Abstract

Research into the impact of marriage and family breakdown abounds. Adverse effects on adults, children and communities range from increased mental health concerns, increased use of opioids, impoverishment, poorer outcomes for future relationships, to decreases in education and increased employment difficulties.

Most clinicians consider couple therapy to be amongst the most difficult therapeutic areas to work. It is fraught with high emotion and complicated by individual personality and cultural differences, mental health co-morbidities, and the subjectivity of personal experience that can cloud an individual’s ability to accept their partner’s own internal experience. Evidenced-based approaches to couple therapy, such as Gottman method couples therapy (GMCT) and emotion focused couples therapy for couples (EFT-C), provide therapists with frameworks, interventions, strategies, and skills to assist in the management of complex presentations. These include co-morbidities such as infidelity, addiction, and other mental health conditions.

Introduction

According to the Australian Bureau of Statistics (ABS, 2016), of the six million families living in Australia, almost five million consisted of couples living together with or without children. Intimate relationships are a vital aspect of human wellbeing. A longitudinal study by Harvard University concluded that happy relationships were the best predictor of improved health in older age. People in close relationships were also found to be more satisfied, have fewer physical and mental health concerns, and lived longer than those who were not in the long term, close relationships (Mineo, 2017).

In Australia, the divorce rate was 1.9 divorces per 1,000 people which, in 2020, represented 49,510 divorces (ABS, 2021). The divorce rate does not take into account the many de facto relationships that may also breakdown. Decades of research have established the long-term negative impact of family breakdown on children and community (e.g., Cherlin & Furstenberg, 1994; Doherty, 1997). The Australian Government Department of Families, Housing, Community Services and Indigenous Affairs Social Policy Research Paper No 42 (Rodgers et al., 2011) reinforced findings from previous international studies that family conflict contributed the most to the differences between those children from divorced and intact families for depression, suicidal ideation, and opioid use. They also found that adults from divorced families of origin were more likely to report a wide range of adverse outcomes compared to their peers from intact families of origin and that those from divorced families were more likely to transition earlier to adult roles such as engaging in sexual intercourse before the age of 16, leaving the parental home before the age of 17, entering live-in relationships before the age of 20, and entering parenthood as a teenager. The odds for these outcomes were more than double for those from divorced families compared to those from intact families.

Studies looking at the impact of relationship breakdown on communities routinely identify that this leads to the growth of more impoverished communities with the natural flow on to higher rates of crime, poorer educational outcomes, and higher use of drugs and alcohol (Hogendoorn et al., 2019). Therefore, assisting couples in understanding how to create healthy, connected, close, and long-lasting relationships can have a substantial positive impact not only on the welfare of individuals, couples, and children, but can also have important positive effects on community and society in general.

Services for couples in contemporary Australia are widely available and highly sought after. Organisations such as Relationships Australia, Anglicare, Catholic Care, etc. offer a range of low-cost, government-funded services to couples and families. In addition, psychologists, social workers, counsellors, and psychotherapists in private practice also routinely provide couple therapy as part of their services to their communities. Many of these practitioners will have completed extensive post-graduate training in evidence-based approaches to couple therapy.

Major theories about the topic

These days there is a substantial volume of books on how to have a successful relationship. In contrast, the amount of that literature based on empirical research is significantly less. Prior to the 1900s, help for couples was generally provided by older family members, religious, or community leaders. The advice provided was strongly linked to cultural mores and religious dogma without regard to the lived experience of the partners in the relationship.

It was not until the 1950’s that psychiatrists and psychoanalysts began working with couples in conjoint sessions on relationship issues. At that time, there were no theories, models, interventions, or techniques for providing couple therapy, so clinicians based their work on their own experience of relationships and their own ideas about what makes for functional couples (Gurman, 2015).

During the 1960s Systems Theory became the predominant approach based mostly on the theories of Virginia Satir (1916-1988), Don Jackson (1920-1968), and Murray Bowen (1913-1990). This approach focuses on what Satir articulated as “the self in the system” (Nichols, 1987), but while Satir argued for the importance of affect and attachment (Satir, 1988), sadly her views were mostly marginalised at the time by more “male” therapeutic values such as rationality as opposed to emotionality and power as opposed to equality in relationships (Gurman, 2015).

Bowen family systems theory arose as the primary approach in Australia to couple and family distress throughout the late 1960s and 1970s. According to Brown (1999), Bowen theory primarily focuses on patterns that develop in families to defuse anxiety which arises due to perceptions of either too much closeness or too much distance in a relationship. Stress is impacted by levels of external pressure and intergenerational familial sensitivities.

According to The Bowen Center, the main goal of Bowenian therapy is to reduce chronic anxiety within the system by increasing awareness of how the system functions; and by improving levels of differentiation with a focus on changing self as opposed to trying to change others. Bowen’s theory consists of eight interlocking concepts where change may need to occur:

1. emotional fusion and differentiation of self
2. triangles
3. nuclear family emotional systems and couple conflict which includes symptoms in a spouse as well as symptoms in a child
4. family projection process
5. emotional cut-off
6. multi-generational transmission process
7. sibling positions
8. societal emotional process.

Bowen made important contributions to the field of couple and family therapy, especially with the introduction of the importance of the legacy of emotional processes across generations and on an individual’s differentiation with the systemic context providing therapists with a multi-level view of the development and perpetuation of interactional patterns within the system (Brown, 1999).

Bowen’s concept of a multi-level family system describes how patterns, themes, and positions (roles) are passed down from generation to generation through the projection from parent to child. The impact will be different for each child depending on a number of variables such as position in the family, their specific relationship with each parent (triangling), temperament, personality, and environmental factors. Bowen recommended a focus on at least three generations of a family when dealing with a presenting symptom. The attention to family patterns over time is seen as an intervention that helps family members see how they might change their own part in the transmission of anxiety over the generations, as well as an assessment tool for the therapist (Bowen, 1978).

Major criticisms of Bowen therapy include: the lack of randomised clinical trials to assess the impact on couple and individual functioning (Baker, 2015); its attention on the mother’s contribution to symptom development without reference to the role of father, and the labelling of women as ‘over concerned’, and their relational roles as ‘fused’ and ‘undifferentiated’ (Luepnitz, 1988). Carter et al. (1988), argued Bowen’s model pressures women to ‘back-off’ while placating and supporting the notion of the distant male. Luepnitz (1988) also criticised Bowen for his focus on being rational and objective in relation to emotional processes which relegates low priority to the expression of emotion in therapy.

