Tag Archives: emotionally focused therapy

Building a foundation in premarital counseling

By Bethany Bray January 31, 2022

For many people, the phrase “premarital counseling” may conjure the image of a young, starry-eyed couple doing short-term work with a counselor or religious leader to discuss issues such as whether they’d like to have children or who will be responsible for cooking and taking out the trash.

While that scenario can and does still happen, more U.S. adults are delaying marriage. According to the U.S. Census Bureau, the median age for first-time marriage was 28.6 for women and 30.4 for men in early 2021. In 2000 and 1980, those statistics were 25.1 and 22 years for women and 26.8 and 24.7 years for men, respectively.

In addition, fewer American adults are choosing to say “I do” at all. The Pew Research Center estimates that roughly half (53%) of all U.S. adults are married, which is down from 58% in 1995 and 72% in 1960. Between 1995 and 2019, the number of unmarried Americans who were cohabiting rose from 3% to 7%.

These gradual but notable changes have led professional counselors to evolve their approaches to meet the needs of today’s premarital couples, regardless of whether they have a wedding date marked on the calendar. For Stacy Notaras Murphy, a licensed professional counselor (LPC) with a private practice in the Georgetown section of Washington, D.C., premarital counseling includes the couples on her caseload who are planning a wedding as well as those who are in unmarried yet long-term relationships.

In the two decades that Murphy has done premarital counseling, she has shifted from a top-down, topic-focused approach to a bottom-up approach that addresses attachment style and other deeper issues. This is not only because couples’ needs have shifted over the years, Murphy says, but also because recent research indicates the meaningful role that attachment plays in human relationships across the life span.

It is still important to prompt couples to talk through “big-ticket items” such as their expectations about finances, children, sex and intimacy, and the role that family and extended family will play in their lives, Murphy says. But premarital counseling should also build a foundation for couples to engage in these types of deep discussions — and navigate conflict when it inevitably arises — on their own in a healthy way, she stresses.

“All of these topics are grist for the mill,” says Murphy, an American Counseling Association member. “At the end of the day, couples want to understand themselves more deeply, and you don’t get there on your own by talking about what your goals are for retirement [and other topics]. … More so, it’s focusing on the steps that partners take to get their needs met and how those conflict and dovetail. It can be a beautiful dance.”

Getting started

Murphy thinks that in many ways, premarital counseling is couples counseling and uses similar tools and approaches. Premarital counseling has a more preventive focus, however, whereas couples counseling with married clients is often focused on repair work and undoing unhealthy patterns.

Tyler Rogers, an LPC and licensed marriage and family therapist who owns a private practice in Chattanooga, Tennessee, begins work with premarital couples by asking some straightforward questions: “Why do you want to do this?” and “What are you hoping to gain by getting married?”

Hearing couples’ perspectives on the why can help a practitioner understand more about the two partners, their relationship and their expectations, he says. If their answers tend to be more surface level, such as “this person makes me happy,” it opens the door to ask other questions and explore deeper with the couple, including offering psychoeducation about how attraction and liking someone are not the same as being “relationally competent,” Rogers notes. These discussions sometimes involve talking through why and how marriage requires “an entirely different skill set” than dating or living together, he says.

This work is still beneficial for couples who are getting married later in life or who have been living together for a while. Counselors will just need to tailor their approach to meet the couple’s experience.

“Sometimes counselors will need to help [more established] couples have a merger marriage, like the merging of two companies,” says Rogers, an associate professor of counseling at Richmont Graduate University. “Older couples [who are getting married] have less idealistic issues clouding what they think is coming [or] are more aware of each other’s problems. They might say, ‘We are really not good at talking about X’ or ‘This is how our conflicts go.’ … It’s a hybrid place of doing some marriage counseling along with premarital work. Couples may already have patterns or habits that aren’t great, but not to a breaking point.”

Practitioners may also work with couples where one or both partners have been divorced or experienced a painful breakup previously, and they come to therapy wanting to “get it right this time,” Murphy says. “These couples know a lot about themselves but also [know that they] need this partner to be very different than the one who hurt them in the prior relationship. We do a lot of unpacking what their needs are. I also acknowledge that it can be triggering for the other partner to hear a lot about someone’s ex.”

Beatriz Lloret, an LPC with a couples counseling private practice in College Station, Texas, takes a two-pronged approach to premarital counseling: One part involves psychoeducation on the components of a healthy relationship, and the other part explores the couple’s attachment style and patterns. In psychoeducation discussions with couples, particularly those who don’t have a healthy example to follow from their parents or family of origin, she often pulls from the Gottman method’s “sound relationship house theory,” including its components of trust and commitment.

