“If we acknowledge love science – LOVE SENSE, we can move forward.  We can move toward a time when “true” love, being known, becomes simpler and easier and more accessible to all of us.”

Dr. Sue Johnson


The Future of Couple and Family Therapy : Attachment Science in Action

APA International Conference: Crossroads of Couple and Family Psychology 2017

- text of plenary by Dr. Sue Johnson – 

As Sol Garfield points out, there are now over 1,000 names for approaches to psychotherapy and 400 systematically outlined methods of intervention. How the “talking cure” as referred to by Freud, first called “psychotherapy” by an English psychiatrist, Walter Cooper Dendy in 1853, has grown. Throughout history we have had many different perspectives on mental misery, symptoms and problems, more and more abstract labels for these problems and lots of varying ideas about how to fix them. Sounds like chaos doesn’t it! – The Greeks saw problems like depression as all about biology – a medical condition (they proscribed taking a bath as the best remedy) and for much of the formative years of western civilization we turned to the demonic possession to explain mental problems and to exorcism or punishment as the remedy. I must admit that occasionally, on a bad day, when my sessions are not going well, I still lapse into this demonic possession perspective and fantasize offering my clients trial by fire as a corrective emotional experience!

In the Couple & Family field, we have perhaps a few less labels for relational problems than our colleagues who practice individual therapy, but we have been slow to develop and test truly transactional models of therapy that really address and integrate both self and relational system. The key issue as I see it is, as one speaker pointed out in her AAMFT plenary in 2000, “Couple & Family therapists have set out on a vast and troubled ocean in a very small theoretical boat”. We have tended to focus on what are essentially individual variables, like the levels of communication skills in relational partners and ignored factors such as patterns of mutual nurturance and emotional connection that our clients see as central to their relationships. We have set out to change relationships – the key relationships on which we scaffold our lives in fact – without a rich, empirically based theory of close relationships. If we are to systematically change the multi-dimensional moving target called an intimate relationship in action – which is a delicate set of self-maintaining feedback loops where the dance defines the dancers and dancers define the dance – we need a clear perspective on the key structuring/organizing variables of this dance and exactly what is necessary to shape such variables in positive lasting ways!

This is especially true since in the 21st century, there are new and tough demands made of psychotherapy. First, therapy has to be brief, so clear direction and a relevant in-session focus are imperative. Second, we need to be able to show that our interventions are on target – that they have real impact and take hold outside our therapy sessions. Third, we need to be able to effectively train the some 70% of clinicians who say they see couples and families (how many have actual training is debateable), especially since relationship distress is actually reported as the main reason people seek out psychotherapy in general. All this is a bit daunting – Unless, like successful mariners who set out on a huge and ever varied ocean and manage to set down on a small specific point of land – we have a map!

To really do the job, such a map has to be broad, inclusive, cohesive and relatively simple, but still rich and complete enough to address individual and interpersonal dysfunction. It would have to describe, predict and explain what goes wrong in close relationships in ways that not only give the therapist clear guidance but also resonate as real and as relevant to clients. It has to offer a convincing picture of how relationships are the context for the development of self over time – to lay out the key elements of intrapsychic and interpersonal health and resilience, so we know what to steer for. It has to give us the route out of helpless into health – key ways to help clients move from relationships that trigger pain, chaos, and a constricted way of being to those that shape more ordered, flexible and healthy lives. Even more than this, if we are to shape change that lasts, such a map has to show us how to move beyond the visible, relatively close shores of rearranging or lessening symptoms into the deeper ocean of restructuring core variables, how we habitually regulate our emotions, give shape to core orienting cognitions about self and other, and engage with and relate to others, as well as deal with the great transitions and existential challenges of human life.