By the late 1970’s behavioural therapists such as Weiss (1975), Stuart (1969), and Jacobson and Margolin (1979) began extending their work to couple contexts with a focus on skills development primarily in the area of communication, problem-solving and behavioural change. The role of the therapist was primarily psycho-educational and directive. By 1995, Christensen et al. (1995) had developed Integrative behavioral couple therapy which was the first approach developed through clinical observation and empirical research.

In Australia, research on this approach has been spearheaded by Professor Kim Halford, resulting in his development of “CoupleCare” (Halford et al., 2006), a home study program for couples. This program was designed for couples to use in their own homes with the use of DVD instruction and telephone or video call assistance from a counsellor. In the program, the couple learn arrange of behavioural strategies and practical skills such as arousal regulation, active listening, empathy training, etc., to enhance their relationship.

During the 1980s and 1990s while studies continued into the mechanisms for change using behavioural approaches to couple therapy, a more emotionally based approach to couple therapy became the focus of several researchers, most notably Drs John Gottman and Sue Johnson. While Gottman conducted extensive observational studies to understand what made relationships fail and what made them successful, Johnson focused on a move away from behavioural therapeutic approaches to an emotionally based approach for therapists to use with couples. Their research has resulted in the development of two highly effective, evidence-based approaches to couple therapy – Gottman method couples therapy (GMCT) and emotionally focused therapy for couples (EFT-C).

Gottman focused on conducting longitudinal observational studies to identify what couple dynamics and interaction patterns either destroyed relationships or strengthened them. He established what became known as the ‘Love Lab’, firstly at the University of Washington, and more recently at the Gottman Institute in Seattle, USA.

GMCT is an integrative approach based on analytic, behavioural, existential, emotionally focused, narrative, and systems theory. It includes three broad phases. The first phase, assessment, begins with a thorough clinical assessment after which the therapist provides the couple with feedback about their assessment using the framework of Gottman’s sound relationship house, and together the therapist and couple formulate treatment goals.

The second phase is the active therapeutic phase during which the therapist uses structured interventions to assist the couple to:

• down-regulate negativity during conflict
• increase positivity during conflict
• build more positivity during non-conflict interactions
• increase understanding meta-emotion discrepancies between partners
• create and deepen a shared meaning system.

The third phase targets relapse prevention during which the therapist is slowly phased out toward the end of therapy with follow-up sessions for up to two years post the active therapeutic phase. GMCT is not a time-limited program of treatment. For most distressed couples, 15-20 sessions would be normal while couples with serious co-morbidities or recent infidelity, might require 25-50 sessions (Gurman et al., 2015).

EFT-C was initially an integration of experiential/gestalt approaches with interactional/family systems theory and was later heavily influenced by attachment theory. EFT-C consists of three tasks for the therapist and three stages of therapy. According to Johnson (2004), the three tasks are:

1. to create a safe, collaborative alliance
2. to access, reformulate, and expand the emotional responses that guide the couple’s interactions
3. to restructure interactions in the direction of accessibility and responsiveness that build secure and lasting bonds.

Its three stages are:

1. de-escalation
2. changing Interactional position
3. consolidation and Integration of new constructive interaction patterns.

EFT-C is a short-term approach to couple therapy and may take 8-20 sessions on average, more distressed, complex couples may require 20–40 sessions. GMCT and EFT-C are currently the two most prevalent approaches to couple therapy utilised in Australia mostly because comprehensive training in both approaches is now readily available around the country.

Gottman method couples therapy (GMCT)

Assessment

Many clinicians doing couples therapy do not use formal assessment. When presented with a couple in high levels of distress and pain, clinicians are often motivated to immediately attempt to help the distressed couple by moving straight into therapy. GMCT strongly recommends the opposite. It is essential to understand the couple’s presenting issues as seen through their eyes; to know their relationship history, individual histories, co-morbidities, and any contra indicators to couple therapy before engaging in therapy. GMCT argues the importance of a comprehensive assessment to ensure the clinician understands the couple’s strengths and areas of concern before beginning treatment. GMCT methods also include a feedback session with the couple to both explore with them the assessment findings and also to work collaboratively with the couple to develop clear and shared treatment goals.

The following is a brief description of the assessment phase and will assist clinicians in organising this phase and, importantly, communicating the plan of assessment and the treatment plan.

The assessment is completed in four sessions—an initial co-joint session, an individual session for each partner and finally the co-joint feedback session. Early in the assessment phase a range of assessment questionnaires completed by the couple provide significant individual and relationship data that assists with the formulation of a treatment plan.

Furthermore, in this phase, the clinician needs to decide when couple therapy is contraindicated. Contra-indicators involve the following:

• Ongoing affairs, secret or reveals: the interviews and questionnaires attempt to collect this data.
• Ongoing characterological domestic violence. GMCT categorises two types of domestic violence – situational and characterological. Situational violence is defined as an argument that escalates out of control where low level violence occurs. It is symmetrical and does not cause physical injuries or generate fear and intimidation. Characterological violence is defined as extreme violence, both emotional and physical. There is a clear perpetrator and clear target, and the aim is to create fear and intimidation. Within couple therapy, situational violence can be treated; characterological violence cannot (Jacobson & Gottman, 1994).
• Significant mental health condition/s that may need to be treated prior to couple therapy if the symptoms are florid.

Initial conjoint session

Following the completion of the client information form and disclosure statements and explanation of the assessment and therapy stages, the initial co-joint session incorporates three distinct components.

1. Couples’ narrative: In this component, the clinician asks a series of questions to understand the presenting issues as seen by the couple. Questions such as:

a. What brings you to therapy now?

b. What are your main concerns and issues in the relationship?

c. What your hopes and concerns about attending couple therapy?

d. Have you attended couple therapy prior to now and what was that experience like?

It is essential the clinician exhibits understanding and empathy and maintains a balance between each partner. The narrative generally takes 15 minutes of a 60-minute session. The clinician then moves the conversation to the oral history interview.

