assessment. Using multilevel growth modeling (MLM), results indicated that therapists experienced significant and positive changes in terms of EFT competence (knowledge and skill acquisition), mature empathy, self-compassion, and attachment over time. Implications for transnational EFT training, specifically in Spanish-speaking countries, are discussed.

They May Disapprove, but I Still Love You: Attachment Behaviors Moderate the Effect of Social Disapproval on Marital Relationship Quality.

The degree of approval for a relationship from one's social network has been shown to predict relationship outcomes. Additional research has shown that attachment can buffer the negative effects of various factors (e.g., depression) on relationships. Using an actor-partner interdependence model in an SEM framework, we research the effects of disapproval from parents and friends for one's relationship on marital relationship quality for self and partner in a sample of 858 married couples. We also examine whether each spouse's attachment behaviors can moderate these effects. Results indicated that one's own attachment behaviors moderate the effects of their own parents' and friends' disapproval on their self-reported relationship quality for both men and women. Partner's attachment behaviors moderate own friend's disapproval on self-reported relationship quality for men and women; additionally, the main effect of partner's friends' and parents' disapproval became nonsignificant with that test. The findings provide evidence that attachment behaviors of both partners play a role in buffering the negative effects of the social network disapproval on relationship outcomes. Clinical implications are discussed.

Se ha demostrado que el grado de aprobación de una relación desde la red social de una persona predice los resultados de las relaciones. Otras investigaciones han demostrado que el apego puede moderar los efectos negativos de varios factores (p. ej.: la depresión) en las relaciones. Utilizando un modelo de interdependencia actor-pareja en un marco de modelos de ecuaciones estructurales, investigamos los efectos de la desaprobación por parte de los padres y los amigos de la relación de una persona en la calidad de la relación conyugal para la persona y su pareja en una muestra de 858 parejas casadas. También analizamos si las conductas de apego de cada cónyuge pueden moderar estos efectos. Los resultados indicaron que las conductas de apego propias de la persona moderan los efectos de la desaprobación por parte de sus propios padres y amigos en la calidad de la relación autoinformada tanto en el caso de los hombres como en el de las mujeres. Las conductas de apego del cónyuge moderan la desaprobación de sus propios amigos en la calidad de la relación autoinformada tanto en el caso de los hombres como en el de las mujeres. Además, el efecto principal de la desaprobación por parte de los padres y los amigos del cónyuge se volvió no significativo con esa prueba. Los resultados ofrecen pruebas de que las conductas de apego de ambos integrantes de la pareja desempeñan un papel en la moderación de los efectos negativos de la desaprobación por parte de la red social en los resultados de las relaciones. Se debaten las implicancias clínicas.

The importance of relationship processes for lowering BMI over time in women with type 2 diabetes in a randomized controlled trial.

OBJECTIVE: Weight change may be affected by dyadic processes within couple relationships. The aim of this secondary data analysis was to explore trends in BMI across time, and assess whether relationship processes (i.e., relationship satisfaction, positive problem-solving), predict BMI trajectories in men and women. METHODS: Data are from 268 participants in the Diabetes Support Project, a randomized trial of behavioral intervention for individuals with type 2 diabetes (T2D) in poor glycemic control. For secondary analyses, BMI was measured at pre-treatment (baseline), 4 months (post-treatment), 8 months, and 12 months. Multiple relationship variables were measured at all time points and were modeled as predictors and correlates of change in BMI across time. RESULTS: In general, BMI trajectories had higher starting values (intercepts) for females than for males in the sample (b = -2.51, p < .05), and slopes trended downward from pre-treatment to 12 months (b = -.09, p <  .05). Downward trajectories of BMI were more pronounced for women with higher relationship satisfaction (b = .05, p <  .05) and higher positive problem solving skills (b = .06, p < .05) at baseline. Change in relationship processes were not correlated with change in BMI across time. CONCLUSION: For women with T2D in this behavioral intervention study, relationship process scores at the beginning of treatment predicted changes in BMI over time, with better problem solving and higher relationship satisfaction at baseline related to steeper decreases in BMI across treatment. Additional research is needed to understand how improving relationship interaction prior to diabetes treatment may positively influence weight loss during treatment.

Baby with the Bathwater? Examining the Relationship between Video Game Use and Relationship Outcomes and the Moderating Effects of Attachment Behaviors among Married Casual Gamers.

We examined whether time together as a problem mediates the link between frequency of video game use and relational outcomes (relationship quality, relational aggression, physical aggression) among 431 married couples. We also examined the moderating effect of couple attachment behaviors on the association between time together as a problem and outcomes. There was no support for a direct or indirect relationship between gaming and outcomes; however, time together as a problem was consistently related to outcomes. Additionally, husband's and wife's attachment behaviors moderated the association between women's reports of time together as a problem and men's relational aggression. Clinical implications are discussed.

Using Difference Scores to Inform Therapy Practice: Differences in Perceptions of Attachment Behaviors between Partners in a Clinical Sample.