“Couples often feel hopeful because they’re about to get married but sometimes mixed and apprehensive about periods of disagreement. The premarital [counseling] becomes couples therapy a little bit to address those issues,” says Lloret, an ACA member. “The beauty of it is that when [clients] are willing to come and dive into it a little, things [improvements] happen fast, especially because the issues are fresh and there is not too much rigidity built up yet.”

In addition to psychoeducation, Rogers and Lloret both say that initial work with premarital couples includes weaving in questions to cover necessary topics such as family of origin, finances and money management, children, and the roles they expect to have within the relationship.

Lloret says some of the clients who seek her out for premarital counseling do so as an alternative or in addition to premarital programs in their faith communities. These couples sometimes want to discuss issues — often those that have connotations of shame, such as sexuality — that they aren’t comfortable discussing with a religious leader or in programs that use a group setting. 

Although Lloret typically sees premarital couples together for the initial intake session, she splits the couple up for the second session to work with each person individually. This helps her get to know and build rapport and trust with each partner, as well as screen for domestic violence, she says. However, beyond issues such as abuse that require sensitivity, she has a “no secrets” policy for these sessions. Clients sometimes reveal that they haven’t told their partner about a chronic illness, a financial problem or a past affair; Lloret stresses the importance of disclosing and working through these issues with their future spouse.

Ellen Schrier, an LPC with a solo private practice in North Wales, Pennsylvania, has several assessment tools she uses to begin work with premarital couples. She says underlying distress — often involving frequent conflict, trust issues, personality clashes or infidelity — is revealed through this process in roughly 90% of the couples she sees. With distressed couples, it is often the case that one partner is pursuing the other, and the other partner is pulling away, withdrawing or avoiding conflict, she notes.

Schrier considers premarital counseling to include all of the unmarried couples she counsels, including those who aren’t engaged or looking to get married. She estimates this work is 30% of her caseload. Like Lloret, Schrier often sees premarital couples individually for a session early on to get to know them and help tailor her work to their needs.

“Often the case is they come in to strengthen the relationship, but there’s more to it,” Schrier says. “As you begin to talk, you realize there are deeper issues or past infidelity. They come in looking for a little boost but actually are struggling with a big problem.”

Addressing attachment

Initial assessment and discussion about content topics (finances, children, sexuality, etc.) in premarital counseling serve a couple of different purposes. One, they provide the practitioner with information about a couple’s personalities and background and, two, they open the door for deeper discussions and work on challenges that underlie those topics, including addressing attachment, repairing broken trust or breaking cycles of conflict and blame.

“The big-ticket-item conversations have to happen, and they can be very triggering, so it’s good to have them in couples therapy,” Murphy says. “My role is to let them talk about that content but then put it into the context of how they’re talking about it. … It’s absolutely critical to teach them about their own attachment style and how that interacts with their partner’s. Across the board, teaching them how to have healthy disagreements is my main agenda. We have such stereotypes that a ‘good marriage’ is one where you don’t have any conflicts, but that is so untrue. Demystifying that process is my job more than anything else.”

Murphy and Lloret use emotionally focused therapy (EFT) with premarital couples and find it useful for helping clients explore and dig into patterns and attachment issues. Throughout this work, the counselor guides the couple as they talk through deep issues that they wouldn’t necessarily recognize or know how to address on their own. Lloret says some premarital couples choose to work with her because she specializes in EFT and attachment.

“The counselor is a moderator to prompt deeper exploration, diving into what’s really inside of you and what’s really inside the other person,” Lloret says. “I don’t give solutions — what do I know [about what] they should do? — but they do.”

Having couples talk about their family of origin and the examples of marriage and relationships they’ve seen in their lives can be a good starting point for attachment-focused work with couples. Research shows that attachment patterns that humans form in early life repeat in romantic relationships, Lloret notes.

Murphy says, “I repeat over and over: ‘I’m not asking questions about your childhood to vilify your parents. They did the best they could. [And] it’s actually a good sign that you’re asking for help. But it’s important to talk through what you have experienced and what you believe.’ We want to get very clear about those expectations and desires and how to talk about them.”

Rogers believes it is important to relay a message to premarital clients who haven’t had healthy or stable examples of relationships in their life that “it’s not your fault; you didn’t choose that.” A counselor can help couples focus on the fact that they don’t have to repeat those experiences in the family they create.

Couples can also seek out other couples that they would like to emulate. Rogers sometimes asks clients to think of people they know whose relationships they admire and then to connect with them as “marriage mentors.”

“Ask them to have dinner with you, and pick their brain and learn from them,” suggests Rogers, an ACA member who previously worked as a Protestant pastor.