2. Oral history Interview: This component is a semi-structured interviewed aimed at gaining the couple’s relationship history including, if appropriate, their first meeting, dating, commitment engagement, marriage, transition to parenthood, children, ups and downs, hard times and changes over time in the relationship. This interview provides data concerning the friendship, conflict and meaning systems in the relationship.
3. Events of the week and conflict interaction discussions: GMCT works from the premise that it is critical to understanding how conflict occurs in the couple’s relationship through direct observation of their interaction. In this component two, ten-minute conversations (i.e., events of the week conversation and a conflict conversation) are set up and recorded. Physiological information is also measured—heart rate and oxygen uptake. The clinician does not intervene but observes the interaction looking for key relationship patterns and conflict indicators such as the ability to empathise, use of the four horseman, repair attempts, pursuer-distancer pattern, emotional distance, acceptance of influence, humour, affection, gentle start-ups, and validation. At the completion of the observation, each partner is asked to review the recording and use a distress rating dial to rate how positive or negative they were feeling during the conversations.

Online Gottman relationship check up (GRCU)

This clinical tool consists of 480 questions about friendship, intimacy, management of emotions and conflict and insight into shared values and goals. There are additional questions about parenting, housework, finances, trust, and individual areas of concern. The questionnaire is completely confidential, fully HIPAA compliant and a detailed report is sent only to the clinician. It is essential the GRCU is completed before the individual sessions are conducted to ensure information concerning co-morbidities and contra-indications to therapy are revealed In October 2020, the Gottman Institute released their Gottman Connect website and accompanying APP. It includes a new enhanced relationship check up and a range of resources for the couple called The Relationship Builder which includes educational resources, couple activities and video demonstrations.

Individual sessions

Following the initial co-joint session, the clinician conducts an individual session with each partner. This session is used to build trust with each individual and learn more about each partner’s perspective, family of origin, history, possible co-morbidities, hopes, expectations, and commitment to the relationship. The individual session provides a discreet opportunity to explore potential contra indicators such as domestic violence and ongoing affairs.

Feedback session

This session provides the opportunity to share your formulation with the couple from the information collected in the GRCU, the initial conjoint and individual sessions. The feedback session is structured using the Sound Relationship House with the clinician explaining each level of the house to the couple whilst giving feedback on their strengths and areas requiring development in each area. It is through these conversations that treatment goals are discussed and agreed upon.

Second phase therapeutic interventions

GMCT typically begins with the down-regulation negativity in a couple’s conflict and ways to increase positivity during conflict moving towards building positivity during conflict and building positive affect during non-conflict, bridging emotional disconnections, and creating shared meaning in the relationship.

It is useful to view the therapeutic intervention in two ways. Some interventions are Set Up interventions. These are structures used to assist the couple in moving into a more in-depth dialogue on an issue. Gottman interventions such as the Gottman Rapoport intervention and Dreams Within Conflict intervention are key examples of set up interventions (defined later in this chapter). The other form of interventions is step in interventions which occur whilst the couple are in dialogue, aimed at either reducing escalation or promoting a deeper understanding of different perspectives. Four horseman intervention and flooding intervention are key examples of step in interventions (defined later in this chapter). Many other interventions are used regularly within GMCT however, only the four mentioned above will be detailed in this chapter.

The following is a detailed description of four interventions commonly used to de-escalate couple conflict.

Set up interventions

Gottman Rapoport intervention is a structured conversation where each partner takes a turn in being the speaker and the listener, providing the opportunity for each other’s positions, feelings and positive needs to be heard, understood, and validated. Anatol Rapoport was a mathematician and social psychologist who worked extensively in international conflict (Gottman & Gottman, 2016).

John Gottman has used some of Rapoport’s assumptions in this intervention. An important assumption of this intervention is the concept of two valid subjective realities, not just one; that both positions are valid, that there is no absolute right and wrong, simply each person has a different perceptive on the same issue. This allows the couple to focus not on facts but on perceptions. This intervention is about slowing down a conversation, reducing physiological arousal levels and ensuring the listener is able to reflect understanding and validate at least part of their partner’s perspective. In this intervention problem-solving is suspended until both partners understand each other’s perspective and each other’s positive needs on the issue are fully understood. The speaker, with the assistance of the clinician, speaks directly to their partner using gentle start-up such as an ‘I-statements’, expressing emotions and avoiding blame and criticism, exploring their perspective with the articulation of a positive need on this issue. The listener is encouraged to take brief notes about what the speaker is saying, assisting in promoting listening and reducing the tendency to form rebuttals in their mind that interrupt listening capacity. Once the speaker is finished, the listener reflects back and validates what the speaker said, including the speaker’s affect. The Gottman Rapoport intervention enables the couple to gain a deeper understanding and appreciation of each other’s perspective and an opportunity to feel more understood and validated by one another thereby creating a corrective emotional experience that enables flexibility and possible compromise on the topic of conversation.

Dreams within conflict

This intervention is specifically designed for couples to explore gridlock conflict on perpetual issues in their relationship. Couples have issues that they continually fight about without resolution, from serious conflicts (e.g., should we have children or not, to small issues such as how one should fold the towels). Over time these conflicts can become stuck, gridlocked, where neither feels heard, understood, or validated. Indeed, perpetual gridlock conflict can create a feeling of vilification, distance, and emotional disconnection. Gridlock is an indication that the dreams embedded in the issue are not being understood or honoured. Dreams are defined as hopes, aspirations, and wishes that are part of one’s identity, personality, and give purpose and meaning to one’s life.

The purpose of this intervention is to move gridlock to dialogue; not to solve the problem but for the couple to engage in constructive ongoing conversation without escalation or vilification. The structure of the intervention again includes a speaker and a listener role, where the listener’s role is to create a climate of safety, allowing the speaker to talk deeply about the meaning for them of the issue, exploring their underlying values, dreams, and fears on the topic. To assist the speaker in deepening the conversation, the listener asks a series of questions like an interview such as:

• What are your core beliefs, ethics and values that are part of your position on this issue?
• Is there a story behind this for you, or does this relate to your background or childhood story in some way?
• Tell me why this is so important to you.
• What feeling do you have about this issue?
• What would be your ideal dream here?
• Is there a deeper purpose or goal in this for you?
• What do you need?
• Is there a fear or disaster scenario in not having this dream honoured?

To move out of gridlock, both need to feel understood and that the deep purpose and dream that exists in their position on the issues is validated and honoured. Acknowledging and respecting each person’s deepest, most personal hopes and dreams is the key to a strong and connected relationship.