Using clinically relevant research methodology, this study focuses on differences (cross-partner difference scores) in perceptions of attachment behaviors (emotional accessibility, responsiveness, and engagement) between partners in couples therapy. In general, findings suggest that higher levels of self-enhancement attachment behaviors (participant perceives self as demonstrating more attachment behaviors than the partner's ratings of the participant) are associated with lower relationship satisfaction and greater relationship instability. The association between attachment behavior difference scores and measures of relationship health is mediated through partner perceived positive communication. These results suggest that differences in perceptions between partners' level of attachment behaviors are an important clinical construct for therapy. As such, clinical recommendations for addressing self-enhancing attachment behaviors, and the mediating role of positive communication, are discussed with recommendations for researchers.

Differentiating Between Attachment Styles and Behaviors and their Association with Marital Quality.

The purpose of this study was to distinguish between the influence of attachment styles and behaviors on marital quality for couples. Data were gathered from 680 couples in a married relationship. Results showed attachment style and behaviors predicted marital quality for both men and women, with higher levels of attachment related to greater quality. Attachment behaviors predicted more of the variance in quality than did styles. Specific implications regarding how therapists may wish to foster behaviors that promote attachment security in marriages are discussed.

Does Improving Marital Quality Improve Sleep? Results From a Marital Therapy Trial.

For most adults, sleep is a dyadic behavior. Only recently have studies explored the dynamic association between sleep and relationship functioning among bed partners. The current study is the first to examine bidirectional associations between changes in insomnia and changes in marital quality over time, in the context of a marital therapy trial. Among husbands, improvements in marital satisfaction were associated with a 36% decreased risk of insomnia at follow-up. Regarding the reverse direction, counter-intuitively, wife baseline insomnia was associated with improvements in husbands' marital satisfaction, but only among the non-treatment-seeking comparison group. Results are discussed in terms of implications for sleep and marital therapy, and suggest that improving sleep may be an added benefit of improving the marital relationship.

The Association between the Parent-Child Relationship and Symptoms of Anxiety and Depression: The Roles of Attachment and Perceived Spouse Attachment Behaviors.

Research shows that the parent-child relationship affects attachment security, which correlates with anxiety and depression in adulthood. Additional research shows that romantic attachment behaviors may supersede individual attachment security and buffer against negative processes. Using data from 680 married couples in the general population, we examined whether attachment mediates the link between the parent-child relationship and depressive and anxiety symptoms in adulthood. In addition, we tested whether perceived spouse attachment behaviors moderate the effects of attachment insecurity. There was an indirect effect of poor parent-child relationships on symptoms via insecure attachment. Perception of spouse's attachment behaviors was related to depression for both spouses, and they moderated the effect of attachment insecurity on depressive symptoms for husbands. Clinical implications are discussed.

The Role of Attachment Behaviors in the Link between Relationship Satisfaction and Depression in Clinical Couples: Implications for Clinical Practice.

Using dyadic, clinical data from 104 couples in committed relationships, the purpose of this study was to determine whether relationship satisfaction was associated with depression through perceived partner attachment behaviors-accessibility, responsiveness, and engagement-for both men and women. We found that one's satisfaction in the relationship was the lens through which they viewed their partner's attachment behaviors and-women's relationship satisfaction was the lens through which her male partner viewed her attachment behaviors. Finally, women's relationship satisfaction is associated with both individuals' depression through her perceived partner's accessibility, responsiveness, and engagement. The findings from this study are important because they provide clinically relevant and mutable constructs in which clinicians can intervene at an attachment level in distressed marriages with depressed partners.

The Brief Accessibility, Responsiveness, and Engagement Scale: A Tool for Measuring Attachment Behaviors in Clinical Couples.

Measuring attachment behaviors is relevant to creating secure couple relationships. This article seeks to test and examine the reliability and validity of the Brief Accessibility, Responsiveness, and Engagement (BARE) Scale-a practical measure of couple attachment-in a clinical sample. Couples took the BARE and other assessments measuring relationship functioning (self and partner reports of relationship satisfaction, relationship stability, positive and negative communication, and attachment styles). Results suggest that the BARE appears to be a reliable and valid tool for assessing couple attachment and can accurately predict and classify whether the couples belong in the clinical or nonclinical group, as well as their level of relationship satisfaction. Results also indicate attachment behaviors are related to relationship outcomes.

Gender differences in couple attachment behaviors as predictors of dietary habits and physical activity levels.

This study used an Actor-Partner Interdependence Model to examine the relationship between attachment behaviors and health practices, as measured by physical activity levels and dietary habits. The sample included 1031 married couples, the majority of which is Caucasian (83.8%). Results suggest that women's attachment behaviors significantly influenced their own health practices (p = .038), such that for every unit increase in poor attachment behaviors, women were 199.8 percent more likely to have poor diet and low physical activity levels (exp(1.098) = 2.998). Men's attachment behaviors were not significantly related to their own health practices. There were also no significant partner paths. Implications for treating women who present with health problems are discussed, as are directions for future research.

