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EFT with Couples facing End-of-Life. Find your partner.

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Presentation on theme: "EFT with Couples facing End-of-Life. Find your partner."— Presentation transcript:

1 EFT with Couples facing End-of-Life

2 Find your partner

3 Couples Movie Clip

4 Couples who are faced with the upcoming death of a partner experience issues both on an individual level and on a relational level Literature Review End-of Life Impact

5 Literature Review End-of Life Impact: Partner with Illness Physical Physical Social Social Emotional Emotional Depression Depression Anxiety Anxiety Spiritual Spiritual (Mohr, Moran, Kohn, Hart, Armstrong, Dias, Bergsland, & Folkman, 2003)

6 Literature Review End-of Life Impact: Caregiver partner Need to provide emotional support Need to provide emotional support Need to provide instrumental support Need to provide instrumental support likely to withdraw emotional support as need for instrumental support increases due to increased distress, resentment, and burnout likely to withdraw emotional support as need for instrumental support increases due to increased distress, resentment, and burnout Emotional distress is often worse on the caregiving partner than the patient; they are less likely to seek out or accept professional help Emotional distress is often worse on the caregiving partner than the patient; they are less likely to seek out or accept professional help Common symptoms: increased fatigue, health problems, and social isolation Common symptoms: increased fatigue, health problems, and social isolation (Mohr et al., 2003)

7 Communication Communication Adjustment to changes in roles Adjustment to changes in roles Adjustment to demands of illness Adjustment to demands of illness Coping strategies Coping strategies (McLean & Jones, 2007; Mohr et al., 2003) Literature Review End-of Life Impact: Relational

8 Rationale for Couple Therapy at End of Life Adaptation to a diagnosis of cancer will be altered by the quality of the couple relationship (Hannum, Giese-Davis, Harding, & Hatfield, 1991) Adaptation to a diagnosis of cancer will be altered by the quality of the couple relationship (Hannum, Giese-Davis, Harding, & Hatfield, 1991) Provide opportunity for relational and personal growth Provide opportunity for relational and personal growth Caregiving partner usually has the largest impact on the overall well-being of terminally ill partner (Mohr et al., 2003) Caregiving partner usually has the largest impact on the overall well-being of terminally ill partner (Mohr et al., 2003)

9 Case Study Jim and Sue White, middle-class, professional White, middle-class, professional Married for 10 years, no children Married for 10 years, no children Sue has been battling a brain tumour for 3 years Sue has been battling a brain tumour for 3 years Her prognosis was recently deemed terminal Her prognosis was recently deemed terminal Doctors are unable to estimate how much time she has left Doctors are unable to estimate how much time she has left Jim has been withdrawing from Sue Jim has been withdrawing from Sue

10 Rationale for EFT use Terminal cancer occurs in the context of relationship Terminal cancer occurs in the context of relationship Circular reciprocity (Stiell, Naaman, & Lee, 2007) Circular reciprocity (Stiell, Naaman, & Lee, 2007) Avoidance of emotional expression by male partners of cancer patients perceived as insensitive and rejecting (Sabo, Brown, & Smith, 1986) Avoidance of emotional expression by male partners of cancer patients perceived as insensitive and rejecting (Sabo, Brown, & Smith, 1986) EFT creates a positive emotional environment EFT creates a positive emotional environment Helps partners regulate emotional and physical functioning, which reduces overall impact of disease (Steinglass, 2000) Helps partners regulate emotional and physical functioning, which reduces overall impact of disease (Steinglass, 2000) Focus on power of emotional communication and attachment helps build resilience in the face of illness (Stiell et al., 2007) Focus on power of emotional communication and attachment helps build resilience in the face of illness (Stiell et al., 2007) Useful in highly emotionally charged experiences (textbook ref), such as terminal illness Useful in highly emotionally charged experiences (textbook ref), such as terminal illness