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At its core, premarital counseling should help clients explore and learn about themselves and “the process of couplehood,” Murphy says. Relationship education is some of the most important ground to cover, she emphasizes. The crux, Murphy says, is helping clients understand that human attachment draws us to want connection and support from others. Counselors can then help teach clients how to give and receive that with a partner in a healthy way.

“At the end of the day, [couples] need to really know each other deeply and take care of each other. … It all comes down to ‘is there someone in this world that has my back?’ That’s the basis of attachment: to be secure, to know that there is someone in this world who thinks we are special, a home base,” Murphy says. “Premarital couples don’t always have a lived experience of worrying about that, and my job is to establish that that’s why we’re here or [to] remind experienced couples [of that]. At the end of the day, it’s the same lecture [both in premarital counseling and couples counseling] about the role of attachment in our lives.”

But sometimes partners can become too attached. Some couples who are in the early stages of their relationship have an attachment that Lloret describes as two hands with interlaced fingers. It’s very hard to move one hand independently when the fingers are so tightly interwoven, she explains.

“They need to [learn to] feel comfortable with a certain amount of emotional distance. They need to find patterns of interaction that are healthy while feeling supported, but also maintaining their own independence,” Lloret says. “It’s common to see these issues in premarital counseling, including communication issues, arguing and misunderstanding. They often label it as a communication issue, but it’s really trying to differentiate while maintaining a bond [and] feeling seen and heard and understood while keeping connection.”

Bridging differences

The number of Americans marrying someone with a different cultural background than their own is increasing with each generation. In 1967, 3% of married U.S. adults had a spouse who was a different race or ethnicity. That number has since grown to 11% of adults being intermarried in 2019, and the percentage is even higher (19%) among newlywed couples, according to the Pew Research Center.

Murphy says discussions about culture and cultural differences between a couple — and the friction, misunderstandings or other challenges that may arise from these differences — can fit naturally into conversations about family of origin and relationship expectations. Here, as with other topics, it’s important for counselors to dig into why clients feel the way they do.

“The goal has to be to keep it curious instead of feeling that your partner’s family does it ‘weird’ or ‘wrong,’” Murphy notes.

Prompting premarital clients to share about how their family celebrates holidays can be a good way to introduce these topics, delve into client expectations and uncover potential sticking points that the couple hasn’t addressed yet, Rogers says. It can also be an opportunity to talk with the couple about how holidays — and other aspects of marriage and long-term relationships — can involve a blend of preferences from the two partners instead of being all one way or the other.

Another important aspect of these discussions involves asking couples how they think their partner views their culture, adds Rogers, who leads trainings on premarital counseling through the Prepare/Enrich program. He sometimes prompts clients by asking, “What aspects of your culture are important to you? What would you like your partner to embrace a little more or understand a little more?” 

“Generally, it’s a conversation they’ve had already without realizing they were having it, in the form of disagreements about things such as family, money or traditions, [and] without realizing that it’s tied to their identity and feeling that their partner’s objection to their stance is a rejection of their culture,” he says. 

Culture ties into how people express love and relate to those they love in many ways, Lloret notes. This includes everything from expectations about gender roles in marriage to a person’s comfort level around discussing sex or displaying affection in public. For example, in Latin American culture, a male partner may be taught that showing possessive behavior and jealousy can be a way to express care and love. But a female partner from an American background might find these expressions overly controlling.

A counselor’s role is to guide clients as they break down the meaning behind feelings and behaviors and explore why aspects of their culture and traditions are important to them, Lloret says.

“When they take the time to clarify what the expectation means, break it down and explore how they make sense of it, and then find ways to compromise and give and take [with their partner], that’s when the beauty comes,” she says. “It’s either explaining, ‘I can’t give this thing up, but it doesn’t mean that I don’t love you,’ or ‘I will compromise because I love you.’ It’s deeper conversations that create connection rather than getting stuck on the differences.”

Building a firm foundation

Premarital counseling should always aim to provide couples with the tools they need to navigate future disagreements and differences on their own. This includes learning to compromise and respond to each other in ways that are not reactive, judgmental or assumptive, Rogers says.

For example, perhaps one partner wants to live close to their parents and have them involved in the couple’s life, whereas the other partner would prefer to maintain some distance from the in-laws. A counselor can serve as a moderator as the couple talks through why they are in favor of or opposed to something and what compromises they are willing to make. Rogers suggests having clients identify specific solutions such as not allowing the in-laws to have a key to the couple’s home or agreeing to limit dinners at the in-laws’ home to twice per month. That approach is more tangible, he says, than one partner saying something vague such as “Don’t worry, my parents won’t be over all the time.” 