A Longitudinal View of the Association Between Therapist Warmth and Couples' In-Session Process: An Observational Pilot Study of Emotionally Focused Couples Therapy.

This longitudinal dyadic clinical process study used coded data from eleven couples to determine the influence of therapist warmth behaviors on couples' warmth behaviors over time in therapy. A mixed effects model was used to examine within- and between-individual variability. Men and women were modeled separately. A series of two-level multilevel models of change were examined, where Time is Level 1 and Individual is Level 2. Findings were mixed. There was no significant relationship between therapist warmth toward wife and wife warmth toward husband; however, there was a significant relationship between therapist warmth toward husband and husband warmth toward wife. Findings demonstrated that 62.9% of the variance in husband warmth toward wife was accounted for by therapist warmth to husband across time in therapy. Specifically, therapist warmth toward husband was significantly and positively related to husband warmth toward wife over time in therapy. Clinical implications and directions for future research are discussed.

Insecure attachment behavior and partner violence: incorporating couple perceptions of insecure attachment and relational aggression.

Intimate partner violence and insecure attachment are therapeutically relevant concepts when working with couples. The link between attachment and intimate partner violence has been examined in the literature, but an area of aggression that often goes unexamined is relational aggression, or using third parties as a means of being aggressive toward a partner. We asked how participants' attachment behaviors were related to their own and partners' relational and physical aggression. We used structural equation modeling to estimate actor-partner interdependence among these relationships in 644 heterosexual couples. Results indicated significant partner paths from attachment to relational aggression, as well as significant actor paths between relational aggression and physical aggression. Implications were discussed. Data for this study were collected from the RELATE assessment.

Older couples with and without cardiovascular disease: testing associations between and among affective communication, marital satisfaction, physical and mental health.

The American Heart Association (Go et al., 2013) estimated that about 2,150 Americans die each day from cardiovascular disease (CVD). For those 65 years of age or older, the total cost of heart related services in 2009 was $121.2 billion (Go et al., 2013). Many people live with the chronic conditions of cardiovascular disease (Petersen et al., 2005). Researchers have identified the genetic, medical, and lifestyle habits of those with CVD, yet there is a dearth of literature focusing on the relational/social aspects of cardiovascular disease and how such factors are associated with the risk, presentation, and maintenance of cardiovascular illness. Considering that men have a higher lifetime risk for developing CVD than women (51.7% to 39.2%; Roger et al., 2012), the purpose of this study was to compare various aspects of the couple relationship among and between couples with a husband who reports CVD and couples in which neither report CVD.

Personal and relationship challenges of adults with type 1 diabetes: a qualitative focus group study.

OBJECTIVE: Little is known about the psychosocial challenges of adults living with type 1 diabetes or its impact on partner relationships. This qualitative study was undertaken to gain better understanding of these issues. RESEARCH DESIGN AND METHODS: Four focus groups were held, two with adult type 1 diabetic patients (n = 16) and two with partners (n = 14). Two broad questions were posed: "What are the emotional and interpersonal challenges you have experienced because you have (your partner has) type 1 diabetes?" and "How does the fact that you have (your partner has) type 1 diabetes affect your relationship with your partner, positively and/or negatively?" Sessions were recorded and transcribed, and analyzed by a team of four researchers, using constant comparative methods to identify core domains and concepts. RESULTS: Four main domains were identified: 1) impact of diabetes on the relationship, including level of partner involvement, emotional impact of diabetes on the relationship, and concerns about child-rearing; 2) understanding the impact of hypoglycemia; 3) stress of potential complications; and 4) benefits of technology. Themes suggest that, although partner involvement varies (very little to significant), there exists significant anxiety about hypoglycemia and future complications and sources of conflict that may increase relationship stress. Partner support is highly valued, and technology has a positive influence. CONCLUSIONS: Adults with type 1 diabetes face unique emotional and interpersonal challenges. Future research should focus on gaining a better understanding of how they cope and the effect of psychosocial stressors and coping on adherence, quality of life, and glycemic control.

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).

Stress spillover of health symptoms from healthy spouses to patient spouses in older married couples managing both diabetes and osteoarthritis.

Many studies examining illness within marriage have investigated how illness in one spouse influences the other spouse. In later-life marriages, where both spouses are more likely to have health challenges, there is an increased likelihood that health symptoms from both spouses affect each other. In the current study we examined how health symptoms in a "healthy" spouse may exacerbate health problems in a partner (the patient) who is managing multiple chronic illnesses. Surveys were collected across 14 days from 27 later-life couples where patients had both diabetes and osteoarthritis. Results indicated that higher healthy spouse symptoms were generally associated with higher patient symptoms, suggesting a spillover effect. Spouse reports of positive and negative mood were inversely linked with patient health outcomes. Spouse reports of higher positive marital interactions were surprisingly linked with higher patients' arthritis activity and activity limitations, possibly indicating a compensatory effect where marital interactions increase with symptoms. Daily spouse reports of positive marital interactions and mood were linked with patient health outcomes even after the spillover of health symptoms was taken into account.