There is only one map that even begins to fit this description – the developmental theory of personality in relational context called attachment theory as originally outlined by John Bowlby. This theory or should we say, this body of science based on a rich conceptual base, first focused on the development of the child in family relationships and now, in the last 20 years, has moved into a focus on adult functioning and adult relationships. As I say this, the main strength of the attachment model becomes apparent. Self in Relationship. Attachment integrates self and system, the individual and the interactional patterns a person shapes and is shaped by. It puts human being where they live – in the context of their relationships and offers us a model of constructive dependency. For the attachment oriented therapist, the essence of man is captured not in the phrase, homo sapiens -the one who knows, but in the phrase, homo vinculum – the one who bonds with others. Man is not only essentially social, he defines himself and learns to survive in a web of close emotional connections with key others. The ultimate threat – tragedy for mankind is isolation – emotional disconnection from others. Love between intimates goes way beyond sex and sentiment. It is an ancient wired in survival code designed to keep those we depend on close to us.

Attachment theory has five very simple normative principles. All of which speak to the task of therapy:

1. First attachment privileges emotion. It is essentially a theory of affect regulation. Contact with a responsive attachment figure calms the nervous system and teaches that nervous system to calm. The work of neuroscientist Michael Meaney captures where this science is going – he finds that attachment cues – in this case responsive connection such as grooming by rat mothers- sets the sensitivity of rat pups nervous system to threat in a manner that lasts across the rat’s lifespan.

baby

(human infant : this child was born with a nervous system and brain that is expecting those hands to be there – this is our biological baseline for physiological homeostasis as human beings)

The essence of attachment security is the ability to maintain or regain emotional balance, and so avoid the chaotic reactivity that shapes mental disorganization, or the numbing out avoidance that shapes constricted awareness and processing of information. Navigating through life is like dancing a tango. When I am in balance, within myself and with a partner, I can move in any direction. I have flexibility and choice. Adults mentally evoke attachment images and memories to keep hold of their equilibrium. It makes sense then that the song voted as the most soothing in America is ‘Like a Bridge over Troubled Water’. It makes sense that I evoke and listen to my husband’s voice in my head and that this voice reassures and calms me as the plane lifts me thousands of feet above the earth.

There are many arguments for primacy of emotion; its links to meaning creation, its ability to move and motivate us, its ability to communicate with others. Emotion tells us what we need and want. It primes us to MOVE to meet those needs. There is no time here for an in depth discussion of emotion per se, but the phrase corrective emotional experience has been used for years to capture what therapists believe is necessary to create change. The power of this kind of experience is supported by new research on the impact of emotional events on memory and how such events are given priority by the brain and remembered more vividly. In the large NIMH study on depression, Castonguay also found that across treatment models that the clients who made significant gains in therapy were those who engaged more deeply on an emotional level in therapy sessions. In Emotionally Focused Therapy we continually find that helping clients deepen emotion significantly predicts significant positive relationship changes at the end of therapy.

As an attachment oriented therapist, I believe the essential element in therapy is that the therapist knows how to move into the emotional channel and stay there WITH the client, discovering, ordering and distilling that client’s experience. One finding from the NIMH study was also that it is this collaborative engagement in emotion regulation that predicts change in clients rather than a coaching approach to working with emotion. Change comes from new emotional experience rather than new explanations.

The Power of Words : an example of how evoking emotion and a sense of emotional connection powers engagement and evokes responsiveness.

It is worth noting that in general C&FT has avoided emotion – assuming that it is epiphenomenal and will change if and when cognition or behavior changes – and that it is just part of the problem and so somewhat dangerous. Sal Minuchin now suggests that to bypass emotion in C&FT is a mistake. I would add that by doing so we ignore a if not the core motivating force in relationships and miss plugging into a megawatt transforming variable – Changing the emotional music changes the dance between intimates – and if this does not occur the music – the beat and rhythm – easily overrides other shifts.