“In premarital counseling, I’m trying to help them learn the process of being a patient, curious person to find out why their partner doesn’t think the way that they think when they don’t agree,” Rogers explains. “A lot of that is teaching them how to communicate why they have the position that they do and encouraging them to do some digging without judgment. … Whatever the issue is, there is a deep why, a reason why they hold these feelings close. The counselor’s role is to help them understand their own why and explain it to their partner, while at the same time being open and accepting [of] their partner’s why.”

Schrier says that couples in premarital counseling often need to learn how to fully listen and acknowledge their partner. “A lot of people don’t have that important skill of listening to someone without reacting … [and] understanding each other’s position and validating it, valuing it, without escalating, getting overwhelmed or angry,” Schrier says.

“Sometimes they need to learn how to have one person speaking at a time without the other person interrupting or adding on to what the partner is saying,” she says.

Schrier uses various activities to help couples practice these skills, including one that has the partners take turns being the “speaker” and the “listener” as they respond to prompts such as:

  • Name three strengths and three challenges in your relationship.
  • What would you like to have more of and less of in your relationship?

Schrier says these conversations help clients with skill building and help her identify things to focus on with the couple. In the process, couples often find things they agree on such as needing to work on communication or making time to have fun together, she adds.

Equipping couples with an expanded emotional vocabulary can help in this realm as well. Clients often fail to realize or fully describe their feelings when in conflict with their partner, Schrier notes. For example, a client who wants more connection from their partner may express that as blame: “You don’t spend enough time with me.”

Schrier has a detailed list of “feeling words” that she gives clients to help prompt more constructive and respectful dialogue. She also sometimes suggests that during disagreements, clients ask their partner (using a nonaggressive tone), “Can you say that in a different way?”

Perhaps a towel left on the bathroom floor triggers an argument between a couple. Initially, the person who discovers the towel may feel intense anger toward their partner, who dropped the towel. But skills learned in counseling can help the person realize what they are feeling beyond anger, she explains.

“Saying ‘I feel disrespected or devalued’ is a better way to talk about it and less reactive. It’s more empowering to say that than to say, ‘You make me angry.’ It gives their partner more to understand and change,” Schrier says. “It’s a way to slow the conversation down a little bit so they can better understand their partner instead of assuming they know what [their partner is] feeling.”

Couples who aren’t able to do this sometimes get “stuck on a hamster wheel” of arguing over the content (in this case, a dropped towel) rather than the feelings of a disagreement, she adds. When this happens repeatedly over time, it can lead to contempt, resentment and distance in relationships.

“It’s so much easier to work on problems when you’re coming in [to premarital counseling] with a spirit of friendship, instead of years later coming in as adversaries with years of misunderstandings and hurt feelings,” Schrier says. “It’s better to do it on the front end and be preventive.”

Premarital counseling can also open the door for couples who need deeper long-term work, Murphy notes. Premarital clients who are not able to fully resolve challenges before their wedding date may need to return for further counseling after they are married or when a life change, such as having a child, upsets the couple’s equilibrium.

“Premarital counseling can be the appetizer to a later full meal of deep couples work that is needed, sometimes years later or with a different clinician,” Murphy says. “It’s important [for counselors] to normalize getting input from different sources throughout the life span.”

Preventive care

Although premarital counseling often covers some of the same ground as couples counseling, there is one major difference: clients’ attitudes. The counselors interviewed for this article said that premarital work is rewarding because most clients are optimistic, enthusiastic and willing to strive to make changes to strengthen their relationship. In addition, growth and improvement often occur quickly.

“Premarital counseling is preventive care in a lot of ways,” Rogers says. “It can be some of the most rewarding, fun work to do with couples. … So many other mental health issues could be helped if we can help people have healthy relationships. We can be instrumental in pushing the ball forward to start marriage off on the right foot rather than addressing things only when they’re in a bad situation.”

 

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Let’s talk about sex

One of the most important “musts” to discuss with couples in premarital counseling is sexuality. This is an area that couples who are older or who have lived together for a while may think they have figured out and don’t need to cover, says licensed professional counselor (LPC) Tyler Rogers.

Rogers sometimes jokes with premarital couples, saying, “John Lennon was wrong. Love is not all you need.”

Couples may have “the basics” of sexual intimacy mastered but need psychoeducation about how a healthy sex life will need to evolve and change over the course of a marriage. There will be times in life when sex isn’t easy and effort has to be made to foster intimacy, Rogers says. It’s important for practitioners to ask premarital couples about their sexual history and expectations regarding sex and, if they are sexually active together, to ask questions to ascertain their level of sexual wellness. Manipulative behavior such as withholding sex can indicate an area that needs more attention in therapy. Factors such as past sexual trauma or pornography use can complicate this issue, Rogers notes, especially when it is undisclosed between partners.