Four horsemen

John Gottman’s research identified four highly destructive interaction patterns that he named the four horsemen of the relationship apocalypse. These are criticism, defensiveness, contempt, and stonewalling. Consistent use of the four horsemen moves relationship interactions onto a battleground where the conversation quickly ceases being about the initial issue raised and moves to every complaint, they have about how they feel their partner is treating them. Criticism and contempt are personalised attacks on the partner’s personality, communicating that something fundamental is not okay with them. Contempt can be condescending, speaking down at their partner, communicating that they think they are better than them. John Gottman was able to predict with 94% accuracy those relationships that will end in separation and divorce based on existing contempt in conflict conversations.

Using a gentler beginning when raising a complaint, with the speaker talking more about what they feel and what they need rather than negatively describing their partner allows the issue to be understood by their partner, providing a real opportunity for that person’s concerns to be heard. Defensiveness and stonewalling are behaviours that redirect the complaint or criticism away, where feedback is received, and the person does not allow themselves to be influenced by the other. Interestingly, when someone is stonewalling, they are experiencing stress and shutting down to stop or avoid the conflict from getting worse. Unfortunately, the opposite is true; defensiveness and stonewalling tend to escalate negative interactions. The capacity of a couple to accept some responsibility for their partner’s concerns and to self soothe when feeling stressed and wanting to shut down, assists in reducing the cascade into negative interactions and the escalation of conflict.

When a couple in therapy uses the four horsemen, the clinician intervenes by stopping the interaction, identifies the horsemen that was used and explains the antidote for the client to use. The clinician then assists the client in using the antidote. The goal is for the couple to experience a different type of conversation, one that doesn’t feel like a personal attack or a rejection of their perspective and that does not build negativity.

Horseman antidote

Criticism: Use a gentle start up.

Defensiveness: Take responsibility.

Contempt: Describe your feelings and needs; don’t describe your partner.

Stonewalling: Do physiological self-soothing.

Flooding

John Gottman noticed in his research that when a couple’s conflict escalated, it was not only their words, tone and volume that escalated, it was also their heart rates and the amount of stress hormones being secreted. This is called flooding or diffuse physiological arousal. The research findings were compelling: the more aroused couples were in conflict, the faster their hearts beat, the faster their blood flows, the more they sweat, the more stress hormones they release, the more their relationships deteriorated in the next three years. What we know is that it is the escalation of the conflict that builds negativity, and it is this build-up of negativity that predicts relationship demise. Flooding in conflict increases negativity in a relationship.

The term flooding refers to a flood of stress hormones (such as adrenalin and cortisol) to the nervous system that generates what is commonly known as the ‘fight or flight’ response.

What happens in your body when flooded?

• A cascade of physiological events takes place in the brain and the autonomic nervous system. Individuals are not in control of this cascade.
• Heart rate increases to 100 beats per minute or above.
• Blood is drawn in from the periphery and into the trunk to minimise haemorrhage.
• The frontal lobe of the brain is deactivated, and the amygdala is activated.
• Blood flow is redirected to vascular beds necessary for fighting or fleeing.
• Non-essential services like digestion are shut down.
• Glycogen in the liver is converted to glucose.
• Blood volume is increased through the renin-angiotensin system; there are considerable increases in myocardial contractility.
• Blood pressure increases.
• Breath becomes faster and shallower.

What happens in interaction with a partner when flooded?

• When people are physiologically flooded, they have trouble processing incoming information, meaning their capacity to listen and understand their partner is significantly impeded.
• In flooding, people cannot remember what they like about their partner, and it is hard for them to either give or receive affection.
• People do not want to be touched, and in many cases, it is even impossible to be polite and gentle with their partner.
• Tunnel vision occurs, and perception becomes distorted so that everything seems dangerous, the partner becomes the enemy, everything said by one’s partner seems like an attack.
• Alternative solutions and creative problem solving becomes difficult, and people can move into what we call ‘repeat yourself syndrome’ where they repeat the same point over and over again with increasing tone and volume in a misguided belief their partner will somehow see the merits of the argument and without equivocation, totally agree with everything being said, Of course, this does not occur.

GMCT includes over 50 couple interventions that therapists can use with couples to not only assist them in better managing conflict but also to deepen friendship and intimacy, create shared meaning, and strengthen trust and commitment in their relationship. Outcome studies and individual case study follow up (derived from authors’ private practice outcome data) routinely indicate that couples who complete a course of GMCT experience ongoing improvements in relationship satisfaction, conflict management and relationship commitment for years afterwards (Babcock et al., 2013).

Emotionally focused therapy with couples (EFT-C)

EFT-C is a non-pathologising experiential, systemic and attachment-based therapy, focused on couple interaction in the present moment, facilitating awareness of emotion within the couple’s interaction to promote positive interaction changes in the here and now.

The clinician observes the dynamics between clients in the therapy setting, ties this behaviour to the dynamics in their home lives, and helps direct new conversations and interactions based on more honest feelings. To accomplish this, the clinician encourages the couple to explore their current issues and assists in the discovery of deeper feelings and emotions that exist. The couple may access deeper past feelings and vulnerabilities that are blocked by the more immediate emotions displayed in their current relationship. They may learn to express these emotions in a way that will help one another connect, rather than disconnect and distance one another. The therapeutic goal is for the couple to learn new ways to listen and stay attuned to the other’s emotions and discover more productive ways to respond to emotional situations.

EFT-C identifies three stages in the therapeutic process, and within the three stages, there are nine steps of the therapeutic process.

1. The first stage is to de-escalate the couple’s negative cycle of interaction and to assist the couple in gaining insight and understanding of the deeper processes of each other’s interactions in their relationship. The clinician assists the couple to see and understand what is underlying the current negative interactions in their relationship. The couple begin to see more substantive emotions and needs that exist with the negative interaction patterns that are commonly masked through the escalation of negativity and the distancing and pursuer patterns.
2. The next stage is to restructure interactions, where the clinician assists the couple to engage in dialogue about their fears in the relationship in a way that can be heard by the other and thereby increase, not decrease, connection. Couples learn to turn toward each other and express their needs and hopes in a way that creates openness and responsiveness.
3. Consolidation is the third stage of EFT-C, where the clinician assists the couple see how they got into negative patterns and points out how they were able to change those patterns and how they can continue these types of conversations in the future.