11 EFT Overview Origins EFT is an integration of Experiential/Gestalt approaches and Interactional/Systemic approaches

12 EFT Overview Origins: Experiential/Gestalt Therapeutic alliance itself is healing Therapeutic alliance itself is healing Acceptance and validation of client experience Acceptance and validation of client experience Belief that people are to make healthy choices Belief that people are to make healthy choices Examine how inner and outer realities define each other Examine how inner and outer realities define each other People are formed and transformed in relationship with others People are formed and transformed in relationship with others Use here-and-now experience of therapy session to foster corrective experiences Use here-and-now experience of therapy session to foster corrective experiences

13 EFT Overview Origins: Systemic Influences Focus is on interaction between members of system Focus is on interaction between members of system Problems are due to interactions Problems are due to interactions Breaking a negative cycle will effect positive change Breaking a negative cycle will effect positive change EFT focuses on using emotion to help break negative cycles and enact new patterns of interaction EFT focuses on using emotion to help break negative cycles and enact new patterns of interaction

14 EFT Overview Origins: Experiential-Systemic Synthesis Focus on present experience, not past Focus on present experience, not past Person is seen as fluid entity Person is seen as fluid entity Experiential approaches focused within the person; excluded relational influences Experiential approaches focused within the person; excluded relational influences Systemic approaches focused on interactions; excluded individual internal responses and meanings Systemic approaches focused on interactions; excluded individual internal responses and meanings

15 EFT Overview Origins: Influence of Attachment Theory Primary attachments create an internal working model of relationships which is played out in all of our relationships (Bowlby in Engler, 2003; Bowlby in Stiell et al., 2007) Primary attachments create an internal working model of relationships which is played out in all of our relationships (Bowlby in Engler, 2003; Bowlby in Stiell et al., 2007) No person is inherently able to regulate their emotions. This develops through relationships. (McWilliams, 2004) No person is inherently able to regulate their emotions. This develops through relationships. (McWilliams, 2004) Attachment injuries – traumatic events that damage the bond between partners, such as chronic illness (McWilliams, 2004) Attachment injuries – traumatic events that damage the bond between partners, such as chronic illness (McWilliams, 2004)

16 EFT Overview Relationship Health A healthy relationship is one in which there is a secure attachment bond Mutual emotional accessibility and responsiveness Mutual emotional accessibility and responsiveness Depathologizes dependency in adults Depathologizes dependency in adults Allows activation of attachment seeking behaviours Allows activation of attachment seeking behaviours Model of others as dependable and trustworthy, model of self as lovable and entitled to care Model of others as dependable and trustworthy, model of self as lovable and entitled to care

17 EFT Overview Relationship Distress Due to attachment insecurity and separation distress Due to attachment insecurity and separation distress Sequence of responses to threat against attachment security Sequence of responses to threat against attachment security Anger Anger Clinging and seeking Clinging and seeking Depression and despair Depression and despair Mourning and detachment Mourning and detachment Rigid interaction patterns such as demand- withdraw can be disastrous Rigid interaction patterns such as demand- withdraw can be disastrous

18 EFT Overview Key Principles Collaborative alliance provides secure base from which to explore Collaborative alliance provides secure base from which to explore Therapist is consultant to process Therapist is consultant to process Emotion is primary in forming attachment behaviours, guiding perceptions, motivating attachment responses Emotion is primary in forming attachment behaviours, guiding perceptions, motivating attachment responses Therapist privileges emotional responses Therapist privileges emotional responses Attachment needs are healthy and adaptive Attachment needs are healthy and adaptive

19 EFT Overview Key Principles Contd Problems are maintained by interactional organization and by dominant emotions Problems are maintained by interactional organization and by dominant emotions Therapist deescalates negative patterns and reactive emotions; help shape new, positive interactions Therapist deescalates negative patterns and reactive emotions; help shape new, positive interactions Change occurs through new emotional experience in present interactions Change occurs through new emotional experience in present interactions The actual client is the relationship, not individual members of couple The actual client is the relationship, not individual members of couple

20 EFT Overview: Three Tasks Task 1 – Create and maintain therapeutic alliance Four qualities of building alliance: Four qualities of building alliance: Empathic attunement Empathic attunement Acceptance Acceptance Genuineness Genuineness Continuous active alliance monitoring Continuous active alliance monitoring