“There can be feelings of shame or guilt, especially if things are not disclosed until after they are married,” he says.

Tensions or misunderstandings regarding sex can cause distress that spills into other areas of the relationship for couples who otherwise have healthy connection, notes Beatriz Lloret, an LPC with a couples counseling practice in Texas.

Lloret says that where she lives, many premarital couples choose to delay sexual experiences — and important related discussions — until after marriage. Clients who fall into this category, many of whom are in their 20s and come from conservative, Christian backgrounds, often explore feelings and judgments regarding sexuality, she says. For some, discovering that their partner has certain sexual preferences or expectations carries a negative meaning or assumption for them. As with learning how to handle conflict in premarital counseling, practitioners may need to equip clients with tools to listen and respond to their partner about intimacy without being reactive or accusatory, Lloret says.

“For couples who don’t get to explore their sexuality until they’re married, once they open the door to this whole universe of sexuality, there’s a chance for a huge mismatch. Sometimes people have very different ways of expressing themselves and relating to pleasure, and it can create a big disconnection,” Lloret says. “They often need to explore judgment in a way to open their heart to the human being they’re in love with and the wiring that is sexual pleasure for that person. [It’s] getting judgment out of the way. There’s no one technique or easy way to do that, but the focus should be on being open and nonjudgmental.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Keeping the focus

By Traci Pulliam Collins August 7, 2017

During the counseling process, most clients will describe some form of interpersonal or relational trouble. This trouble might be identified as relationship dissatisfaction, conflict in a marriage or partnership, or even the absence of relationship (loneliness).

One theoretical approach — emotionally focused therapy (EFT) — works well in individual, family or couple counseling. EFT for couples is a well-researched, evidence-based treatment with a systematic approach of steps and stages. Although the theory and working model are easy to understand, application of the model can be quite challenging. This steep learning curve may discourage counselors from implementing the model to its full potential.

Experience lends a few recommendations that may help counselors persevere through the learning curve on their way to becoming effective EFT counselors.

Back in the July 2012 issue of Counseling Today, Stacy Notaras Murphy addressed the question, “What’s on the radar of today’s counselor?” The American Counseling Association members surveyed for this article provided a wide range of responses, but a few topics were repeated across the group, including EFT for couples.

New professionals may hope to add EFT to their tool belts and develop a range of competencies. Midcareer professionals and seasoned counselors may desire to diversify their tools for couple therapy or to jump on board with this innovative approach. No matter the reason for the interest, counselors want an approach that is grounded in theory and is supported by empirical evidence. In addition, professional development can be costly and time precious; therefore, it is important to seek training that will pay off in effectiveness and ease of application.

EFT has solid empirical support for effectiveness, but the application may troublesome. Counselors may become impatient when learning new skills or techniques that do not fit neatly into or integrate with their current style of practice. EFT requires a paradigm shift for most counselors who learn the model.

 

EFT overview

EFT is a brief model rooted in attachment theory with humanistic and systemic influences. Counselors assist couples by using EFT to create a more secure attachment style between partners while also using experiential techniques. Les Greenberg and Sue Johnson formulated EFT in the early 1980s, and Johnson developed a systematic outline of steps and stages for clinicians to follow when helping couples move toward secure attachment and greater connection.

In 2004, Johnson published the second edition of The Practice of Emotionally Focused Couple Therapy: Creating Connection, which is the go-to source for understanding the theoretical and practical application of the EFT framework. Johnson has studied the dynamic attachment dance between partners, providing a road map for creating a secure bond that is divided into three stages:

1) De-escalation

2) Restructuring interactions

3) Consolidation

De-escalation, consists of a series of steps aimed at identifying the negative cycle the couple find themselves in — ultimately leading to disconnection. Identifying their attachment needs and discovering their distressing interactions reframed in the attachment language and cycle moves couples toward de-escalation.

Normalizing their interactions as a distressing dance that many couples find themselves engaged in helps the couple try to connect. This also provides an opportunity to briefly educate clients on the EFT model, its treatment protocol and the implications of research findings. Taking this action can provide couples with reasons to more deeply engage in the therapeutic process.

Restructuring interactions is the working stage in which interpersonal interactions shift from the original cycle to a new pattern of emotional attunement and secure connection. This is the place where the withdrawers re-engage and the blamers soften if the partners explore and share their attachment vulnerabilities and relationship needs.

Finally, in consolidation, couples apply the improved relationship functioning and more secure attachment bond to the problems that arise in day-to-day life.

