Attachment Theory: A Guide For Couples Therapy

Presentation by Susan Johnson
Reviewed by Victoria Dickerson

            The title of the presentation was "Attachment Theory: A Guide for Couples Therapy." The task: to take clinicians and researchers through the difficult process of seeing how certain theory and research are relevant to specific clinical practice. In my experience as a therapist, I have found that the single most daunting undertaking has been that of making sure my work is coherent with my thinking. What Sue Johnson has done in her work and her writing is create a coherency between a practice approach to couples therapy and a theory of adult love, namely attachment theory. This was what she showed in her presentation.

            It would seem to trivialize Sue's immense body of work to try to summarize here what her talk covered. I would recommend that readers go to her more recent articles, two of which were included in the conference packet. (Johnson, S.M.; Hunsley, J.; Greenberg, L; Schindler, D; [1999]. Emotionally focused couples therapy: Status and Challenges. Clinical Psychology: Science and Practice, 6:67-79 and Johnson, S.M.; Whiffen, V.E; [1999]. Made to measure: Adapting emotionally focused couple therapy to partners' attachment styles. Clinical Psychology: Science and Practice, 6:366-381.) What I will do is highlight the major ideas as they jumped out at me in Sue's very clear and animated presentation.

             It is always a pleasure to be in the company of someone who obviously has great passion for her work and ideas. Sue has developed an approach that not only addresses some of the clear deficits in clinical couples work but has also assiduously researched its effectiveness. Since she first developed and described her theory and approach in the early 1980s, I imagine Sue has devoted concentrated time and energy continuing to critique and refine her work. We, at the Clinical Research Conference at Niagara-on-the-Lake, in October, 2000, were fortunate to be able to participate in the current culmination of her ideas.

            Sue commented early in her presentation that the application of attachment theory to adults was a revolutionary event for couples therapy. She suggested that without a theory we know neither what happens nor why. Attachment theory is a way of understanding the nature of marital distress. It helps us appreciate the extent of fear and despair that can occur when separation looms as a possibility. Partners, in their attempt to protect themselves, confirm the other's fear.

            Prior to the creation of EFT, couples therapy was primarily practice-driven, with interventions being mostly behavioral; also, there was no clear theoretical perspective on relationships that was shaping clinical practice. Further, there were disparate understandings, including intrapsychic dynamic theory, systemic focus on interactional patterns, and some attention to the interplay of cognitions and emotions, but no approach that was able to combine these ideas. EFT views relationships from an attachment perspective and relates this to how the couples' process of expressing needs show up in interactional patterns.

·            Couples therapy, namely EFT, accomplishes the following (this from my notes):

·      focuses on attachment needs, contact, comfort, and on separation distress

·      privileges emotional responses and restructures fear

·      creates a collaborative alliance

·      shapes new bonding cycles

·      focuses on models of self

·      addresses specific attachment moments

            Nine treatment steps are outlined in EFT, summarized in three categories: first, de-escalation of the negative cycle; second, changing interactional patterns; and third, consolidation and integration. A key focus in the second set is what Sue calls "softening." This is an event where a partner, coming from a position of vulnerability, can ask for their attachment needs to be met. In a very illustrative video-taped session, Sue showed the occurrence of such an event in work with a couple, where the female partner was risking reaching for her spouse, and he was being availiable and responsive (i.e., able to ask for what he needed in a way that was clearly being experienced differently by his female partner).

            Use of video tapes as a way of illustrating clinical work is almost always compelling. My experience is that participants want to see the work in order to understand better what the presenter is telling them. However, what a workshop participant sees and what the taped clinician and clients actually experienced in the room may be quite different. For example, after the presentation, one questioner asked how what was shown could be considered systems' work, as this particular video excerpt was not necessarily a good illustration of systemic thinking, even though, both theoretically and in practice, EFT is said to address interactional patterns. I wondered, and asked Sue later, how she was thinking about gender and power. Again, this was not readily apparent in what was being shown. She responded, however, that the kind of mutuality and equality evident in the change event on the tape can be seen as a comment on power and gender. She said, "Men are encouraged to go beyond gender based constraints and access their dependency needs as well as becoming more attuned and nurturing to their wives. A secure bond between adults would appear to preclude a one-up, one-down, relationship. Usually, most distressed couples see the other person as having the power — even when they are being coercive." Sue's response is a good example of how one of the hardest things to describe — or even to show — is what happens in the room, how it happens, and what the therapist and client are thinking.

            On another note, Sue also briefly talked about attachment injury and relationship trauma, including the effect of betrayal of trust, indicating that such injury needs to be resolved first.  

            There is a fair amount of clinical research that supports EFT as an effective treatment modality. The research shows that 70-73% of couples in EFT recover from distress and that a two-year follow-up shows stability in these findings (again from my notes). Sue's recent articles (cited above) summarize in greater detail nine studies of clinical outcome research and also comment on four studies that address the process of change in EFT. She also addresses the need for future research.

            Having experienced many different presentations, in conferences as well as classrooms, and having been on both the giving and the receiving end, I am pleased to say that Sue Johnson's presentation was both engaging and compelling. Her personal involvement and enthusiasm for the topic shined through, as she skillfully combined balanced amounts of conversation, didacticism, overheads and video. And the brief question-and-answer session, afforded by what little time remained, aptly highlighted Sue's sincere thoughtfulness in response.

            In the introduction to her talk, I commented that Sue and I come from very different epistemological positions. Subsequent to her presentation, we had a conversation about those epistemological differences, which led to an agreement to share video tape and comments to see where we differ and where we connect. To my mind, this outcome is precisely what a clinical research conference has to offer, at least in possibility. So, this brief article is an attempt, even though I come from a different theoretical metaphor (narrative), to summarize Susan Johnson's presentation on her work — emotionally focused couples therapy — based on her metaphor (attachment theory). I am always pleased to engage in an experience of learning with someone whose ideas are different from my own.

Victoria Dickerson is the president and one of the co-founders of planet-therapy.com, a large mental health internet site offering continuing education workshops for professionals and information for consumers. She was also the co-founder and co-director of Bay Area Family Therapy Training Associates, a narrative therapy training center in the San Francisco Bay Area. She has also written extensively and offers workshops on the narrative metaphor.