Limits of therapy

EFT-C identifies three fundamental limits to therapy:

• The clinician does not decide if the couple should end or continue the relationship; the decision is only for the couple.
• Information in the individual sessions is confidential unless it seems crucial for the therapy to move forwards. The clinician will advise that partner to disclose relevant information with their spouse.
• The clinician cannot change the relationship, only the couple can. The couple is responsible for their relationship between therapeutic sessions.

Contra-indications for EFT-C

The critical question with contra-indicators is: can the clinician create safety in therapy? Two major considerations for making this decision are the following:

1. ongoing domestic violence
2. competing attachments (ongoing affairs or serious addiction).

Stage 1: Assessment and de-escalation (includes the first four of the nine steps)

Assessment is carried out in the first stage of the therapy with the clinician using conjoint and individual sessions to create a therapeutic alliance, formulate couple issues and concerns, and gain individual and relationship histories.

Individual assessment sessions are completed after one or two initial couple sessions. These sessions aim to develop rapport with the couples and to understand their perspective on the relationship, negative interaction patterns and attachment issues. Further, the individual session covers the following areas:

• commitment or ambivalence to the relationship
• previous attachment trauma
• previous relationships
• childhood and family background
• affairs
• domestic violence
• mental health issues
• drug and alcohol use
• medical conditions
• chronic pain
• sexual difficulties.

The individual session provides a discreet opportunity to explore possible contra indicators such as domestic violence and ongoing affairs.

Throughout the first phase of counselling, the clinician relies on the use of EFT-C micro-skills such as empathic listening, normalising, mirroring, or reflecting, reframing individual stories and perspectives. Importantly, the clinician tracks and articulates the negative interaction pattern and reflects back the problem cycles. These processes assist the client in becoming more aware of their emotions and how their emotions can affect themselves and others.  It helps the client become more confident in the changes that are occurring.

Step 1: Identify the relational conflict issues

The clinician assists the couple to identify the presenting issues within the relationship and assess the effects on the relationship.

Step 2: Identify the negative interaction pattern in which the conflict is expressed

The clinician and couple explore the interaction pattern at the heart of the problem. This occurs through identifying positions of withdrawal and pursuit within the interaction and tracking the steps in the reactive cycle. Tracking the negative interaction cycle is identifying how the couple interacts in relation to each other’s feelings, thinking and behaviour, and how attachment needs are met or not.

Step 3: Access unacknowledged emotions underlying the interactional position

Through discussion, the clinician assists the couple to explore each partner’s feelings in relation to the conflict cycle, with a focus on emotions that had not previously been expressed—accessing the underlying and often hidden attachment fears that perpetuate the negative interaction cycle.

Step 4: Reframe the problem in terms of the negative interaction cycle

The clinician begins to reframe the issues of the relationship away from deficits in either individual into seeing the problem within the negative interaction cycle. Reframing assists in the de-escalation of conflict and help the couple move towards validating each other’s different perspectives on the same issue. This step is to help the client view the problem from their partner’s point of view, helping each partner to understand the other’s emotions and needs.

Stage 1 is complete when the couple gains awareness that the core issue in the relationship is the negative interaction loop creating their distress, hurt and pain. This negative, self-reinforcing cycle is nicknamed the demon dialogue in Hold me tight (Johnson, 2008). At the end of stage 1, the couple is able to take ownership of their part in the negative interaction cycle and understand what draws them back into it. They recognise how each other’s attachment fears are triggered and how this continues the negative cycle.

Stage 2: De-escalation (includes the steps five through to seven)

In Stage 2, the clinician facilitates deepening the expression of primary attachment emotions to generate new pathways of connection and interaction, rebuilding secure and safe attachment bonds. Each partner expresses their deeper unmet attachment needs that have been hidden in the negative interaction pattern. Each partner takes a risk, to allow vulnerability, to turn towards each other and ask that these previously hidden attachment needs be met. These acts are intentionally structured interventions known as “enactments”.

The clinician uses a range of micro-skills and techniques such as:

validation—expressing the legitimacy of the person’s emotion

empathic reflection—highlighting and commenting on emerging emotions, noticing verbal and micro-expressions of the client

heightening of emotions—validating the emotion of the client whilst emphasising and evocating a stronger connection for the client with that emotion. Heightening enhances vulnerable emotions that can lead to a high arousal state that moves the client towards a greater understanding of themselves and others. The use of metaphor or imagery assists heightening.

empathic conjecture—the clinician works on the edge of a client’s experience to move the client forward in his/her experience such that new meaning can emerge. Often these conjectures address the attachment fears related to self and others.

restructuring interactions—the clinician offers a new suggestion for the couple, which in turn builds on a new emotional experience that seeks a different response to one’s partner. This challenges the couple’s old relationship interaction patterns and creates the possibility of something new.

tracking the cycle—the clinician names the steps in the negative interaction pattern between the couple from the material they bring into the session. The clinician, step by step, talks through the feelings, thoughts, and behaviour of the couple in interaction, touching on deeper emotions and attachment fears and needs.

reframe—the clinician draws out the attachment needs through reframing the negative interaction of the withdrawer and pursuer.

enactments—the clinician sets up small experiences/experiments for the couple to express primary emotions to one another (e.g., Can you turn to your partner and tell them how lonely you are feeling right now?)

RISSC—to enable the client to contact and engage with difficult emotions, the following RISSSC acronym is useful.

• Repeat: the key words and phrases repeated several times.
• Image: images capture and hold emotion in a way that abstract words cannot.
• Simple: keep words and phrases simple and concise.
• Slow: a slow pace enables emotions to unfold this process.
• Soft: a soft voice soothes and encourages deeper experiencing and risk-taking.
• Client’s words: the clinician uses the client’s words and phrases in a collaborative and validating way.

These skills and techniques ensure the therapist is attuned to the couple allowing the couple to feel heard, understood, and safe.

Step 5: Promote the identification of disowned needs

The clinician assists the couple to express and understand each other’s needs, wants and desires. This step places significant emphasis on the importance of understanding the other’s needs and wants fully through dialogue, and once achieved, to move towards meeting those expressed needs and wants.

Step 6: Promote partner acceptance

The clinician encourages each partner to accept the other’s emotional experience and acknowledge their changing experiences.