 

Development of an EFT counselor

The EFT model reframes the counselor’s conceptualization perspective toward looking at couples through an attachment lens. This lens shapes the counselor’s understanding of human experience and strengthens the empathic attunement abilities, preparing the EFT counselor to frame even the most hurtful behaviors of a partner into the need for attachment and connection.

This process can be challenging for a counselor, requiring intentionality and constant emotional engagement (a leaning in if you will) with clients. The counselor’s leaning in creates moments of vulnerability and welcomes clients out into the open. Proper application of EFT is counseling at its best; it is draining and invigorating at the same time.

After spending years learning this model and interacting with folks across the developmental spectrum of EFT counselors, several important themes come to mind for me:

  1. a) Experiencing tough moments of feeling lost
  2. b) Being confused
  3. c) Having memorable and highly purposeful moments
  4. d) Realizing I am in a constant state of learning

It seems likely that I will never arrive at perfection, and the learning curve is continuous.

Perhaps the EFT counselor continues this difficult learning curve because of the successful moments. Witnessing couples creating connections and more secure attachments is a deeply moving, powerful and, at times, sacred experience.

Although those moments may cause some EFT counselors to desire more, it seems that counselors can benefit from acknowledging and preparing for the learning curve and managing the developmental process. The following section contains suggestions that may enhance mastery of the learning curve

 

Anchor yourself with the empirical evidence

The EFT clinician–researcher partnership is an important component of the following the model principle. Clinicians can glean confidence by utilizing the EFT research evidence to enhance their learning curve. This involves familiarizing oneself with the professional literature sources and staying current with EFT research findings.

The EFT model has grown in popularity, and a body of research has evolved. In 2016, Stephanie Wiebe and Sue Johnson published a review of EFT research, building on a previous meta-analysis in which a large effect size of 1.3 and a 70-73 percent recovery rate were found. The more recent review presented an examination of applying the EFT model to specific issues facing couples (e.g., depression, trauma, attachment injuries such as an infidelity), pointing out how EFT research findings have surpassed the standards for being perceived as an evidence-based approach for couples.

The strength of empirical evidence places EFT for couples on the radar for counselors as an approach that clinicians can feel good about using. Couples can benefit from learning that the EFT approach is organized and well-researched, and that the research findings indicate effectiveness for couple therapy.

 

Trust the model

When beginning a session, remember what the EFT counselors and researchers before you have experienced and contributed. The research evidence provides a secure base. Much like the theoretical roots in attachment theory, counselors must stay grounded and rooted in the evidence of sound research and design.

Integrating other techniques or frameworks is a deviation from the model and may bring more confusion than comfort. Remember, this model works, and it works powerfully. Trust the model and stay the course, even when things get tough.

 

Avoid getting caught up in the details

The presenting issues that couples will voice may seem endless. Before realizing it, you can begin wondering whether one partner should just help more with the dishes and things might be all better.

In that moment, you have moved away from the influence of empirical evidence and training — the steadfast counseling seat — and shifted to the couch with the couple. At this point, the room can quickly be filled with shared frustration and hopelessness.

The details are so important to the clients, because these details represent something much greater (i.e., loneliness, abandonment, feeling inadequate). On one hand, the details do not hold the solution, but they do provide hints toward the couple’s particular pattern, or the dance.

 

Refresh and reflect

The EFT model is organized and simplified into steps and stages. Yet application of the theory is not so simple. It is important to revisit your materials and ground yourself in the steps and stages, skills and interventions. Consider a refresher course or spend time reviewing your training materials to bring you back to the model in the purest sense.

Observe another EFT counselor in action, such as the “EFT in Action” live couples counseling observation by Lorrie Brubacher, certified EFT therapist and supervisor, at the Carolina Center for EFT. This live demonstration offers a reminder of the core interventions that can help regenerate your work.

Even better, watch your couples counseling taped sessions to observe your process, finding moments of strength and instability to inform your practice. All of these steps will support a deeper understanding of EFT in action.

 

Seek a learning community

EFT counselors guide couples to greater awareness, vulnerability, connection and effective dependency in their relationships. In 2003, Johnson described the significance of dependency in relationships in a chapter of Attachment Processes in Couple and Family Therapy. She provides a powerful paradigm shift from partners being overly dependent or independent to effectively or ineffectively dependent.

Correspondingly, EFT therapists should embrace the effective dependency of the EFT learning community. Beyond the referral networks, EFT communities can provide feedback, encouragement and connectivity. An EFT support system makes the EFT learning curve journey more meaningful and enjoyable.