2. Attachment science stresses that a felt sense of emotional safety is a prime requirement for full attention to and engagement with experience – for priming curiosity about how experience unfolds– for reflection, for learning. This felt sense of safe haven, which is exactly what we feel when connected to a loving attachment figure, allows us to turn off our vigilance for threat and take in new information. It has been shown to facilitate the ability to move into metacognition, and so revise realities. Attachment, which acknowledges our vulnerability while offering us a model of constructive dependency, has already, in the last 40 years, revolutionized the way we see our children and how we parent. Now it is beginning to help us see that strength as adults is not vulnerability denied – it is vulnerability embraced with the support of others.

This focus on safe haven, it seems to me, is what we are really talking about when we talk about the power of the therapeutic alliance as a general factor that is essential to positive therapeutic outcome. But alliance for me isn’t so much a general factor; it differs in its quality and implementation in different models. If we use attachment as a guide to alliance building, as we do in EFT, we constantly use our own emotional presence and empathic responsiveness to build a platform of safety with our clients. We soothe as we challenge, titrate risks – slice risks thinner according to the clients capacity to handle them, and just like a good attachment figure, we actively offer antidotes to shame and self-denigration. (I say to Al, “Of course you clam up and freeze around other people Al. This was your only option in your violent family. It was your only safety. It saved your life. But now your only protection is more like a prison – yes?”).

This felt sense of safety is not a nebulous or woo woo phenomena. In our latest study looking at changing couples attachment bonds from chronic insecurity to safe haven security, we put women who were insecure and unhappy in their relationships in a brain scan machine. Before therapy, when they saw a big X in front of their face that signalled they could be shocked on their ankles, their brain went into alarm, like this:

and they reported that the shock was painful. This occurred whether they were alone, a stranger held their hand or their partner held their hand. After bonding conversations in therapy, their brain still responded to this threat in this way when they were alone or with a stranger. But after therapy, when their partner held their hand and they saw the X, their brain looked like this:

and they reported the shock as simply ‘uncomfortable’. This is the power of a felt sense of security on the mammalian brain; this is the power of the co-regulation of fear – the most powerful emotion of all. Please note, the prefrontal cortex did not turn on here. The fear was not simply “controlled” better by holding a partner’s hand. The threat was encoded differently at source. Contact comfort really does offer us a safer world. It changes the way we perceive danger. For me this also speaks to the fact that our reliance on others, especially for the first years of our life when it is literally true that if we call and no-one comes, we die, has shaped our nervous system, our brain, the hormones that flood our body, our very physiology and our emotional life. Attachment is biology –biology that translates into interactional pattern, linking the dance between neurons to the patterns in the dance between intimates.

3. Attachment science tells us that connection with others is not only a source of safety to go to, it offers a base to go out from – it is a continuing source of strength throughout life. Attachment is an evolutionary theory – it suggests that survival is the birthright, not of the fittest (Darwin never said this) but of the most nurtured, those whose nervous systems have been tuned for equilibrium by loving connection find it easier to hold onto that equilibrium in stressful situations. Survivors of 9/11 who could turn to others and use their support recovered much better from this trauma than those who could not do this.

Safe connection EMPOWERS us. Being able to trust others – reach for them – is expansive for the self. To use the language of positive psychology, secure connection broadens and builds, fostering flexible, balanced individuals. We differentiate and grow WITH others not from others. Secure attachment builds a more positive, articulated and coherent sense of self (Mikulincer 1996). We then have internal models of ourselves as acceptable and entitled to care and others as trustworthy and able to be relied on. The 2007 Feeney study on the Dependency Paradox found that when a romantic partner accepts the other’s dependency needs and responds when needed, this other partner becomes more confident, autonomous and able to risk and reach their career goals faster. Effective dependency is our species greatest strength.

To enable clients use healthy effective dependency strategies – that is to accept and acknowledge their attachment vulnerabilities and needs and REACH for others in a way that evokes connection, rather than using the two less affective strategies of PUSHING and coercively demanding caring or avoidantly TURNING AWAY from others and denying attachment vulnerabilities, is a key part of any attachment oriented therapy. This represents a quite a change in our field where pathologizing terms have been used for our need for others; terms like enmeshment, fusion, lack of individuation, and co-dependency. These three strategies arise in relation to a therapist, a partner in couple therapy, or a family member in family therapy.