Step 7: Facilitate expression of needs and wants to restructure the interaction based on the new understandings and create bonding events

The clinician will guide each partner in learning how to interact more positively. A bonding exercise may accompany this step to help the couple promote a healthy new connection. The couple can risk the direct expression of their needs and wants to one another and have the capacity to create a new positive interaction that is responsive to unmet attachment needs.

Stage 3: Consolidation and integration: (includes steps eight and nine)

Stage 3 involves consolidating the learning and experience of the EFT-C therapeutic experience by integrating and consolidating the changes made during therapy and creating a plan for continued success outside of therapy. The clinician uses encouragement and support and aftercare teaching to promote relapse prevention.

Step 8: New solutions

The clinician supports the couple to collaborate in solving pragmatic problems. Now that differences are no longer triggers of attachment threats, and new solutions are more readily forthcoming. With the new, more positive foundation in place, solving these problems become much easier than it seemed in step one.

Step 9. Consolidation

In consolidation, the couple will take new skills and interaction patterns into their lives to continue developing effective ways to interact and new, more adaptive behaviours.

As with all humanistic therapies, the task of building and maintaining an alliance with each partner remains critical thought the three stages and nine steps of the EFT-C process. The other two key tasks are reprocessing emotional experience and restructuring new interactions between partners; creating corrective emotional experiences for the couple, reconfiguring their interaction patterns from negative escalated interactions to conscious attuned interactions that build connection and attachment.

Conclusion

Couples therapy requires a thorough assessment, formulation, and treatment plan due to the complexity of individual needs and couple interaction patterns/dynamics. The therapist needs a deep understanding of relationship theory, a well-developed, evidence-based framework and therapeutic process to competently manage the emotional and frequently escalated issues that couples present with, and a well thought out and executed follow up and relapse prevention plan. Pre and post assessment is highly recommended as part of this process.

Engaging in specific couple therapy training in an evidenced-based approach such as GMCT and/or EFT-C for couples provides therapists with the specialised knowledge, framework, interventions, and skills to ensure their couple clients are provided with best practice treatment and outcomes.

Recommended resources

Information for post-graduate training in Gottman Method Couples Therapy can be found at:

Professional Training Workshops including certified Gottman Method Couples Therapy

The Gottman Institute, upcoming events

Information for post-graduate training in EFT-C for couples can be found at:

EFT Training & Certification Overview

Helpful YouTube channels:

The Gottman Institute

Dr. Sue Johnson

Great reading:

Dr John Gottman has published over 200 journal articles and authored or co-authored over 40 books, below are a few of his most recent books. A list of journal articles, some with dynamic links, can be found on this John Gottman webpage.

Gottman, J., & Gottman, J. (2018). Eight dates: Essential conversations for a lifetime of love. Workman Publishing Company.

Gottman, J., & Gottman, J. (2018). The science of couple and family therapy. W. W. Norton and Company.

Gottman, J, & Silver, N. (2013). What makes love last: how to build trust and avoid betrayal. Simon and Shuster.

Gottman, J, and Silver, N. (2015). The seven principles for making marriage work. Random House.

Greenberg, L., & Goldman, R. (2008). Emotion-focused couples therapy: The dynamics of Emotion, Love and Power. American Psychological Association.

Johnson, S. (2008). Hold me tight. Little and Brown Company.

Johnson, S. (2013). Love Sense. Little, Brown Spark.

Johnson, S. (2018). Attachment theory in practice. Guilford Press.

Glossary of terms

acceptance of influence (Gottman method couples therapy)—taking your partner’s opinion into account, and being open to using their contribution to make shared decisions

Bowen theory—a theory of human behaviour describing a family system where each family member has an assigned role with the expectation to respond to each other per their assigned role. The family is considered an emotional unit by applying systems thinking processes to describe the unit’s complex interactions. The aim is to maintain patterns of behaviour within a system that can be beneficial or dysfunctional to its members.

conjoint sessions—clients from a couple are seen together in a therapy session by one clinician

contempt (Gottman method couples therapy)—is the third horseman of the apocalypse. Contempt is communicating to your partner an attitude of superiority, that you look down at them, implying your partner is inferior, less than or worthless. Contempt is used to create a position of moral superiority.

consolidation and integration (emotionally focused therapy with couples)—third task of EFT-C where the couple continue to reorganise their cycle of interaction by finding new solutions to their relationship problems and sharing their changed emotional experiences. With the clinician providing feedback to the couple on their accomplishments.

contraindicated (Gottman method couples therapy and emotionally focused therapy with couples)—defines the limits of not proceeding with therapy for a couple, citing the possible risk of harm that it may cause to either client within the couple. For both approaches, therapy is contraindicated when there is an ongoing affair or the presence of domestic violence within the relationship.

criticism (Gottman method couples therapy)—is the first horsemen of the apocalypse. Criticism is an attack on your partner’s character, focusing on your partner’s defects rather than the actual issue or complaint.

de-escalation—the clinician facilitates a reduction in harmful interactions between the couple through identifying patterns of interactions, emotions, behaviour, and unmet attachment needs, creating emotional safety for the clients

defensiveness (Gottman method couples therapy)—is the second horsemen of the apocalypse and is an automatic batting away of their partner’s issue or complaint. Often defensiveness is a response to criticism. Defensiveness is a lack of taking responsibility and accountability for one’s own actions including an inability to listen and validate your partner’s perspective.

demon dialogue (emotionally focused therapy with couples)—rigid and negative patterns of conflict communication that prevent safe communication by the confusion of emotional signals, preventing safe connection between partners. Dr. Johnson describes three demon dialogues as being: find the bad guy AKA mutual attack, the protest polka AKA demand and withdraw, and flight and freeze AKA tension and avoidance.

disowned needs (emotionally focused therapy with couples)—the clinician helps the couple to understand the needs and wants of each individual. Then how to convey these needs. The premise is to be able to meet your partner’s needs, firstly you must understand them.

differentiation of self (Bowen theory)—the ability to be socially connected to others while remaining independent in one’s emotional functioning

diffuse physiological arousal (DPA) (Gottman method couples therapy)—an internal alarm system that sets off a chain reaction from the brain to the body in response to a threat (perceived or real) alerting danger. Priming the body for the fight or flight response; heart rate increases, blood flow to the gut and kidneys slows down and stress hormones such as cortisol, adrenalin, and catecholamine are released. Another term for DPA is flooding.