 

Final thoughts

The EFT model indicates several parallel lessons for EFT counselors in training. Remembering the successes provides a touching motivation to help more couples find connection by using the powerful EFT model.

The developmental process for EFT counselors can be very demanding, and the learning curve can be tough for even seasoned couples counselors. Yet, somehow, having a hand in or orchestrating the dance between partners is so rewarding that it provides motivation to keep going.

In the EFT process, you may observe one partner painfully waiting on the edge of his or her seat, session after session, for the other partner to show up and be emotionally responsive. Then when it happens, the emotional relief is so overwhelmingly wonderful that the couple leap across the room to embrace in a tearful hug.

 

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Traci Pulliam Collins is a licensed professional counselor and national certified counselor. She works as a professional counselor in Greensboro, North Carolina. Currently, she is pursuing her doctoral degree at North Carolina State University. Contact her at tpcolli2@ncsu.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Walking with clients through their final days

By Laurie Meyers October 31, 2016

During the time that Kerin Groves spent by her dying client’s hospital bed, she could tell that he felt conflicted. “I sensed he kept hanging on because his adult children were unable to cope with him dying,” she recalls. “The son kept urging him to fight and get better, even though the patient was in his 90s and ready to go.”

When the man’s children left his room for the day, he visibly relaxed. Groves, a licensed professional counselor (LPC), gently pointed out the difference in his tension level.

“[I] let him know it was OK to go whenever he was ready, and I assured him that I would be there to help his son get through it,” Groves says. “He looked right at me, held my gaze for a time and then closed his eyes for the last time. Given permission and support, he was able to go in peace.”

Groves, an American Counseling Association member who has worked with older adults in retirement communities, assisted living, nursing homes and home care settings, is among a select number of counselors who routinely help individuals and their families cope with the process of dying.

Acceptance and denial

Receiving a terminal diagnosis, or having a loved one receive it, is almost too much to comprehend initially, says Mary Jones, an LPC who spent 20 years counseling patients and their families in an oncology center. “People go into shock, and there is an inability to wrap their minds around what they are hearing,” she says.

Loved ones who are in the room when the terminal diagnosis is given often go through a secondary trauma — shock at what they are hearing and concern for their loved one’s feelings, Jones says. In fact, she adds, these loved ones may initially experience more anxiety than the person receiving the diagnosis.

branding-images_final-daysJones counseled patients with varying prognoses, including those who would go on to live long lives after treatment, but in her role, she often saw people at the very end, when they had been told they had only months or weeks to live. “Once they know that treatment isn’t working and there are no more options, it seems like people hit a fork in the road emotionally,” she says.

One path certain patients chose was accepting their impending deaths but also determining to answer a weighty question: What do I do next? In her role as a counselor, Jones would talk to these clients about their legacies — what they wanted to say to or leave behind for their loved ones.

One of her clients was a father with a young son. He made a video that talked about the things he wanted his son to know but wouldn’t be there in person to tell him. The video included subjects such as what the son should know about middle school, about girls and about sex.

The other fork in the path that Jones commonly witnessed was complete denial of the terminal diagnosis. She heard patients make statements such as “This isn’t happening” or “I’m not going to die.”

As a counselor, her role was to try to guide these patients toward acceptance. She acknowledges that the task was difficult. “It so goes against our belief and training and experience [as counselors] to have to say to someone, ‘But your end is near,’” she says.

Jones would sit with these patients and encourage them to talk about their feelings regardless of what they were: fear, anger, sadness, disbelief, etc. After validating what they were feeling, she would circle back around to acceptance and the importance of deciding what they wanted to do or say before they died.

Groves, currently a private practitioner in Denton, Texas, often used existential and person-centered therapy when working with individuals in denial about their impending death. “Person-centered therapy gives the patient the lead in directing the conversation in the way they feel it needs to go, at their own pace,” she says. “We talk about denial openly and how it helps or serves a purpose, as well as how it might work against them. Helping a client make a cost-benefit analysis regarding denial is empowering and respectful of [his or her] needs.”

Of course, it isn’t uncommon for family members to be dealing with denial too. Jones, who would also provide family therapy in her role, says this can create tension between family members and the person who is dying, just when that person needs more support than ever.

Seeking support

Emotional support from family members is important, but the principal source of support for many clients is their husband, wife or partner. If discord is already present in the couple’s relationship, these problems will only be exacerbated by the stress of serious or terminal illness, says ACA member Nicole Stargell, who has used emotionally focused therapy (EFT) with couples facing breast cancer diagnoses. EFT operates on the premise that to feel “attached” (safe and secure) in a relationship, couples must be able to manage and share their emotions, she explains.