21 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions EFT therapists recognize key universal emotions EFT therapists recognize key universal emotions anger/rage, fear/anxiety, joy/elation, shame/disgust, sadness/despair, surprise/curiosity anger/rage, fear/anxiety, joy/elation, shame/disgust, sadness/despair, surprise/curiosity Step-wise process of emotions: Step-wise process of emotions: Appraisal Appraisal Arousal Arousal Reappraisal Reappraisal Action Tendency Action Tendency

22 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions Contd Emotions inform interactions and help in organizing adaptive responses to a persons environment Emotions inform interactions and help in organizing adaptive responses to a persons environment Primary emotions Primary emotions Secondary emotions Secondary emotions Instrumental emotions Instrumental emotions 3 key issues in focusing on emotion: 3 key issues in focusing on emotion: Involvement Involvement Exploration Exploration New emotion New emotion

23 EFT Overview: Three Tasks Task 2 – Access and Reformulate Emotions Contd Skills for Emotional Engagement RISSC RISSC Validation Validation Evocative Responding Evocative Responding Heightening Heightening Empathic conjecture and interpretation Empathic conjecture and interpretation Self-disclosure Self-disclosure

24 EFT Overview: Three Tasks Task 3 – Restructure Key Interactions Tracking and reflecting interaction Tracking and reflecting interaction Simple reflection: when he does this, you do that Simple reflection: when he does this, you do that Framing and reframing interactions Framing and reframing interactions Example EFT Reframes: Example EFT Reframes: Fighting against the Enemy of the Negative Cycle Fighting against the Enemy of the Negative Cycle Withdrawal as an attempt to Protect the Relationship Withdrawal as an attempt to Protect the Relationship Pursuing to Fight for a Connection Pursuing to Fight for a Connection Restructuring interactions using enactments Restructuring interactions using enactments Structured, focused, choreographed Structured, focused, choreographed

25 EFT Overview Further Interventions Resolving attachment injuries Help injured partner discuss the impact and the significance of the attachment Help injured partner discuss the impact and the significance of the attachment Other partner then able to better understand how the event has injured their partner in attachment terms. Other partner then able to better understand how the event has injured their partner in attachment terms. Aid injured partner in further discussing the injury in terms of expressing grief and fear. Aid injured partner in further discussing the injury in terms of expressing grief and fear. Other partner realizes their role in the injury and expresses their own emotions. Other partner realizes their role in the injury and expresses their own emotions. Injured partner is able to ask their partner for support in dealing with emotions Injured partner is able to ask their partner for support in dealing with emotions A new narrative of the event has been constructed by the couple and each partner is able to understand the others experience of the event. A new narrative of the event has been constructed by the couple and each partner is able to understand the others experience of the event.

26 EFT Overview Process of Change Nine treatment steps, organized into three stages Nine treatment steps, organized into three stages In mildly troubled couple, the partners usually progress through steps at parallel rate In mildly troubled couple, the partners usually progress through steps at parallel rate In more highly troubled couple, the more withdrawn or passive partner is invited to progress through the steps slightly ahead of partner In more highly troubled couple, the more withdrawn or passive partner is invited to progress through the steps slightly ahead of partner Begin with one or two conjoint sessions, then one with each partner Begin with one or two conjoint sessions, then one with each partner Typically lasts 8 to 15 weekly sessions Typically lasts 8 to 15 weekly sessions

27 EFT Overview Mechanisms of Change Levels of Change: Expansion of Experience Expansion of Experience Engagement of the Partner in a Different Way Engagement of the Partner in a Different Way New View of the Partner is Offered to His/Her Mate New View of the Partner is Offered to His/Her Mate New Cycle is Initiated New Cycle is Initiated A Bonding Event Occurs in the Session A Bonding Event Occurs in the Session Shifts in Both Partners Sense of Self Shifts in Both Partners Sense of Self

28 EFT Overview Stage 1: Cycle De-escalation Goals Couple to have overarching perspective of their interactions Couple to have overarching perspective of their interactions Each partners reality is validated Each partners reality is validated Partners are encouraged to unite against the negative cycle Partners are encouraged to unite against the negative cycle Initiate new cycle that promotes attachment security Initiate new cycle that promotes attachment security