Dan has been depressed for ever. He has had years of therapy but he constantly beats himself up, tells himself to take obsessive care of others, and feels unentitled to any needs of his own. He seems immovable. What can I do that my other talented colleagues have not been able to do? Only evoke the power of his connection with the one person he talks about with soft emotion on his face – his mother. He imagines her in the chair in my session, and talks about her with me until she is present for him. Then we distil his pain and I ask him to share this pain with his mother in an imaginal encounter. His mother tells him – “My son, my son, you are such a good man. You try so hard to be perfect. You are dying inside. You don’t have to be perfect to be loved. You hurt too much. You must turn and let someone in to care for you.” He weeps. Priming his memory of loving attachment and caring, cues his compassion for himself in a way that moves him to action and new ways of engaging others.

4. Attachment theory states that disconnection from others induces panic, disorientation and pain in the mammalian brain. C&FT has focused mostly on conflict but from an attachment point of view conflict, which happens in happy and unhappy relationships, is the inflammation – the virus is emotional distance and disconnection. Attachment gives us a map to our emotional ups and downs as well as our triggers and their meaning. Emotional disconnection from loved ones HURTS – literally. The brain scan research of Nancy Eisenberger shows that the emotional pain of rejection is coded in the same part of the brain and in the same way as physical pain. Rejection is a danger cue for our species, just like stepping on a nail. The ability to tune into and make sense of someone’s pain is invaluable for a therapist.

I would like to show you in a short clip how this pain can take us over and how the three options, secure reaching, and insecure strategies -protesting and demanding, and avoidant turning away play out when this pain of disconnection is triggered. These strategies can become muscle memory –habitual and form styles that, if insecure, begin to limit our ways of seeing and responding to others. This repertoire of responses to disconnection are easier to see, less able to be disguised in a child, but separation distress goes from the cradle to the grave. I would also like you to note that the trigger for this cascade of emotional chaos is not active rejection or aggression but a simple lack of response, a still face, a stonewalling reaction from an attachment figure. (Note – the simple lack of response is traumatizing – this gives us new way to see marital distress- to grasp, for example, the devastating impact of withdrawal).

I must admit that, in the end, for me as a therapist, it is not the clear conceptualization or the hundreds of studies (over 600 now and counting) offering evidence that is nigh irrefutable at this point that make me passionate about the power of this perspective. It is that the theory itself never lets me down in my sessions. It is my secure base – it always helps me makes sense of the drama of people’s lives and relationships, helps me grasp how and where my clients are stuck. As Bowlby himself stated, when we understand the drama of attachment, everything a client does is suddenly “perfectly reasonable.”

Tim is sent to see me with his wife by his army psychologist who is at a loss with him. He has full blown PTSD from his war experiences and since he has stopped numbing out with alcohol his agitation and suicidal depression have taken over. The bizarre thing is that he is not waking up with nightmares about war – but about an incident 28 years ago when Sarah, his wife of 35 years, became friendly with another man in her university class and went for some coffees with him without Tim’s knowledge. He rails obsessively about her “infidelities” – belligerently implying that she must be mentally ill and unstable to have done this and he can never “forgive her”. She first quietly reassures, reasons, empathizes, until, unable to breathe, she dashes out of the room. This man says he has walked through ‘fields of corpses’, and survived the loss of his “faith in God and Man”, but he is caught here and pushing away the one person who can best help calm his fragile nervous system and help him heal. Tim yells at me that I don’t understand and he is right. Until I tune into the attachment channel. This man has lost every touchstone. He is whirling in hopeless and helplessness. Vigilance is in his every breath. Of course his mind first goes to checking his lifeline – his connection with his wife – seeking the danger cue, the fatal flaw, and when he finds it, THIS is the danger that galvanizes him. Unfortunately this panic and the rage cues her self-protective withdrawal and so PROVES to him again that she is unreliable –not to be trusted. As we unpack this drama, and how Tim is caught in and constantly creates it, Sarah begins to assert herself, naming his panic and more effectively calming him and herself. Tim accesses that proving that even Sarah cannot be trusted gives him 2 seconds of control, followed by the hell of finding himself ALONE with his ghosts and fears. Tim improves, learning to reach for his lady – Sarah improves, their relationship improves. The military psychologist asks me what I did. I tell her that the map offered by attachment science explained this drama and led us out the other side. She says, “You always think it’s about attachment” I reply, “Yes. In essence, it always is. At least attachment dilemmas are at the heart of so many issues. Because that is who we are.”