When certain people experience conflict or distress, they withdraw — sometimes physically — and don’t want to talk about the problem or issue, Stargell says. Other people are “pursuers,” she continues, and their desire is to talk about what is wrong. Pursuers will actively seek responses from their partners.

Anytime that either partner displays withdrawing or pursuing behaviors, implicit assumptions are being made, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. For instance, partners who withdraw often do so because they perceive themselves not to be strong enough to cope or view themselves as being deficient in some other way. When pursuers try to talk to withdrawers about what is wrong, this just reinforces the withdrawers’ feelings of deficiency, Stargell explains. Meanwhile, pursuers are thinking that withdrawers don’t regard them as being important enough to try to talk things through with them. As a result, both partners end up feeling alone and unsupported, which isn’t good for either individual’s mental or physical health, she says.

Using EFT, Stargell would identify the cycle of misunderstanding that plays out repeatedly between the couple but make it clear that neither partner is to blame. Next she would help the couple start to reframe their interactions by asking them to talk about a conflict and actually say out loud what they were thinking in response to their partner’s behavior.

Stargell would then help the couple see that their reactions had more to do with self-blame than with the other person’s actions. In other words, there was no implicit message attached. She would also have the couple role-play, taking turns presenting a problem and practicing reacting differently to what the other person said or did.

Stargell also works with couples to identify triggers or recurring situations that tend to set off the negative cycles. For instance, in the week following chemotherapy, the partner who is a withdrawer and is undergoing treatment might retreat emotionally, in part because he or she is sick and feels like a failure for not being able to perform his or her normal role, such as being the one who washes the dishes. Because the withdrawing partner is sick, the pursuer doesn’t want to push for interaction. However, Stargell says, it’s not uncommon for the pursuer to feel some anger or resentment about the things the partner with cancer — or the couple together — can no longer do. The withdrawer can typically sense the underlying tension, which makes him or her withdraw even more. Together, Stargell and the couple would talk about what the couple could do differently the next time the withdrawing partner has chemotherapy.

Approaching the end 

There are many ways that counselors can support and assist clients who know that they are dying. “I have helped clients find meaning in their personal [histories] and accept suffering during the dying process by engaging in life review and reminiscence, with both laughter and tears, allowing them to say what they haven’t been allowed to, reconciling unfinished business from the past [and] helping them connect with and share their true feelings with their loved ones,” Groves says. But sometimes, the most significant role is “just sitting with them in silence as a companion,” she adds.

Groves has also helped clients facing death to work through their fears and concerns. These have included issues such as feeling guilt about being ready to die when family members beg them to keep fighting; fear of more pain or agony; weariness from long medical treatments; spiritual doubts or fears; and anger over family conflicts erupting or being exacerbated during the medical crisis.

Jones would sometimes take on a sort of facilitator role with these patients, making sure they received what they wanted or needed in their final weeks or days of life. But counselors can also advocate for patients in other ways, Jones says. Especially toward the end, patients with terminal illnesses can experience a significant amount of pain but may not want to take yet another medication. She recommends that counselors working with this population educate themselves about alternative methods of pain relief and relaxation techniques.

As the end approaches, some individuals find it easier to accept that they are going to die, whereas loved ones often have the opposite reaction, Groves notes. “Curiously, people who are near death may be more calm … because they have accepted their prognosis, while their loved ones struggle with denial and avoidance because they are not ready to let them go,” she says. “When a person dies, the opportunity to make peace with them is over, so at least when the person is still hanging on, the belief or hope that it can be reconciled is still there. They may fear letting that person die with unfinished business still between them but struggle to vocalize those unsaid things because they don’t feel it’s appropriate or acceptable.”

Groves says counselors can also play an important role in preparing family members for what to expect in the dying process. “If hospice is involved, their nursing staff may make an extra effort to help counselors explain to the family what is happening biologically, the signs of impending death and other medical information,” she says. “A counselor can also be of help with active listening, reflecting feelings, normalizing emotional responses, addressing spiritual and existential concerns, and [exuding] warmth. Many people do not know what to do or say, so they do or say nothing at all, leaving the family members stranded in their grief. Counselors are equipped to sit with people in pain and be present with them.”

Groves also believes that being present when a loved one dies can be very healing for family members. “It’s very hard to witness a death and, frankly, most people fear and avoid that experience,” she says. “They are typically afraid they will be overwhelmed with their feelings and be unable to cope. But if one is willing and able to tolerate the discomfort, with the support of the counselor, being with a dying person in their final moments allows one to genuinely embrace the natural process of death and confront its reality, which is important for healthy grieving.”

 

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Related reading: See Counseling Today‘s November cover story, “Grief: Going beyond death and stages

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.