29 EFT Overview Stage 1: Cycle De-escalation Step 1: Identify relational conflict issues Step 1: Identify relational conflict issues Step 2: Identify negative interaction cycle where these issues are expressed Step 2: Identify negative interaction cycle where these issues are expressed Step 3: Access unacknowledged emotions underlying the interactional position each partner takes in this cycle. Step 3: Access unacknowledged emotions underlying the interactional position each partner takes in this cycle. Step 4: Reframe problem in terms of the cycle, accompanying underlying emotions, and attachment needs. Step 4: Reframe problem in terms of the cycle, accompanying underlying emotions, and attachment needs.

30 Scenario #1 Role Play: Stage 1

31 EFT Overview Stage 2: Changing Interactional Patterns Goals Have withdrawn partners reengaged in the relationship Have withdrawn partners reengaged in the relationship Partners are able to confide in and seek comfort from each other Partners are able to confide in and seek comfort from each other Partners are becoming mutually available and responsive Partners are becoming mutually available and responsive

32 EFT Overview Stage 2: Changing Interactional Patterns Step 5: Encourage each partner to identify with disowned attachment needs and aspects of self. Step 5: Encourage each partner to identify with disowned attachment needs and aspects of self. Step 6: Promote acceptance by each partner of the other partner's experience Step 6: Promote acceptance by each partner of the other partner's experience Step 7: Promote expression of needs and wants to restructure the interaction; create bonding events Step 7: Promote expression of needs and wants to restructure the interaction; create bonding events

33 Role Play: Stage 2 Scenario #2

34 EFT Overview Stage 3: Consolidation and Integration Goals To consolidate new responses and cycles of interaction To consolidate new responses and cycles of interaction If you practice the new cycle enough times it will become the norm If you practice the new cycle enough times it will become the norm

35 EFT Overview Stage 3: Consolidation and Integration Step 8: Facilitate the emergence of new solutions to old problems Step 8: Facilitate the emergence of new solutions to old problems Step 9: Consolidate new positions and cycles of attachment behaviour Step 9: Consolidate new positions and cycles of attachment behaviour

36 Role Play: Stage 3 Scenario #3

37 EFT Overview Termination During stage three the therapist is less directive During stage three the therapist is less directive Therapist outlines positive changes that have occurred during therapy Therapist outlines positive changes that have occurred during therapy Discuss goals for the future and any feelings about termination Discuss goals for the future and any feelings about termination Couples are welcomed to return Couples are welcomed to return

38 EFT Overview Predictors of Success Positive therapeutic alliance = success Positive therapeutic alliance = success With male partners who have been described by their partners as inexpressive With male partners who have been described by their partners as inexpressive With female partners who feel that their partner still cares for them With female partners who feel that their partner still cares for them Areas that have NOT influenced the success of EFT with couples include: age, education, income, length of marriage, cognitive complexity, or religiosity. Areas that have NOT influenced the success of EFT with couples include: age, education, income, length of marriage, cognitive complexity, or religiosity.

39 EFT Overview Applicability & Diversity Used with diverse ages, classes, backgrounds, and sexual orientations Used with diverse ages, classes, backgrounds, and sexual orientations Positive outcomes for males and females Positive outcomes for males and females Often used with gay and lesbian couples Often used with gay and lesbian couples Couples with issues of low sexual desire are often difficult to treat in a few sessions Couples with issues of low sexual desire are often difficult to treat in a few sessions Effective with traumatized partners, depressed partners Effective with traumatized partners, depressed partners Can be used with couples where there is mild and infrequent violence and/or emotional abuse Can be used with couples where there is mild and infrequent violence and/or emotional abuse