down-regulation negativity (Gottman method couples therapy)—the use of positive emotions to facilitate the body’s return to homeostasis caused by the physiological arousal of negative emotions

dreams within conflict intervention (Gottman method couples therapy)—this intervention is specifically designed for couples to explore gridlock conflict on perpetual issues in their relationship. The purpose of this intervention is to move gridlock to dialogue; not to solve the problem but for the couple to engage in constructive ongoing conversation without escalation or vilification.

emotional cut-off (Bowen theory)—driven by high levels of anxiety in self and within the relationship, describes the pattern of extreme emotional distancing to address unresolved attachment needs

emotional distance—a symptom of an unhealthy relationship dynamic that obstructs the development of intimacy

emotional fusion (Bowen theory)—the formation of intense relationships where individual choice is minimised to maintain harmony within the relationship

enactments (emotionally focused therapy with couples)—the clinician nurtures a new interaction experience, with the couple experiencing each other as being available and responsive. Designed to reduce relationship distress and enable change by highlighting and heightening brief snippets of attachment related relationship dynamics.

family projection process (Bowen theory)—the process of parents transferring their emotional problems to their children. Describes the primary way parents transfer their emotional problems to their children.

flooding Intervention (Gottman method couples therapy)—intervention used to reduce physiological arousal with one or both partner in couple therapy. The intervention including identifying when one or both partners are flooded, moving them into a relaxation exercise until their heart rates have reduced from above 100 beats a minute to nearer to rest. Once this is completed the therapist encourages the couple to re-engage in the dyadic conversation.

four horsemen of the apocalypse (Gottman method couples therapy)—a metaphor to describe the counterproductive communication and behaviours that can predict relationship failure if left unchanged. These being criticism, defensiveness, contempt, and stonewalling. Each horseman corrodes away at the level of trust and commitment within the relationship.

four horseman intervention (Gottman method couples therapy)—intervention used to stop the four horsemen through the identification of their use and rephrasing the conservation using each associated antidote. To foster healthy, productive communication habits.

gentle start-ups (Gottman method couples therapy)—crucial in resolving relationship conflicts that protect both people from feeling either attacked or defensive. A gentle start up is the antidote to the horseman of criticism and involves a partner saying what they feel about a situation and what they need rather than describing negative attributes of their partner.

Gottman Rapoport intervention (Gottman method couples therapy)—Gottman Rapoport intervention is a structured conversation where each partner takes a turn in being the speaker and the listener, providing the opportunity for each other’s positions, feelings and positive needs to be heard, understood, and validated

gridlock conflict (Gottman method couples therapy)—couples have issues that they continually fight about without resolution, from serious conflicts (e.g., should we have children or not, to small issues such as how one should fold the towels). Over time these conflicts can become stuck, gridlocked, where neither feels heard, understood, or validated. Indeed, perpetual gridlock conflict can create a feeling of vilification, distance, and emotional disconnection.

multi-generational transmission process (Bowen theory)—a family’s level of functioning is influenced by the instability or functioning of previous generations

negative cycle of interaction (emotionally focused therapy with couples)—describes the repeating interaction between each partner’s surface emotions and negative behaviours, thoughts, and feelings that cause relationship distress. Driving the cycle is the maladaptive attempts at intimacy or closeness within the relationship.

perpetual issues (Gottman method couples therapy)—John Gottman’s research identified that 69% of conflict in a relationship was perpetual in nature, meaning that most conflict is not solvable and is based on individually held values, family backgrounds, experiences, and personality

primary attachment emotion (emotionally focused therapy with couples)—repressed primary emotions drive the negative interaction cycle between a couple. Emotional attachment is rebuilt through honest emotional expression.

pursuer-distancer pattern (Gottman method couples therapy and emotionally focused therapy with couples)—a relationship pattern that describes attempts to relieve relationship anxiety and stress. Through attempts of turning towards (pursue) or turning away (distance) from their partner.

repair attempts (Gottman method couples therapy)—any preventative statement or action that averts escalation between partners. A repair attempt strategy is unique to each couple, designed to amend rather than fix what is broken.

shared meaning system (Gottman method couples therapy)—is the attic level of the sound relationship house that consist of rituals, goals, roles, and values. That encompasses the legacy of a relationship to reflect a life together that is full of meaning. It is the creation of culture, beliefs, and stories that form the shared meaning.

sibling positions (Bowen theory)—people who grow up in the same sibling position, having the same functional characteristics of personality

societal emotional process (Bowen theory)—describes how the emotional system influences behaviour on a societal level, promoting both progressive and regressive periods in a society

set up intervention (Gottman method couples therapy)—these interventions are structures used to assist the couple in moving into more in-depth dialogue on an issue or past regrettable incident. Examples include the Gottman Rapoport intervention and the dreams within conflict intervention.

step in interventions (Gottman method couples therapy)—these interventions occur whilst the couple are in a set up intervention, aimed at either reducing escalation or promoting a deeper understanding of different perspectives

stonewalling (Gottman method couples therapy)—the fourth horseman of the apocalypse is stonewalling and is a form of defensiveness. Stonewalling is when one shuts down interaction and stops responding to their partner. Internally the person stonewalling is experiencing heightened levels of stress and physiological arousal.

the sound relationship house (Gottman method couples therapy)—is the relationship theory for relationships by John and Julie Gottman. It is divided into three interrelated components of friendship, conflict, and meaning systems. The sound relationship house has 7 floors and 2 walls of trust and commitment.

systems theory (family systems)—a philosophy that focuses on the interdependence of individuals within a group to understand and improve relationships

triangles or triangulation (Bowen theory)—the recruitment of a third person into a conflict between two people to reduce relationship tension.

Reference list

Australian Bureau of Statistics. (2021). Marriage and divorce, Australia. https://www.abs.gov.au/ausstats/abs@.nsf/mf/3310.0.

Australian Bureau of Statistics. (2016). Australia today. The way we live now. https://www.abs.gov.au/ausstats/abs@.nsf/mf/2024.0

Babcock, J., Gottman, J., Ryan, K. & Gottman, J. S. (2013). A component analysis of a brief psych-educational couples’ workshop: One year follow-up results. Journal of Family Therapy, 35: 252–280. https://doi.org/10.1111/1467-6427.12017

Baker, K. G. (2015). Bowen family systems couple coaching. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (pp.246-267). The Guilford Press.

Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson.

Brown, J. (1999). Bowen family systems theory and practice: illustration and critique. Australian and New Zealand Journal of Family Therapy, 20(2)https://doi.org/10.1002/J.1467-8438.1999.TB00363.X

Carter, E., Walters, M., Papp, P., & Silverstein, O. (1988). The invisible web, gender patterns in family relationships. Guilford.

Cherlin, A., & F Furstenberg, F (1994) Step families in the United States: A reconsideration. Annual Review of Sociology, 20, 359–381.

Christensen, A., Jacobson, N., & Babcock, J. (1995). Integrative behavioral couple therapy. In N. S. Jacobson, & A. S. Gurman (Eds.), Clinical handbook of marital therapy (2nd ed., pp. 31–64). Guilford Press.

Doherty, W. (1997). The scientific case for marriage and couples education in health care paper. University of Minnesota.

Gottman, J. M., & Gottman, J. G. (2016). Level 1 clinical training; Gottman method couples therapy. The Gottman Institute.

Gurman, A. (2015) The theory and practice of couple therapy. In Gurman, A., Lebow, J., & Snyder, D. (Eds.), Clinical handbook of couple therapy (5th ed.). Guilford Press.

Halford, W., Moore, E., Wilson, K., Dyer, C., Farrugia., C., & Judge, K. (2006). CoupleCare: Couple commitment and relationship enhancement: A guidebook for life partners. Academic Press.

Hogendoorn, B., Leopold, T., & Bol, T. (2019). Divorce and diverging poverty rates: A risk-and-vulnerability approach. Journal of Marriage and Family, 82(3), 1089-1109.

Jacobson, N., & Gottman J. M. (1998). When men batter women. Simon & Schuster.

Jacobson, N., & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. Brunner/Mazel.

Johnson, S. (2004). The practice of emotionally focused marital therapy: Creating connection (2nd ed.). Brunner/Routledge.

Luepnitz, D. (1988). The family interpreted: psychoanalysis, feminism, and family therapy. Basic Books.

Mineo, L. (2017). The Harvard Gazette. https://news.harvard.edu/gazette/story/2017/04/over-nearly-80-years-harvard-study-has-been-showing-how-to-live-a-healthy-and-happy-life/

Nichols, M. (1987). The self in the system. Brunner/Mazel.

Rodgers, B., Gray P., Davidson T., & Butterworth P. (2011). Parental divorce and adult family, social and psychological outcomes: The contribution of childhood family adversity. Department of Families, Housing, Community Services and Indigenous Affairs Social Policy Research Paper No 42: Australian Government. https://www.dss.gov.au/sites/default/files/documents/05_2012/sprp_42.pdf

Satir, V. (1988). The new peoplemaking. Science and Behavior Books.

Stuart, R. (1969) Operant interpersonal treatment for marital discord. Journal of Consulting and Clinical Psychology, 33, 675-682.

Weiss, R. (1975). Marital separation. Basic Books.

Author information

Trish Purnell-Webb is a Clinical Psychologist, Clinical Director of the Burleigh Heads Psychology Clinic in Burleigh Heads, Queensland, Australia, and the Senior Partner of Relationship Institute Australasia. She is also the first Australian practitioner to become a Senior Certified Gottman Method Couples Therapist, Master Trainer, and Consultant for the Gottman Institute. Trish has travelled to North America several times in the past ten years to be trained directly by Drs John and Julie Gottman.

Trish is certified to present all three levels of the Gottman Method training sequence, as well as the Art & Science of Love couple workshop. Trish frequently presents Gottman Method trainings for clinicians throughout Australia, New Zealand, Asia, and the USA. Trish has also undertaken training in Emotionally Focused Therapy for Couples having completed an externship, and all Core Skills training offered by the International Centre for Excellence in Emotionally Focused Therapy and integrates this into her work with couples.

Because of Trish’s training and experience in couples therapy and clinical mental health disorders especially Post Traumatic Stress Disorder and Mood Disorders, Trish has been involved in the development and delivery of a number of couple programs and clinical treatment programs for the Department of Veteran’s Affairs, The Australian Defence Force and Open Arms (Formerly known as Australian Veterans and Veteran’s Families Counselling Service).

Trish is also trained in:

• Cognitive Process Therapy (CPT)
• Schema Therapy
• Cognitive Behavioural Therapy (CBT)
• Acceptance and Commitment Therapy (ACT)
• Motivational Interviewing

Trish has been in private practice on the Gold Coast in Queensland, Australia since 1997 and provides a range of services to members of the general public including couples therapy, intensive marathon couples therapy, couple workshops and is an active educator and speaker to many community and professional organisations.

Trish has recently co-authored a book called 365 Simple Ideas to Improve Your Relationship with her business partner John Flanagan.  This book provides a unique daily guide for couples and contains a daily tip and a task designed to help them make positive change in their relationship.

To learn more about Trish, listen to this We All Wear it Differently podcast where Trish is interviewed about her journey into and through Psychology and Couple Therapy.

John Flanagan has, since completing his Bachelor of Social Work in 1988 and later a Masters in Gestalt Therapy, had an extensive history in direct service delivery with couples, families, and young people.

John was the first Social Worker in Australia to become a Certified Gottman Therapist, Master Trainer, and Consultant. This means that John has completed all levels of training and mentoring available through the Gottman Institute in Seattle, USA and can now provide training to other therapists in this modality as well as provide couples with world-class couple workshop experiences. He is one of only 26 therapists in the world to hold this standing. John is a certified presenter for all levels of Gottman therapist training and the Art and Science of Love Couples Workshop. He has completed his Certificate IV in Workplace Training and Assessment and has delivered a broad range of training both accredited and non-accredited.

John is trained to provide therapy to individuals, couples, and groups in a range of therapeutic approaches including:

• Gottman marital therapy
• Emotionally focussed therapy for couples
• Cognitive Processing Therapy
• Motivational Interviewing
• Gestalt Therapy
• Cognitive Behavioural Therapy

Over the last 20 years, John has provided a range of psycho-educational group programs to Australian veterans and their families in areas such as trauma, post-traumatic stress disorder, depression, anxiety, and resilience. He has provided training to therapists and human service organisations in Australia, New Zealand, Hong Kong, Malaysia, the USA.