5. The last principle of attachment science that I am going to list is that accessibility/openness to experience and to others and attuned emotional responsiveness are essence of secure bonding and of mental health. Research such as Ted Huston’s finds that emotional responsiveness is the most potent predictor of relationship quality from just married to 15 years in, so it is a sine qua non to cultivate responsiveness to emotional cues in couple therapy.

When we consider openness and responsiveness as the building blocks of secure attachment, its seminal to consider the nine studies of key change events in the couple therapy modality, in EFT (summarized in Greenman and Johnson, 2013 -Family Process) that predict lasting shifts in relationship satisfaction, trust, forgiveness of injuries and the development of more secure bonding responses. We call these powerful choreographed interactions, withdrawer re-engagement and blamer softening, or more colloquially, Hold Me Tight conversations. They speak to the fact that a good theory allows us to pinpoint specifically what is necessary to create key change events that transform relationships as well as outline exactly how the therapist can set them up. In EFT, these events cannot occur before the couple have established a secure base and have ceased to constantly trigger each other’s worst fears; then they can risk becoming open, and learn to state their attachment fears and needs in a manner that pulls their partner close, helping this partner move into empathic responsiveness. There is enough emotional charge in these events to light up the New York skyline. A charge that ensures they are processed intensely and held onto in memory in a way that redefines a relationship. To reiterate – the necessary and sufficient conditions for change in an attachment oriented intervention such as EFT are: safe therapeutic alliance – espec re TASK relevance for client / deepening of emotion into corrective experiences/Affiliative bonding sequences – TEA (very English).

So in Stage 2 of EFT, Anna makes a clear emotional bid for Sam’s love, the way a child does who ‘knows” her mother will be there for her, so no disguises and no defences; Anna is out in the open. She says, “I get real scared, no, I get terrified when I can’t find you, reach you, when you become a stranger. I need to know I can come and get your reassurance. The reassurance that I, with all my quirks, I am your special one; the one you chose – the one you want. Am I enough for you – to be your special one?” Her openness moves her husband to tears and instantly evokes every ounce of wired in empathy that he possesses. He reassures her. In these moments the dance between the couple is redefined, and so are the dancers. When Anna knows she is loved, she sees herself differently; when Sam understands that he knows how to please and hold his partner he seems to grow two inches. Oh – and the therapist also grows two inches because she helped them get here!