40 Popular Notions of End-of- Life Issues

41 Resources for Couples

42 Group Member Reactions Topic: Couple Therapy at End-of-Life Topic: Couple Therapy at End-of-Life Similarities Similarities Differences Differences We engaged in much discussion about whether the illness should be chronic (e.g. MS) or something terminal We engaged in much discussion about whether the illness should be chronic (e.g. MS) or something terminal Approach: EFT Approach: EFT Similarities Similarities We appreciated the importance of focusing on attachment during this difficult time of life, so EFT seemed a great fit We appreciated the importance of focusing on attachment during this difficult time of life, so EFT seemed a great fit Most of us found that EFT was a very dense and complicated approach Most of us found that EFT was a very dense and complicated approach Differences Differences

43 References Engler, B. (2003). Personality theories: An introduction, 6 th ed. Houghton Mifflin: New York. Hannum,J. W., Giese-Davis, J., Harding, K., & Hatfield, A. K. (1991). Effects of individual and marital variables on coping with cancer. Journal of Psychosocial Oncology, 9(2), 1-20. McLean, L.M., & Jones, J.M. (2007). A review of distress and its management in couples facing end-of-life cancer. Psycho-Oncology, 16, 603-616 McWilliams, A.E. (2004). Couple psychotherapy from an attachment theory perspective: A case study approach to challenging the dual nihilism of being an older person and someone with a terminal illness. European Journal of Cancer Care, 13, 464-472. Mohr, D.C., Moran, P.J., Kohn, C., Hart, S., Armstrong, K., Dias, R., Bergsland, E., & Folkman, S. (2003). Couples therapy at end of life. Psycho-Oncology, 12, 620-627 Sabo, D., Brown, J., & Smith, C. (1986). The male role and mastectomy: Support groups and mens adjustment. Journal of Psychosocial Oncology 4(1-2), 19-30. Stiell, K., Naaman, S.C., & Lee, A. (2007). Couples and chronic illness: Attachment perspective and emotionally focused therapy interventions. Journal of systemic therapies, 26(4). 59-74. Steinglass, P. (2000). Family processes and chronic illness. In Cancer and the Family, Baider, L., Cooper, C.L., & Kaplan-DeNour, A. (Eds.), pp. 3-15. John Wiley: West Sussex, England.

44 Rationale for Couple Therapy at End of Life optional slide –already covered in video Reduce psychosocial distress Reduce psychosocial distress For ill partner, it can ameliorate the perception of severity of symptoms (Mohr et al., 2003) For ill partner, it can ameliorate the perception of severity of symptoms (Mohr et al., 2003) For caregiver, it can ease bereavement (McLean & Jones, 2007) For caregiver, it can ease bereavement (McLean & Jones, 2007)

45 Dying represents a threat to the attachment and attachment behaviours are activated in times of threat (McWilliams, 2004) Dying represents a threat to the attachment and attachment behaviours are activated in times of threat (McWilliams, 2004) Potential relationship issues Potential relationship issues Securely attached relationships show ability to take turns in being caregiver and care receiver (McWilliams, 2004) Securely attached relationships show ability to take turns in being caregiver and care receiver (McWilliams, 2004) Withdraw-pursue or withdraw-withdraw cycles (Stiell, Naaman, & Lee, 2007) Withdraw-pursue or withdraw-withdraw cycles (Stiell, Naaman, & Lee, 2007) Application of Attachment Theory

46 Important to be comfortable with grief process Important to be comfortable with grief process Issues of countertransference Issues of countertransference Higher awareness of end of life, become fearful of own life Higher awareness of end of life, become fearful of own life Self care (depression, burn out) Self care (depression, burn out) Awareness of own philosophy and theoretical base (ensure that it works with group participants) Awareness of own philosophy and theoretical base (ensure that it works with group participants) Use of Self

47 StrengthsWeaknesses - Bridging a gap in available services - Providing individuals with support - Uses evidence based practice in the development of a successful group development of a successful group - Participants are invited to co- construct the group experience construct the group experience - Group invites participants to reflect on presently occurring interactions on presently occurring interactions - Pilot group so there are no previously established guidelines or outcome established guidelines or outcome studies studies - Lack of clarity - What will happen when clients - What will happen when clients die die - Is it beneficial to have a closed - Is it beneficial to have a closed group group - Length of group - Length of group - Diversity in age group - Diversity in age group Critical Analysis


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