This is the promise of attachment science, that we can pinpoint the blocks to healthy functioning and set up in-session change events that target the exact shifts necessary to move clients into a healthy space. This is particularly fascinating in a treatment designed to change something as apparently nebulous as romantic love relationships – which we have all agreed for centuries are totally illogical and mysterious in nature; something we simply fall into and out of but cannot understand or shape. At present, there are 17 positive outcome studies of EFT, some with depressed and anxious couples, and 3 positive follow-up studies over 2-3 years that suggest that the effects of treatment last over time, some where couples continue to improve after treatment in terms of satisfaction in fact. (I believe that these follow-up effects occur because when we find out how to fulfill our attachment longing – which attachment suggests is the most powerful motivator known to man, the ultimate unconditioned reinforce- we naturally hold on tight to the behaviors and responses that got us there). We have also studied the forgiveness of injuries such as affairs with positive results. In our last study of session by session change we found that in 20 sessions relationship satisfaction increases, attachment avoidance decreases a little in every session, attachment anxiety decreases in couples when they can share attachment fears and needs in Hold Me Tight conversations, and couples showed more positive secure base attachment behaviors like expressing emotional needs when rated on interactional tasks. We also have just completed the first study of our Hold me Tight educational program based on the book of that name. There are already 2 new adaptations of this program – one for Christian couples and one for cardiac patients –. We do need more studies of EFFT – (only one at present). There are also two positive studies of our basic 4 day externship training on EFT – a training taken by over 3000 health professionals a year in North America and now supported by over 60 affiliated communities worldwide teaching EFT. I invite you to look at the international center for excellence in EFT – ICEEFT website for an ongoing list of publications, studies and also training DVD’s. In these DVDs we make it easy to see EFT in action.

Attachment science offers couple and family therapists a rich coherent way to make sense of the drama of relationship distress – a way that is seen as relevant and on target by couples – / a way to grasp, deal with and use the megawatt emotions that are part of love relationships/ to accept the needs and longings that drive the drama/ to find the blocks to empathy and safe engagement and dismantle them/ to focus down on the key moments of disconnection and potential connection/ to shape small healing moments of bonding in every session/ to shape more secure attachment – this security predicts almost every variable associated with health and resilience named in our discipline. If we can shape and heal relationships, we can create relationships that heal where partners broaden and build each others personal strengths.

Conclusion -

We are talking here about the potential positive impact of attachment science on the practice of Couple & Family Therapy and where it can take us as a discipline.

To move to a more general level for a moment, I also believe that attachment offers a general corrective direction for the practice of psychotherapy in general. In 1985, at a conference much like this one, Carl Rogers was asked what he thought the field of psychotherapy had learned over the last 100 years. He stated that he didn’t know. He went on to say, “I’ve learned to be more human in the relationship, but I am not sure that that’s the direction the profession is headed.” There are times when I wonder where we are headed. Are we aspiring to be purveyors of impersonal techniques, quick fixes for one symptom or another, labeling our clients into categories and coaching them to pick up the new behaviors stipulated in our manuals? Or are we surrogate attachment figures that offer a safe compassionate place in which clients come to meet us and confront their stuck places with us, so they can grow and discover how to be human – how to be truly alive. As a therapist, who do you want to be? I love being a therapist because I am constantly discovering what it is to be human with my clients.

In a world that is becoming lonelier and lonelier, (one quarter of Americans now say they have no-one at all to confide in), where we take selfies (not relfies with another person in the picture), where there is an epidemic of depression and anxiety, a world of “friends” who are simply pictures on a flat screen, attachment science challenges us to keep psychotherapy relational, to treat people not problems or disorders defined by committee, to use science as professionals but never become impersonal, to actively be a force for shaping a world – a civilization – that fits our basic nature – homo vinculum and where that nature can flower. We are concerned with the sustainability of our planet. Seems to me that mental health professionals are key players in the sustainability of our human species with all its vulnerability and need to live in a connected relational world.

I am going to end with one of my favorite quotes – by Sal Minuchin and Nichols (1993). Minuchin and Nichols state that there is now:

Hope for new ways of being together.

This is the song our society needs to hear:

the song of me-and-you,

the song of the person in context,

responsible to and for others.

To hear it, we need the courage to renounce

the illusion of the autonomous self and to accept

the limitations of belonging.”

Limitations ???-   It is time for us to honor our nature as social bonding animals, to see the amazing richness and opportunity in embracing this nature, and for us as professionals to play a key leadership role in creating a civilization where relationships are prized and prioritized (not relegated to incidental status) where we feel confidant and competent to shape the partnerships and families we dream of – where we can truly belong and thrive.